Archive for February, 2012

Update on Statins

Wednesday, February 29, 2012 // Uncategorized

Statins are the most effective class of cholesterol lowering medications.  This class includes popular drugs such as Lipitor (atorvastatin), Zocor (simvistatin) and Crestor (rosuvastatin).  There have been reports of “statin” brain over the years.  The FDA mentions that in their latest safety alerts.  Part of the problem is that sometimes when you get to an age where an elevated cholesterol is of concern you might not be able to remember names quite as well.  If you think that you have some cognitive problems  and you are taking a statin for primary prevention ( you have never had a heart attack) then the risk to stopping it for several months is low.  Reports of an increased risk of diabetes with statins has been going on for several years.  Most experts think that the benefit outweighs the risk, but if the risk of a heart attack is low, why take the risk of diabetes?  The risk of liver damage is something that people have heard about, but is unusual. the FDA lowered the dosing guidelines of Simvistain recently due to concerns about drug interactions and increased risk of muscle inflammation.  Musle inflammation is uncommon, but muscle pain is.

Here is the Journal Watch summary followed by the FDA news relief.

The FDA is making several changes to the labels of statins following a comprehensive review, the agency announced on Tuesday:
Incident diabetes and increased blood glucose are possible with statin use. Several meta-analyses found an increased risk for diabetes (9%–13%) in patients taking statins.
Reversible memory loss and confusion are possible, though rare. The FDA said there is no evidence that these side effects lead to significant cognitive decline later.
Routine monitoring of the liver enzyme alanine aminotransferase is no longer required, although testing before statin initiation and as clinically indicated is still recommended. The agency has concluded that serious liver injury among patients taking statins is rare and cannot be prevented with routine monitoring.
Use of lovastatin is now contraindicated with strong CYP3A4 inhibitors — including itraconazole and erythromycin — to reduce the risk for rhabdomyolysis. Lovastatin’s new label also lists dose limitations and several other drugs to avoid.

Statin Drugs – Drug Safety Communication: Class Labeling Change

AUDIENCE: Cardiology, Family Practice, Patients


ISSUE: FDA has approved important safety label changes for the class of cholesterol-lowering drugs known as statins. The changes include removal of routine monitoring of liver enzymes from drug labels. Information about the potential for generally non-serious and reversible cognitive side effects and reports of increased blood sugar and glycosylated hemoglobin (HbA1c) levels has been added to the statin labels.

The lovastatin label has been extensively updated with new contraindications and dose limitations when it is taken with certain medicines that can increase the risk for muscle injury.

Read the FDA Drug Safety Communication for more information.


BACKGROUND: Statins are a class of prescription drugs used together with diet and exercise to reduce blood levels of low-density lipoprotein (LDL) cholesterol (“bad cholesterol”). Marketed as single-ingredient products, including Lipitor (atorvastatin), Lescol (fluvastatin), Mevacor (lovastatin), Altoprev (lovastatin extended-release), Livalo (pitavastatin), Pravachol (pravastatin), Crestor (rosuvastatin), and Zocor (simvastatin). Also marketed as combination products, including Advicor (lovastatin/niacin extended-release), Simcor (simvastatin/niacin extended-release),and Vytorin (simvastatin/ezetimibe).


RECOMMENDATION: Healthcare professionals should perform liver enzyme tests before initiating statin therapy in patients and as clinically indicated thereafter. If serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs during treatment, therapy should be interrupted. If an alternate etiology is not found, the statin should not be restarted.

Healthcare professionals should follow the recommendations in the lovastatin label regarding drugs that may increase the risk of myopathy/rhabdomyolysis when used with lovastatin.

Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program:

  • Complete and submit the report Online:
  • Download form or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178

[02/28/2012 – Drug Safety Communication2 – FDA]
[02/28/2012 – Consumer Update3 – FDA]

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A Doctor’s Kid

Thursday, February 2, 2012 // Uncategorized

I was a doctor’s kid, so I read with interest this essay in this week’s JAMA (Journal of the American Medical Association) by Mike Brake.  It resonated with me.  The absences from school events.  Making rounds with him on Sundays.  Today’s generation of physicians want to have time to spend with their families.  They aren’t willing to let the importance of their profession outweigh the importance of their personal lives.  It is understandable, but there is a price that we all pay for that.

A Piece of My Mind
JAMA. 2012;307(5):465-466. doi: 10.1001/jama.2012.38

A Doctor’s Kid

  1. Mike Brake, BS

[+] Author Affiliations

  1. Author Affiliation: Oklahoma City, Oklahoma ([email protected]).

More author information

Standing beside my father’s bed in a cramped, makeshift intensive care unit, listening to his Cheyne-Stokes respirations, I realized that he had certainly rounded on hundreds of patients in this very room. The old hospital, like the not-so-old man in the bed, was nearing the end of its useful life. The room still bore an antique wooden louvered half-door, and you almost expected to see a grainy black-and-white Lew Ayres as Young Dr. Kildare hurrying through the narrow halls. My father had trained here, at mid-century, and he had driven back here to die, just months before its staff and patients were to move a mile east to a shiny new 1970s facility.

As his breathing slowed, I thought what it had meant to be a doctor’s kid.

It had been a mixed blessing.

