Archive for December, 2010

The Christmas Crud

Thursday, December 23, 2010 // Uncategorized

Never fails. This time every year my phone starts to ring off the hook with people who have cold symptoms. It’s not the flu, that usually starts a little later. It’s just a series of old fashioned, cold or rhinoviruses. Sore throat, runny nose, nasal congestion and cough. Maybe a low grade fever.
Curable? No. We just treat the symptoms with pain relievers, decongestants and expectorants. Antibiotics are of no use unless a secondary infection develops. This usually 5-7 days into the cold when a certain worsening takes place. Fever develops or the patient develops facial pain with a nasty postnasal drainage.
People understandably want to be well during the holidays and want to do anything they can to shorten the duration.  There are a variety of alternative treatments which have been advocated over the years. One of these is echinacea or purple coneflower. The evidence that it is effective is scant. This is the latest article which deals with it’s minimal effectiveness.
Echinacea Does Not Significantly Affect Cold Duration or Severity
Echinacea does not significantly reduce cold severity or duration, although there are “trends … in the direction of benefit,” according to an NIH-supported study in the Annals of Internal Medicine.
Some 700 patients aged 12 to 80 with new-onset colds were randomized to receive open-label echinacea, blinded echinacea, placebo, or no pills for 5 days. Overall, self-reported cold duration was slightly improved — by about half a day — with echinacea than with placebo or no pills, but this difference did not achieve statistical significance. In addition, cold severity was slightly, but not significantly, improved with active treatment.
The researchers conclude: “The pharmacologic activity of echinacea probably has only a small beneficial effect in persons with the common cold. … Individual choices about whether to use echinacea … should be guided by personal health values and preferences, as well as by the limited evidence available.”
Annals of Internal Medicine

Save your money.  Don’t expect a quick fix. Wash your hands to avoid spreading it to everyone else and avoid taking unnecessary antibiotics.

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Can Vitamin D Prevent the Flu?

Monday, December 13, 2010 // Uncategorized

The short answer is no.
As I have previously reported, Vitamin D is very trendy. It is being promoted as a pancea for a variety of conditions from colds to heart disease. It may be, but we don’t know. This is a recent article from the Wall Street Journal on the subject. I didn’t realize that there was a Vitamin D Council. That’s a little scary. I don’t know why a vitamin needs a council to promote it’s use unless there is some economic interest.

Can Vitamin D Replace Flu Shots?

By LAURA JOHANNES
Vitamin D, long known for its beneficial effect on bones, is increasingly being studied to see if it helps prevent colds and flus. Based on early research results, some doctors are recommending high doses to help stave off the upper respiratory infections, with some even speculating it could be a substitute to the annual flu shot. But while it’s well established that vitamin D boosts the immune system, many scientists say so far there’s insufficient evidence that taking it will help keep a cold or flu away.

Until recently, scientists have blamed the higher prevalence of flu cases during winter to the tendency of humans to congregate inside or the low humidity of cold weather, which makes viruses survive in the air longer. Increasingly, scientists are exploring another possible explanation: During the wintertime, we are outside less, resulting in lower vitamin D absorption from the sun.

“Unless you are out there in the sun all the time, which hardly anyone is doing in wintertime, it’s impossible to get enough,” says James R. Sabetta, director of infectious diseases at Greenwich Hospital in Greenwich, Conn., who has studied the effect of vitamin D on respiratory infections.

Michael Sloan
Vitamin D is naturally present in few foods, such as salmon and herring, so humans need to get it either from sunlight or dietary supplements. In a recent report, the Institute of Medicine tripled the amount of vitamin D recommended for most Americans to 600 international units a day. The IOM is an arm of the National Academy of Sciences, which sets government nutrient levels.

But, based in part on early evidence that vitamin D helps prevent upper respiratory infections, some scientists recommend daily levels of 2,000 to 4,000 IUs or even higher. The Vitamin D Council, a nonprofit scientist group supported by vitamin makers and other commercial interests, recommends 5,000 IUs daily—but warns that this dose doesn’t replace the conventional recommendation of a flu shot. “I recommend vitamin D and a flu shot to cover all your bases,” says the council’s executive director John Cannell.

It’s true that basic science shows that vitamin D boosts innate immunity, or the body’s first line of defense against pathogens, says Pennsylvania State University scientist A. Catharine Ross, chairman of the IOM committee that made the latest recommendations. But the recommended increase was based on vitamin D’s proven positive role in bone health, she says. The panel reviewed the studies and found “no strong evidence that supports the idea that increased levels of vitamin D are going to be protective” against upper respiratory infections, she adds.

