June 14, 2013 | 7:01 am

Hepatitis A Outbreak Linked to Frozen Berry and Pomegranate Mix

Posted by Albert Fuchs, M.D.

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Product label.
Image credit: CDC.

Hepatitis A is an illness which affects the liver and is caused by a virus. (You’ll be shocked to learn it's called the hepatitis A virus.) It is usually transmitted through food and water contaminated by human feces, even in microscopic amounts. In the US outbreaks have frequently been linked to food workers who have hepatitis A and contaminate food with their hands. The disease typically causes fatigue, abdominal pain, jaundice (yellowing of the skin and eyes), and dark urine. Patients typically recover completely without lasting damage to the liver. Unlike other forms of viral hepatitis, hepatitis A does not cause chronic infection. After the patient has recovered, the virus is cleared from the body and the patient is no longer infectious. Recovery is followed by lifelong immunity.

An outbreak caused by a negligent restaurant worker is bad enough, but we live in an interconnected international food marketplace. Contamination of the food supply can happen anywhere from the farm to the consumer’s hands; the farther upstream the contamination, the more people may be affected.

The most recent food-borne hepatitis A outbreak has been sickening people since March. This week the Centers for Disease Control and Prevention (CDC) updated their findings from their ongoing investigation. The outbreak has been linked to Townsend Farms Organic Anti-Oxidant Blend frozen berry and pomegranate mix. As of Wednesday 97 people have become ill in eight states including California. About half of those affected have been hospitalized. There have been no deaths. The berry and pomegranate mix is sold at both Costco and Harris Teeter, though all the affected people who recall eating the berry mix bought it at Costco.

The product has obviously been removed from store shelves. If you have any, discard it immediately. If you have eaten this product in the past two weeks and have never been vaccinated against hepatitis A, contact your doctor immediately. Vaccination may lower your chance of becoming ill.

I've written previously about food-borne illness, about the lack of evidence that anti-oxidants have health benefits, and about the lack of evidence that organic food is healthier than food grown with industrial fertilizer and pesticides. This is an unfortunate story in which these topics intersect. The recent media coverage of the outbreak included an interview with the wife of one of the people sickened with hepatitis A. She expressed surprise that organic food could become contaminated. But there has never been any suggestion that organic food is less likely to bear infectious diseases than food grown with pesticides. Even organic food producers have never made such a claim. If anything, the withholding of industrial fertilizers may increase the likelihood of food contamination if animal waste is used instead and if it is not cleaned off the food.

So please wash all uncooked fruits and vegetables before eating them, even frozen produce. Please wash your hands after using the bathroom. And please feel free to buy organic food because you think it tastes better, or because you’d like to spend more money on food, or because you know it will impress the intriguing hipster checking out your shopping cart. But don't do it for health benefits.

Learn more:

Multistate outbreak of Hepatitis A infections potentially associated with “Townsend Farms Organic Antioxidant Blend” frozen berry and pomegranate mix (CDC)
Advice to Consumers (CDC)
CDC: 87 Now Sickened in Hepatitis A Outbreak (WebMD)
Hepatitis A victim shocked organic berries almost led to liver transplant (CBS News)
Hepatitis A (review article by the Mayo Clinic)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

June 7, 2013 | 6:35 am

A New Weapon against Hospital-Acquired MRSA Infections

Posted by Albert Fuchs, M.D.

Scanning electron
micrograph of MRSA
bacteria. Credit: Janice
Haney Carr/CDC

The bacterium Staphylococcus aureus can live on our skin and in our noses without causing disease. Such a condition is called bacterial colonization, to contrast it from infection in which the bacteria causes illness. When the skin is broken or when host immunity is weakened Staph. aureus can enter the blood stream or other body spaces and cause life-threatening infection. Because medical procedures frequently involve puncturing or cutting the skin, Staph. aureus accounts for more health care-associated infections than any other germ.

That would be bad enough, but one strain of Staph. aureus, called methicillin-resistant Staph. aureus (MRSA), has developed resistance to many of the antibiotics most commonly used against Staph. infections, making it particularly difficult to treat. Controlling the spread of MRSA in health-care settings has become a national priority. Many hospitals have implemented programs to remind staff to wash their hands before and after contact with patients and to identify and isolate patients colonized with MRSA. Hospital-acquired MRSA infections have actually declined in recent years, perhaps due to these efforts, but in 2011 they still affected 62,500 patients and killed more than 9,000.

ICU patients are especially vulnerable to life-threatening hospital-acquired infections, for two reasons. First, they are the sickest patients in the hospital and their immune system is frequently not working well. Second, they undergo many invasive procedures that cause potential portals of entry for infection. Some hospitals screen all patients (or all ICU patients) for MRSA by swabbing their nose. Those who test positive are then placed under contact isolation – they are moved to a private room and all staff must don gloves and a disposable gown prior to coming into contact with them. Nine states have mandated by law such MRSA screening and isolation procedures.

But is this the best way to protect hospitalized patients from MRSA infection?

Other hospitals have stepped up their MRSA efforts even further. They screen all patients for MRSA. Those who test positive are isolated and also undergo decolonization – an attempt to kill the MRSA on their skin and in their nose. This is usually done with an antibiotic gel that is placed in the nostrils and antibacterial wipes that are used to clean the patient’s skin.

Last week the New England Journal of Medicine published a very clever experiment that tried to elucidate the best way to minimize ICU-acquired MRSA infections.

Rather than randomize patients, they randomized whole hospitals. 43 hospitals were randomized to three different MRSA strategies for their ICU patients. Hospitals in the first group employed the traditional screen-and-isolate strategy. All ICU patients were screened for MRSA and those who were found to be colonized were placed under contact isolation. The second group used a screen-and-decolonize strategy. All ICU Patients were screened for MRSA and those who tested positive were placed under contact isolation but also underwent decolonization with the antibiotic nasal gel and the antibacterial skin wipes. The third group had the simplest strategy – universal decolonization. Their ICU patients did not get tested for MRSA. Instead, all the patients were decolonized with the antibiotic nasal gel and the antibacterial skin wipes.

Hospitals in the third group had the fewest MRSA infections. They also had the fewest blood-borne infections from any germ. That makes sense given that the antibacterial wipes would be expected to kill many pathogens, not just MRSA. The authors calculated that 181 patients would need to undergo decolonization to prevent one MRSA infection, and 54 patients would need to undergo decolonization to prevent one bloodstream infection from any pathogen.

Besides being the most effective, universal decolonization had another important advantage; it eliminated the need for swabbing everyone’s nose. This eliminated the expense of doing all those tests for MRSA and also eliminated the delay of waiting for the test result, since decolonization could proceed immediately.

Occasionally fortune smiles on us and the simplest solution turns out to be the most effective. The practicality of this approach makes it possible to implement it in virtually any hospital immediately.

There are some possible drawbacks. The most serious is that universal use of the antibiotic nasal gel and the antibacterial skin wipes could eventually lead to bacterial resistance to either of them. If they were to be used universally, some program to test for resistance should be also implemented. But a more immediate hurdle is that eliminating screening for MRSA would run afoul of state law in nine states.

An editorial in the same issue of NEJM states

[T]he folly of pursuing legislative mandates when evidence is lacking has been shown, and laws mandating MRSA screening should be repealed.

That is indeed a worthy goal. If this were generalized to the repeal of all “legislative mandates when evidence is lacking”, the effects of this study would be revolutionary.

Learn more:

Winning the MRSA Battle in Hospitals (Well, NY Times health blog)
New Tack in Preventing Hospital Infections (Wall Street Journal)
Disinfect All ICU Patients To Reduce 'Superbug' Infections (Shots, NPR health blog)
Targeted versus Universal Decolonization to Prevent ICU Infection (NEJM article, by subscription)
Screening Inpatients for MRSA — Case Closed (NEJM editorial, by subscription)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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May 24, 2013 | 3:34 pm

Little Evidence that Low-Salt Diet Prevents Heart Disease

Posted by Albert Fuchs, M.D.

Photo credit: Jorge
Royan/Wikimedia

We know that people with high cholesterol have a higher risk for strokes and heart attacks than people with low cholesterol. So if a medicine lowers cholesterol it should also lower the frequency of strokes and heart attacks too. Right? Not necessarily. Estrogen lowers cholesterol and doesn't lower stroke or heart attack risk. We also know that people with high blood pressure have a higher risk for strokes and heart attacks. Does that mean that a food that elevates blood pressure increases stroke and heart attack risk? Again, not necessarily.