Vitamin D boosts immunity by stimulating production of cathelicidin, an antimicrobial protein that serves as a “natural antibiotic” in the body, says Michael Zasloff, a professor of surgery and pediatrics at Georgetown University Medical Center in Washington, D.C.

But so far studies looking directly at whether higher vitamin D levels help prevent upper respiratory infections have had mixed results. A Japanese study of 167 schoolchildren first published online in March in the American Journal of Clinical Nutrition, found that vitamin D supplements helped reduced incidences of influenza A but not influenza B.

Influenza A and B are the two main types of flu viruses responsible for seasonal flu epidemics every year, according to the Centers for Disease Control and Prevention. Swine and bird flus are specific subtypes of influenza A.

In an observational study published in June, Dr. Sabetta and colleagues followed 195 people during winter and found that people with a blood serum concentration of 38 nanograms per milliliter of vitamin D had half the risk of getting an upper respiratory tract infection as those with levels below that threshold. The people with higher vitamin D levels hadn’t gotten any more flu shots and weren’t taking more of other vitamins than those with lower levels, according to the study. The study, however, didn’t rule out the possibility that the group with higher vitamin D also had better overall nutrition.

“We’re very confident and we think this is going to be verified” by other studies, says Dr. Sabetta, an associate clinical professor at Yale University School of Medicine.

A 167-person study by researchers at Winthrop University Hospital in Mineola, N.Y., puts something of a dent in the vitamin D claims. The study found people taking 2,000 IUs a day of vitamin D got about the same number of upper respiratory infections as a group who got a placebo during the three-month flu season.

If vitamin D has a small positive effect, a large randomized trial will be needed to see it, says author John Aloia, chief academic officer at Winthrop University Hospital. “We found no evidence that vitamin D was protective,” he says. It’s also possible that it’s necessary to start taking vitamin D several months before flu season to build up levels in advance, he adds.

Vitamin D is generally safe, but in high doses scientists say it can pull calcium from bones, causing kidney problems and heart disease. The IOM report says vitamin D may be toxic if you take more than 10,000 IUs a day, and warns the risk of harm may begin to increase at 4,000 IUs daily.

Write to Laura Johannes at [email protected]

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How Doctors Try to Spot Depression

Friday, December 10, 2010 // Uncategorized

This is from Tuesday, December 7th’s Wall Street Journal. 

 This is a program that I am working to implement in the practice in this coming year.

How Doctors Try to Spot Depression

Appearing anxious and overwhelmed on a routine visit with her primary-care provider, Lucy Cressey was prescribed an anti-anxiety medication and referred for talk therapy with a social worker.

The treatment recommendations came after Ms. Cressey agreed to fill out two questionnaires during the medical visit at the John Andrews Family Care Center in Boothbay Harbor, Maine, last year. Ms. Cressey scored high on both questionnaires, designed to help depression and anxiety.

Following the recent death of her best friend, a tough spinal surgery and some family financial woes, “a lot of stressors just snowballed for me,” says Ms. Cressey, a 52-year-old veterinary technician. “But in rural Maine it’s not so cool to talk about being depressed or anxious, and those questionnaires really open some doors for them to help you.”

A growing number of primary-care providers are using screening tools to assess depression and other mental-health conditions during routine-care visits. They are also coordinating care of depressed patients with behavioral-health specialists. Such so-called mental-health-integration programs have been shown to reduce emergency-room visits and psychiatric-hospital admissions, and to increase employees’ productivity at work.

One in four American adults who visit their primary-care doctors for a routine checkup or physical complaint also suffer from a mental-health problem, federal data show. But patients often don’t raise the issue and doctors are too busy to ask. As a result, many never get treatment: Less than 38% of adults in the U.S. with mental illness received care for it last year, according to the federal Substance Abuse and Mental Health Services Administration.

A number of health-care groups work in tandem with behavioral-health providers. And some insurers, including Aetna, are promoting integrated care. About 5,000 physicians participate in Aetna’s Depression in Primary Care program, which reimburses them for administering a Patient Health Questionnaire, or PHQ-9, to patients. Aetna is also training behavioral-health specialists, and stationing them in primary-care offices.