The confusion here is a misunderstanding of the difference between clinical outcomes and intermediate outcomes. A clinical outcome is something that a patient notices herself and that impacts her life directly – like a stroke, a heart attack, or a bone fracture. An intermediate outcome is something that is measured by the doctor and that doesn't cause symptoms directly – for example, elevated blood pressure, elevated cholesterol, or low bone density. Intermediate outcomes can be risk factors for clinical outcomes but shouldn't be confused with them.

What does this have to do with salt?

Lots of evidence shows that eating more salt raises blood pressure, so doctors have always made the assumption that eating more salt also increases the risk of strokes and heart attacks. But as we've seen with estrogen and many other examples, guessing the effects on clinical outcomes from intermediate outcomes is frequently incorrect. In 2005 the USDA and Department of Health and Human Services wanted to revise their dietary recommendations for salt intake. Given the very little scientific evidence they had, what they did was both simple and presumptuous. They knew that 1,500 mg of sodium intake daily was the minimum needed for adequate nutrition. They also knew that at daily intake levels above 2,300 mg of sodium (which is about a teaspoon of salt) blood pressure begins to increase. So the US recommendations since 2005 have been that everyone should eat no more than 2,300 mg of sodium daily, and that people at very high risk of stroke and heart attack should ingest no more than 1,500 mg.

How are we doing? Well, on average Americans ingest 3,400 mg of sodium daily, well above the recommendations. A host of policy initiatives has been spawned by the recommendations in an effort to educate consumers, clarify food labels, and coerce restaurants to lower sodium.

But did anyone test the effects on the clinical endpoints?

The institute of Medicine (IOM) was commissioned to review all the studies relating to the health effects of sodium intake. Their report (which is over 150 pages) was released last week. A major conclusion of the IOM paper is that the quality of the current evidence linking salt to health outcomes is very poor. There are virtually no randomized studies and the rest of the studies suffer from important methodological flaws (like imprecisely measuring salt intake or using self-reported food diaries to estimate salt intake). The surprising and worrisome finding was that some of the randomized trials actually found worse outcomes with very low salt intakes. This isn't as preposterous as it may sound. We have no solid understanding on salt’s effect on the body beyond that on blood pressure, so there could be many mechanisms that could explain worse cardiovascular outcomes with a very low salt diet.

The IOM endorsed the current belief that there is very likely a quantity of daily salt intake above which the risk of cardiovascular disease increases. The current evidence is simply insufficient to figure out what that limit is.

I’m always impressed when science comes up with the answer “We have no idea” because that’s very likely to be honest. Those who are more committed to enacting policy than to figuring out the truth are less likely to confess ignorance and to wait for better studies before making up their minds. The American Heart Association issued a press report criticizing the IOM paper and arguing essentially “But salt increases blood pressure!” which no one disputes.

So for now add me to the list of salt agnostics. I frequently ask patients to cut down on salt in the short term to avoid fluid retention, for example when traveling. But we should have the honesty to admit that in terms of long term outcomes we don’t know how much salt is too much.

And if you’re not going to eat that pickle, can I have it?

Learn more:

No Benefit Seen in Sharp Limits on Salt in Diet (New York Times)
Low-Salt Benefits Questioned (Wall Street Journal)
Is Eating Too Little Salt Risky? New Report Raises Questions (NPR)
Sodium Intake in Populations: Assessment of Evidence (Institute of Medicine)
Shaking the Salt Habit (American Heart Association)
New IOM report an incomplete review of sodium’s impact, says American Heart Association (American Heart Association Media Alert)

Merck Knows More about Zetia than They’re Telling Us (my post in 2007 explaining the difference between clinical outcomes and intermediate outcomes)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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May 17, 2013 | 2:55 pm

Understanding Angelina

Posted by Albert Fuchs, M.D.

Angelina Jolie. Credit:
George Biard / Wikipedia

This week actress Angelina Jolie revealed in a New York Times op-ed that she underwent preventive double mastectomy. As would be expected of a personal revelation of such a well-known celebrity, it drew intense media attention. Her disclosure was brave and selfless and may save the lives of women in a similar situation, but is likely to be misunderstood by her myriad fans.

Jolie’s mother died at the age of 56 of cancer. (We are not told what kind of cancer.) This lead Jolie to pursue genetic testing which found that she had a harmful mutation in a gene called BRCA1. This mutation greatly increases her risk of breast and ovarian cancer. It was this finding that led her ultimately to choose preventive double mastectomy in an attempt to minimize her future breast cancer risk. Her description of her decision and ordeal is poignant. If you haven’t, please read it.

In this story of empowerment and survival, where is the potential for misunderstanding? Women are likely to misunderstand two issues – who should seek genetic testing for cancer causing mutations, and who should be considering preventive double mastectomies.

Let’s unpack the decision to get genetic testing first. Mutations in two genes called BRCA1 and BRCA2 are linked with very high risks of breast and ovarian cancer. But these mutations are quite rare in the general population, and these mutations are estimated to be responsible for only 5 to 10% of breast cancers and 10 to 15% of ovarian cancers. So genetic testing is not recommended for everyone. The National Cancer Institute lists the following groups of women as having a higher likelihood of a harmful BRCA1 or BRCA2 mutation.

• For women who are not of Ashkenazi Jewish descent:
  • two first-degree relatives (mother, daughter, or sister) diagnosed with breast cancer, one of whom was diagnosed at age 50 or younger;
  • three or more first-degree or second-degree (grandmother or aunt) relatives diagnosed with breast cancer regardless of their age at diagnosis;
  • a combination of first- and second-degree relatives diagnosed with breast cancer and ovarian cancer (one cancer type per person);
  • a first-degree relative with cancer diagnosed in both breasts (bilateral breast cancer);
  • a combination of two or more first- or second-degree relatives diagnosed with ovarian cancer regardless of age at diagnosis;
  • a first- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis; and
  • breast cancer diagnosed in a male relative.
• For women of Ashkenazi Jewish descent:
  • any first-degree relative diagnosed with breast or ovarian cancer; and
  • two second-degree relatives on the same side of the family diagnosed with breast or ovarian cancer.

Women without these family history patterns are very unlikely of having a harmful BRCA1 or BRCA2 mutation. If you believe you might be in one of these groups the best way to get tested is to first consult a geneticist. A geneticist will evaluate your family and personal history and help you select the relevant genetic tests to order.

The other issue that women may misinterpret is Jolie’s decision to have a double mastectomy. This decision is entirely reasonable in a woman with a harmful BRCA1 or BRCA2 mutation, because of her very high lifetime risk of breast cancer. Unfortunately in recent years women have increasingly asked surgeons for mastectomies in situations in which mastectomies are not indicated. In an excellent and sobering article about how the drive to increase breast cancer awareness has unduly frightened hundreds of thousands of women, miscommunicated the benefits of mammograms, and failed to communicate the frequent harms of screening, Peggy Orenstein states that thousands of women consider double mastectomies after being diagnosed with low-grade breast cancer. In most women with localized breast cancer lumpectomies have been proven to be as effective as mastectomy in preventing recurrence, and the risk of breast cancer in the other breast is very low, so the decision to have a double mastectomy is driven purely by fear and a misunderstanding of the risk. It’s also important to know that bilateral mastectomies do not decrease the risk of breast cancer to zero because some breast tissue always remains. So preventive mastectomies are only helpful for women at very high risk of breast cancer, and even for them, preventive surgery isn’t the only option.

So I applaud Ms. Jolie for her courage in telling her story in the hopes that other high-risk women seek genetic counseling. And I hope that her fans understand that her decision and advice do not apply to the vast majority of women who are at average risk of breast cancer.

Learn more:

My Medical Choice (New York Times Op-Ed)
BRCA1 and BRCA2: Cancer Risk and Genetic Testing (National Cancer Institute)
Jolie’s Disclosure of Preventive Mastectomy Highlights Dilemma (New York Times)
Actress's Move Shines Light on Preventive Mastectomy (Wall Street Journal)
Angelina Jolie, Breast Cancer Game-Changer (Wall Street Journal)
Our Feel-Good War on Breast Cancer (New York Times Magazine)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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May 10, 2013 | 9:23 am

Suicide Rate Among Baby Boomers Increases Sharply

Posted by Albert Fuchs, M.D.

The Golden Gate Bridge is the second most common site for suicide in the world. Photo by Wikipedia.