Health groups increasingly recognize that physical and emotional health are intertwined. Many patients with mental-health problems have two or more other issues such as heart disease, obesity or diabetes. As many as 70% of primary-care visits are triggered by underlying mental-health issues, according to behavioral-health researchers.

Intermountain Health in Salt Lake City, Utah, uses the PHQ-9 depression-screening tool in about 70 of its 130 medical practices. “The aim is to see if we stabilize patients and get them well in primary care, or whether we need to transition them to a behavioral-health expert,” says Brenda Reiss-Brennan, director of the Intermountain Mental Health Integration program.

Wayne Cannon, an Intermountain physician helping lead the effort, says that patients who are asked to fill out the PHQ-9 form might be classified as mildly, moderately or severely depressed. Scoring programs on the questionnaires include guidelines to help doctors determine whether patients need just watchful waiting, medication or a course of psychotherapy. Patients can be immediately seen by a behavioral-health specialist in what’s known as a “warm hand-off,” Dr. Cannon says, making them more comfortable and likely to follow through with treatment.

 Amy Young, a 32-year-old patient at Intermountain who has multiple sclerosis and takes antidepressants, says her primary-care doctor last year referred her to a psychologist who works in the same office and knew about some struggles faced by MS patients. “Your primary-care doctor can’t talk to you for an hour at a time like a therapist can,” says Ms. Young. “They can talk to each other if they have questions about anything going on with me and I feel much more relaxed because I’m used to going to the same office.”

Intermountain says its own studies show that adult patients treated in its mental-health integration clinics have a lower rate of growth in charges for all services than those treated in clinics without the service. It also found that depressed patients treated in the clinics are 54% less likely to have emergency-room visits than are depressed patients in usual care clinics.

Patients being treated for depression should have the PHQ-9 test regularly administered, says John Bartlett, senior adviser in the mental-health-care program at the nonprofit Carter Center in Atlanta, which promotes mental-health treatment in primary care. If doctors don’t offer it or don’t repeat it, patients should take the test on their own and alert their doctor to any worrisome score, he says. The test is available free online at depressionscreening.org.
 MaineHealth, a network of providers in the state that includes the John Andrews Center where Ms. Cressey is treated, recruited behavioral-health specialists to work in doctors’ offices in different communities. Cynthia Cartwright, program director, says MaineHealth created an Adult Wellbeing Screener combining questions from the PHQ-9 for depression, and other tests for anxiety, bipolar disorder and substance abuse. “It’s hard sometimes to reduce depression symptoms to the questions on a form, but you have to start somewhere, and I think they help doctors notice, ask about and treat mood disorders,” says Debra Rothenberg, one of the physicians participating in the program.

Because behavioral-health services are typically covered separately under most insurance plans, doctors often have to advise patients to seek out additional mental-health care by calling their insurer for a referral. But many patients don’t follow through to make the appointments, and there are often limits to their mental-health coverage. That is changing as new federal rules take effect prohibiting insurers from setting stricter limits on mental-health benefits than they do for other illnesses. And mental-health-integration programs are expected to get a boost from the new federal health law, which includes funding for programs creating “medical homes” that coordinate physical- and mental-health care for patients.

In the Aetna program, the insurer’s case managers help track patients’ progress and alert physicians if they are not improving. Case managers also assist with referrals to additional mental-health services.

Primary-care physicians increasingly are using screening tools to assess depression during routine-care visits.
Aetna’s studies show that on average, patients completing the case-management program experienced a 4.7% increase in productivity at work, based on a questionnaire measuring the impact on productivity of employee health problems. Hyong Un, Aetna’s chief psychiatric officer, says the insurer uses its own records to identify patients who may be candidates for depression screenings, including those who have stopped filling their antidepressant prescriptions.

Richard Wender, chair of the department of family medicine at Thomas Jefferson University in Philadelphia, says participation in the Aetna program has helped motivate its doctors to administer the screens and follow up with patients. Having a behavioral-health specialist in the same office “has helped us assess behavioral-health issues more frequently and have a plan in place to deal with them,” he says.

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The Death of Private Practice

Saturday, December 4, 2010 // Uncategorized

From NPR. 

Will  private practice disappear?  I don’t think so.  Personalized care is something that some people will continue to lobby for. 

check up
iStockphoto.comYour checkup may be changing.

Of all the scary scenarios predicted for the new health law this is among the scariest: A new survey of doctors predicts the rapid extinction of the private-practice physician.

A survey of some 2,400 MDs from around the country found nearly three quarters said they plan to retire, work part-time, stop taking new patients, become an employee, or seek a non-clinical position in the next one to three years.

But are these changes really the result of the new law?

 Doctors responding to the survey seemed to think so. “Doctors strongly believe the law is not working like it needs to – for them, or for their patients,” said Lou Goodman, president of the Physicians’ Foundation, who conducted the survey.

But most of the provisions of the new law affecting doctors and patients haven’t taken effect yet.

And slightly more doctors said that the lack of a fix to the Medicare physician pay issue is a bigger issue for them than the actual overhaul; by 36 to 34 percent.

The paper that accompanied the survey says all those docs leaving their practices will be replaced by a managed care employee or “concierge” doctor who will require an upfront annual payment.

The bottom line, however, is buried at the bottom of the news release about the study. It comes from the advisory panel commissioned to write the paper on the effect of the new law on doctors:

“Despite its many problems, healthcare reform was necessary and inevitable and many of the changes mandated by the ‘formal’ reforms likely would have occurred on their own within the ‘informal’ delivery of care, owing to economic and demographic forces.”

In other words, things were changing anyway, with or without the passage of the Patient Protection and Affordable Care Act. Blaming the new law just gives doctors a convenient scapegoat.

And whether or not it might actually be better for patients to get their care from larger groups of doctors, rather than those practicing alone or in pairs, is a discussion that will continue to rage among experts.

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New Calcium and Vitamin D Guidelines

Wednesday, December 1, 2010 // Uncategorized

Calcium and Vitamin D are frequently in the news these days.  Almost every possible malady has been reported to be associated with Vitamin D deficiency and calcium supplements have been recently  been associated with an increased risk of heart disease.  We know that the nutrients in food are associated with a decreased risk of many diseases, but the role of supplements of these nutrients remains unproven.  The following is a brief summary of the guidelines.

Dietary Reference Intakes for Calcium and Vitamin D

Calcium and vitamin D are two essential nutrients long known for their role in bone health. Over the last ten years, the public has heard conflicting messages about other benefits of these nutrients—especially vitamin D—and also about how much calcium and vitamin D they need to be healthy.

To help clarify this issue, the U. S. and Canadian governments asked the Institute of Medicine (IOM) to assess the current data on health outcomes associated with calcium and vitamin D. The IOM tasked a committee of experts with reviewing the evidence, as well as updating the nutrient reference values, known as Dietary Reference Intakes (DRIs). These values are used widely by government agencies, for example, in setting standards for school meals or specifying the nutrition label on foods. Over time, they have come to be used by health professionals to counsel individuals about dietary intake.

The committee provided an exhaustive review of studies on potential health outcomes and found that the evidence supported a role for these nutrients in bone health but not in other health conditions. Overall, the committee concludes that the majority of Americans and Canadians are receiving adequate amounts of both calcium and vitamin D. Further, there is emerging evidence that too much of these nutrients may be harmful.

Health Effects of Vitamin D and Calcium Intake

The new reference values are based on much more information and higher-quality studies than were available when the values for these nutrients were first set in 1997. The committee assessed more than one thousand studies and reports and listened to testimony from scientists and stakeholders before making its conclusions. It reviewed a range of health outcomes, including but not limited to cancer, cardiovascular disease and hypertension, diabetes and metabolic syndrome, falls, immune response, neuropsychological functioning, physical performance, preeclampsia, and reproductive outcomes. This thorough review found that information about the health benefits beyond bone health—benefits often reported in the media—were from studies that provided often mixed and inconclusive results and could not be considered reliable. However, a strong body of evidence from rigorous testing substantiates the importance of vitamin D and calcium in promoting bone growth and maintenance.

Dietary Reference Intakes

The DRIs are intended to serve as a guide for good nutrition and provide the basis for the development of nutrient guidelines in both the United States and Canada. The science indicates that on average 500 milligrams of calcium per day meets the requirements of children ages 1 through 3, and on average 800 milligrams daily is appropriate for those ages 4 through 8 (see table for the Recommended Dietary Allowance—a value that meets the needs of most people). Adolescents need higher levels to support bone growth: 1,300 milligrams per day meets the needs of practically all adolescents. Women ages 19 through 50 and men up to 71 require on average 800 milligrams daily. Women over 50 and both men and women 71 and older should take in 1,000 milligrams per day on average to ensure they are meeting their daily needs for strong, healthy bones.