Every primary care doctor has had the experience of listening to a very depressed patient explain that things are hopeless, that chronic medical problems or financial setbacks or family conflicts have pushed the patient past his ability to cope, that he can't imagine how things could ever get better, that he would be better off dead.

Unfortunately, suicide in the United States is increasingly common. An article in the CDC’s Morbidity and Mortality Weekly Report earlier this month reviewed the suicide statistics between 1999 and 2010. The number of suicides increased by almost a third over that decade, from 29,181 in 1999 to 38,364 in 2010. In 2009 the numbers of suicides surpassed the deaths due to motor vehicle crashes for the first time. Though previously suicide was a problem predominantly among teens and senior citizens, the increase over the last decade has been largely in middle-aged adults. This trend is worrisome to public health officials since current attempts at suicide prevention are not targeted to working age adults.

The cause of this increase in suicides isn’t known. In an attached editorial CDC officials speculate about three possible causes. The recent economic downturn certainly may be contributing, as previous difficult economic times have correlated with increases in suicide rates. Another possible cause may relate to the generation of baby boomers themselves. Statisticians call this a cohort effect. Baby boomers had a higher rate of suicide in their teens than prior generations. Perhaps something unique about baby boomers and the times in which they came of age increases their risk of suicide. They certainly were disproportionately involved in the idealism (and radicalism) of the 1960s. It is certainly possible that many of them expected to build a very different world than the one they find themselves in. Finally, prescription pain medications are being prescribed and misused in unprecedented quantities. The authors speculate that the widespread addiction to opiates might be contributing to the increasing frequency of suicide.

Two years ago Freakonomics Radio, the series of podcasts inspired by the bestselling economics book, had a fascinating podcast about suicide. When you have an hour, I highly recommend listening. The podcast mentions that after media reports of suicide, especially in which the victim is famous or portrayed in a positive or sympathetic light, the frequency of suicides increases. Apparently even songs about suicide have been known to trigger “contagions” of suicide. So the media slowly learned to highlight in their stories the grief of loved ones, the disfigurement of the victim’s body, the missed opportunities to get help, in an attempt to make suicide less inviting to those who are contemplating it.

So with that in mind, allow me to offer a few personal observations gleaned from caring for many depressed patients during 15 years of practice.

• Depression is treatable. I've seen many hopelessly suicidal, miserably sad patients get better.
• Hopelessness and pessimism are a symptom of the depression, not a rational assessment of the situation. I've cared for people with catastrophic health problems and terrible family and financial situations, but no depression. They didn't want to kill themselves. Depression alters judgment and makes a better future seem impossible.
• Suicide causes permanent grief to loved ones.
• All you have to do is postpone suicide for now, and get help. That doesn't limit your options later. You can always think about suicide again in the future.

So while every primary care doctor has cared for a patient at the depths of depression, we've all also seen them months later after the medications and the talk therapy have started to work. They may still be suffering, but they’re glad they’re alive and are relieved that they didn't do anything irreversible before. Perhaps now that we know about this trend we can focus more attention on depressed baby boomers and convince them that hope is not lost.

Get help:

National Suicide Prevention Lifeline
(800)273-8255
(800)273-TALK

Learn more:

Suicide Rates Rise Sharply in U.S. (New York Times)
Suicides Soar in Past Decade (Wall Street Journal)
Suicide Rate Climbs For Middle-Aged Americans (NPR Shots)
Economic downturn cited as suicide rate jumps for those between 35 and 64 (Daily News)
Suicide Among Adults Aged 35–64 Years — United States, 1999–2010 (Morbidity and Mortality Weekly Report)
The Suicide Paradox (Freakonomics Radio podcast)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment

April 26, 2013 | 4:53 pm

Avian Flu (N7N9) Makes Leap from Bird to Man

Posted by Albert Fuchs, M.D.

Electron micrograph of H7N9
influenza virus. Credit: CDC

Do you remember the H1N1 swine flu that made tens of millions sick and killed thousands of people in 2009? Well, one if its cousins, a bird flu with the name H7N9, is causing some death and consternation in China.

This strain has long been circulating among birds, but since earlier this year people have become ill with this respiratory virus, all so far in China. This week’s issue of the New England Journal of Medicine (NEJM) published a review of the public health findings thus far.