Determining intake levels for vitamin D is somewhat more complicated. Vitamin D levels in the body may come from not only vitamin D in the diet but also from synthesis in the skin through sunlight exposure. The amount of sun exposure one receives varies greatly from person to person, and people are advised against sun exposure to reduce the risk of skin cancer. Therefore, the committee assumed minimal sun exposure when establishing the DRIs for vitamin D, and it determined that North Americans need on average 400 International Units (IUs) of vitamin D per day (see table for the Recommended Dietary Allowances— values sufficient to meet the needs of virtually all persons). People age 71 and older may require as much as 800 IUs per day because of potential changes in people’s bodies as they age.

Questions About Current Intake

National surveys in both the United States and Canada indicate that most people receive enough calcium, with the exception of girls ages 9–18, who often do not take in enough calcium. In contrast, postmenopausal women taking supplements may be getting too much calcium, thereby increasing their risk for kidney stones.

Information from national surveys shows vitamin D presents a complicated picture. While the average total intake of vitamin D is below the median requirement, national surveys show that average blood levels of vitamin D are above the 20 nanograms per milliliter that the IOM committee found to be the level that is needed for good bone health for practically all individuals. These seemingly inconsistent data suggest that sun exposure currently contributes meaningful amounts of vitamin D to North Americans and indicates that a majority of the population is meeting its needs for vitamin D. Nonetheless, some subgroups—particularly those who are older and living in institutions or who have dark skin pigmentation—may be at increased risk for getting too little vitamin D.

Before a few years ago, tests for vitamin D were conducted infrequently. In recent years, these tests have become more widely used, and confusion has grown among the public about how much vitamin D is necessary. Further, the measurements, or cut-points, of sufficiency and deficiency used by laboratories to report results have not been set based on rigorous scientific studies, and no central authority has determined which cut-points to use. A single individual might be deemed deficient or sufficient, depending on the laboratory where the blood is tested. The number of people with vitamin D deficiency in North America may be overestimated because many laboratories appear to be using cut-points that are much higher than the committee suggests is appropriate.

Tolerable Upper Levels of Intake

The upper level intakes set by the committee for both calcium and vitamin D represent the safe boundary at the high end of the scale and should not be misunderstood as amounts people need or should strive to consume. While these values vary somewhat by age, as shown in the table, the committee concludes that once intakes of vitamin D surpass 4,000 IUs per day, the risk for harm begins to increase. Once intakes surpass 2,000 milligrams per day for calcium, the risk for harm also increases.

As North Americans take more supplements and eat more of foods that have been fortified with vitamin D and calcium, it becomes more likely that people consume high amounts of these nutrients. Kidney stones have been associated with taking too much calcium from dietary supplements. Very high levels of vitamin D (above 10,000 IUs per day) are known to cause kidney and tissue damage. Strong evidence about possible risks for daily vitamin D at lower levels of intake is limited, but some preliminary studies offer tentative signals about adverse health effects.

Conclusion

Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, however, does not support other benefits for vitamin D or calcium intake. More targeted research should continue. However, the committee emphasizes that, with a few exceptions, all North Americans are receiving enough calcium and vitamin D. Higher levels have not been shown to confer greater benefits, and in fact, they have been linked to other health problems, challenging the concept that “more is better.”

Some additional information:

Natural sources of vitamin D — Vitamin D is made in the skin under the influence of sunlight. The amount of sunlight needed to synthesize adequate amounts of vitamin D varies, depending upon the person’s age, skin color, sun exposure, and any underlying medical problems. The production of vitamin D from the skin decreases with age. In addition, people who have darker skin need more sun exposure to produce adequate amounts of vitamin D, especially during the winter months.

Another important source of vitamin D is foods, where it may occur naturally (in fatty fish, cod-liver oil, and [to a lesser extent] eggs). In the United States, commercially fortified cow’s milk is the largest source of dietary vitamin D, containing approximately 100 international units of vitamin D per 8 ounces. Vitamin D intake can be estimated by multiplying the number of cups of milk consumed per day by 100 (2 cups milk=200 international units vitamin D). In other parts of the world, cereals and bread products are often fortified with vitamin D.

Although vitamin D is found in cod liver oil, some fish oils also contain high doses of vitamin A. Excessive vitamin A intake can be associated with side effects, including liver damage and fracture.

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