The review stated that up to now 82 people have been confirmed to have H7N9 in 6 different regions of China. Most of them were extremely ill, but that is largely because of the way in which they were identified – patients with severe respiratory illness were tested for the virus. Of these 82 patients, 17 have died (21%) and 60 remain critically ill. The incubation period ranged from 1 to 10 days, and those who died were ill for a median of 11 days.

Four of the patients were poultry workers and 77% had known exposure to live animals, mostly chickens. This suggests that the majority of the cases are due to transmission from birds to humans. There were no confirmed cases of human to human transmission but in two families human to human transmission could not be ruled out.

The concern is that eventually, through random mutations, H7N9 will get better at human to human transmission. Then, as in the swine flu epidemic of 2009, since the entire human population has never been exposed to H7N9, we will be a very large non-immune target. Like the first spark in a forest that hasn’t burned in many decades, very rapid spread would be likely.

Yesterday the first case in Taiwan was reported, so the virus has spilled out of mainland China.

Is it time to panic? No. Not unless you frequent live poultry markets in China. H7N9 has not been detected in people or birds in the US. American health officials are keeping a close eye on the spread of the virus. They are trying to determine how many people have mild disease from H7N9 to better calculate how lethal it is. (People with mild illness may not be seeking medical attention. If hundreds of people have had undiagnosed mild illness then the virus is much less deadly than if the only people who got the virus are the 80-or-so we know about.) They are also waiting for the first confirmed transmission from person to person. That’s when all the measures that we saw in 2009 will be revisited – a new vaccine, reminders for people to stay home when sick, and despite official reassurances everybody freaking out.

Learn more:

Preliminary Report: Epidemiology of the Avian Influenza A (H7N9) Outbreak in China (NEJM)
Avian Influenza A (H7N9) Virus (Centers for Disease Control and Prevention)
China's H7N9 bird flu death toll likely to rise (Los Angeles Times)
China Reports Three New H7N9 Bird Flu Cases; Jiangxi Has 1st Suspected Illness (Forbes)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment

April 19, 2013 | 6:48 am

The American College of Physicians Releases Prostate Screening Guidelines

Posted by Albert Fuchs, M.D.

Photo credit: Graham Colm /
Wikimedia Commons

My regular readers have been following the controversy about prostate cancer screening for some time. The controversy boils down to the following question. Should healthy men be routinely tested for prostate cancer? The most recent chapter in the controversy was written last year when the US Preventive Services Task Force (USPSTF) recommended against prostate cancer screening for men of any age. If this is news to you, or sounds absolutely preposterous, follow the previous link to read about the rationale of the USPSTF recommendation. The bottom line is that the benefits of screening have been shown to be very small or nonexistent, while the harms are proven and significant.

But where does that leave physicians? If you’re a man between 50 and 70 and you've seen me for an annual exam in the last year, you know that the recommendations have led to very difficult discussions without very clear guidance. Many men are used to annual screening and are distressed at the idea that suddenly we would do nothing to detect a potential cancer. Younger healthier men are especially puzzled about what to do since they would be most likely to die from an undiagnosed prostate cancer, though they would be least likely to develop prostate cancer.

To clarify our current understanding, and provide direction that is somewhat more useful to primary care physicians, last week the American College of Physicians released guidance statements that crystallize their recommendations.

Guidance Statement 1: ACP recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer. ACP recommends that clinicians base the decision to screen for prostate cancer using the prostate-specific antigen test on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences. ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in patients who do not express a clear preference for screening.

Guidance Statement 2: ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in average-risk men under the age of 50 years, men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years.

I find this very helpful, and it will help guide my conversations with men who are 50 to 69. It incorporates our current understanding while acknowledging that patients have unique values, anxieties, and preferences that should inform their care. If you’re a man between 50 and 69 give Guidance Statement 1 a close reading and tell your doctor what you think. If you love a man of that age, send him this post.

Learn more:

Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians (Annals of Internal Medicine)
Doctors group questions prostate cancer screening (Reuters)

Some of my previous posts about prostate cancer:

Many with Prostate Cancer Do Not Benefit From Surgery
Why I Won’t Have a PSA Test When I Turn 50

Tangential Miscellany

The images and stories from Boston are terrifying and heartbreaking. I believe there is a fascinating story to be written about the medical aspects of the minutes, hours, and days after the explosions. I hope we eventually read that story. By all accounts the first responders, the emergency department staffs, and the surgical teams did extraordinary work very quickly. The newspaper stories suggest that many of the wounded have survived life-threatening injuries because of the fast and organized work of many dedicated professionals. I know that all of you join me in wishing physical and emotional recovery to the injured, calm and focus to the medical teams, and deep condolences to the bereaved.

This Sunday is Ciclavia, a citywide event in which 15 miles of streets are closed to traffic and open for strolling, biking, and exploring the city. It’s a perfect opportunity to demonstrate that we will still gather in large groups, have fun, get some exercise, and wear Red Sox hats.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment

April 12, 2013 | 6:39 pm

ACP Potpourri

Posted by Albert Fuchs, M.D.

Image credit: ACP

Greetings from San Francisco, where I am attending the American College of Physicians 2013 Scientific Program, their annual conference covering the latest progress in internal medicine. Though the conference is obviously geared for physicians, I've compiled below a half dozen points from the various lectures that I think might be of interest to patients. Feel free to skim, and if you want to learn more about any point, follow the links.

• Ezekiel Emanuel, MD, PhD, gave the keynote address. Those unfamiliar with his biography and his work on healthcare reform can learn more by following the link. His speech highlighted the many changes anticipated in healthcare in the next few years and was intended to reassure us that physicians will be leaders in the transformation of American medicine. The specifics he discussed, however, were largely centrally planned policy directives over which physicians will have little influence. This makes me suspect that physicians will be passengers, not drivers, in the coming revolution.
• More than one lecture mentioned the very important study a year ago that demonstrated that patients with sinus infections treated with antibiotics don’t improve any faster than on placebo. A very large fraction of all antibiotic prescriptions are for sinus infection, and as my regular readers know antibiotic use increases the risk of bacterial resistance and of Clostridium difficile infection. The latest recommendations for acute sinusitis is to use only nasal decongestants and pain relievers for 10 days after symptom onset. The vast majority of patients improve with only symptomatic treatment, either because they had a viral infection (for which antibiotics are ineffective) or because the nasal decongestants allowed drainage of the sinuses, allowing the patients' immune system to kill the few remaining bacteria. Only patients who have not improved in 10 days should be prescribed antibiotics. This may be a difficult change both for patients and physicians. I know that despite my best efforts I am occasionally pressured by (well-meaning) patients to prescribe unnecessary antibiotics. I hope I can educate patients about this in a way that does not frustrate them.
• The new medications for obesity were discussed by several speakers. Belviq (lorcaserin) and Qsymia (phentermine/topiramate) will be available by prescription soon for treatment of obesity. The difference in attitudes towards these medications of the different speakers was fascinating. The professor who was a general internist was hesitant to recommend them based on the absence of long-term safety data and the terrible safety track-records of prior obesity medications that were withdrawn from the market. The obesity specialist, on the other hand, seemed quite enthusiastic to prescribe these medications given how empty our armamentarium is for this serious problem. (I side with the general internist.)
• An important study last year showed that in patients with blood clots in their legs who are treated with a blood thinner (warfarin, Coumadin) for 6 to 18 months should continue taking aspirin thereafter to prevent a recurrent clot.
• Women with normal bone density or mild osteopenia can wait 10 to 15 years before next rechecking their bone density, with very little risk of missing their transition to osteoporosis. I really should be recommending bone density testing less frequently in these women.
• More than one lecturer on various different topics mentioned Choosing Wisely, the partnership between the American Board of Internal Medicine and various physician specialty organizations dedicated to educating physicians and patients about tests and treatments that have no benefits. Speakers about topics from ranging from preoperative chest X rays to CT scans for acute sinusitis showed us the studies proving that the tests are worthless and mentioned that Choosing Wisely is trying to get physicians to stop ordering such tests. I remain supportive of the program’s goals but pessimistic about its effectiveness. This may be effective if enough patients become well-informed, but hoping that thousands of physicians will behave against their interests by ceasing to order high-price low-benefit services is unrealistic. This may be another reason for patients to choose physicians who have no incentive (or disincentive) to recommend any specific test or treatment.

Finally, I was pleasantly surprised to find that many of the studies that were highlighted by the professors were ones I wrote about over the year. Reviewing the literature has helped me understand the studies, and composing the posts in non-technical language has helped me remember the key points. There is no better way to learn than to teach. Thank you for reading.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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