The children of physicians, especially in the 1950s, could be forgiven for feeling a bit smug. Doctors were then held in maximum regard, and that reverence spilled over to their offspring. In elementary school I was one of two kids who could proudly say, “My Dad is a doctor,” which brought awed looks from classmates and teachers alike. I never heard, “You must be rich.” Internists in those days made a decent living, but their incomes were hardly princely. After my father died I sorted through some old patient billing cards in his basement. Office calls then were $5, and a house call, often conducted at 2 AM in a sleet storm, was $12. Of the hundreds of yellowed index cards in those boxes, perhaps a third were marked “Uncollected,” since his mid-50s practice was in a less affluent part of town.

The reflected aura we basked in as doctor’s kids was not one of envy, but of respect. Few Americans questioned the primacy of the medical profession in those days. Fewer still proposed any fundamental change in the traditional fee-for-service, family doctor at the bedside model. My grandfather had been a physician too, and my father retained his battered and creased old leather bag, with its chrome speculum and reusable glass syringes and suture kits. My grandfather had gone directly from high school to medical school in the years just before the First World War. My father completed college in 1941, spent four years in the Pacific in the Army Air Corps, and returned to enroll in med school in 1947, the year of my birth. Yet their practices, and the drugs and technologies they employed, were similar. So were the aphorisms passed along to medical offspring of that era.

“Ninety percent of what goes wrong with people, they’ll get better on their own,” my father once told me. “Two or three percent will kill them no matter what we do. We can really only cure the other seven or eight percent.” A good summary then, a good summary in 1917, and not a bad estimate even today.

He came home following duty in the occupation of Japan and landed on the clogged waiting list for medical school. That fall his name came up one short . . . until a newly admitted student was badly injured in a freak automobile crash. Thus he found himself a member of the entering class of 1951.

The shared secret of medical families then, as now, was how grueling the training could be. Before she died my mother assembled a scrapbook for each of her children. In mine are two snapshots, stamp dated 1951, of my father in his medical school graduation cap and gown, holding a 4-year-old me. The next several pages include snaps of birthdays and Christmases and zoo outings, but he isn’t in them. He was at the hospital—that same hospital where he would die two decades later—pulling the endless duty and on-call shifts that then, and for decades to come, would characterize internship and residency training. I have no doubt that it made good doctors of most.

We heard some of the stories at rare dinner-table conversations. The patient with uterine cancer who would soon die. The obese woman who came to the ER complaining of abdominal pain, only to deposit a full-term infant in the toilet. (“I pulled him out and scraped off the toilet paper and he was fine,” my father chuckled as my brother and I stared wide-eyed at this godlike figure who could retrieve a life from the plumbing.) His growing interest in cardiology in the years before that field became such a prominent subspecialty.

After he entered private practice, he occasionally took his two oldest children along on weekend hospital rounds. We’d sit stoically in the ER waiting area, closely monitored by a stern white-dressed nurse in her rigid batwinged cap, while he went upstairs to do . . . well, mysterious and wondrous things, we were certain. My interest in things medical grew as a natural result of such proximity. I asked questions, and often received answers. “This is your liver,” he would tell me, showing me where to press. “This is your sternum. The bones up here are called the clavicle.” When I badly sprained my ankle playing baseball I learned how to wrap my own Ace bandage. When I had a minor surgery in second grade I chatted with the anesthesiologist, asking what he would use. (“Not ether,” he assured me.)

Doctor’s kids were always a bit different. When the Salk and Sabin polio vaccines debuted, my classmates lined up outside the school clinic, nervous and frightened by the cattle call atmosphere. We got our first polio shots in the dining room while Mom set the dinner table.

“Here,” my father said. “Roll up your sleeve.” Swipe, dart, plunge, extract. “You’re good to go.”

We later joked, as most medical offspring do, that our legs could have become detached from our bodies and Dad would have tossed us some Band-Aids with a curt “You’ll be OK.” My sex talk, at 14 or so, consisted of being handed a worn textbook titled Principles of Obstetrics and Gynecology with the admonition to “Look through that and let me know if you have any questions.” It took the loss of virginity some years later to inform me that there were healthy pudenda in this world.

I am sure that the children of engineers take well to math. The offspring of geologists probably find volcanoes especially fascinating. Kids born to mechanics likely learn to work on cars from an early age. But the doctor’s kid often takes a unique interest and pride in his or her parent’s profession. My adolescent reading included Intern by the anonymous “Doctor X,” one of the first personal accounts of postgraduate medical training. I devoured the books of Dr Tom Dooley, the medical missionary who became a minor celebrity for his work in Vietnam and Laos. On my rare encounters with medical practitioners, I asked questions beyond my years (“What’s the prognosis for acne?”), often eliciting chuckles when I mentioned that my father was a doctor.

“Ah, yes,” the ENT or dermatology specialist would say knowingly.

My father left private practice for institutional medicine. He retained his military reserve status through the years, serving as flight surgeon for an Air National Guard unit. And then he died, too young, not a great doctor, with no accolades or professional honors, without even a roster of loyal and grateful patients to mourn him. But he had been an MD. I would not.

Despite a strong intellectual interest in things medical, I chose journalism and literary pursuits. None of my siblings would enter medicine either. It may be that we were simply unsuited for it, or that we had seen the toll it can take on a family. But we remained indelibly and positively marked by our exposure to the noblest of professions, as I believe all doctor’s kids are.

As a young newspaper reporter I specialized in crime, which involved daily encounters with trauma and the medical system. ER staffs soon learned that they did not have to offer a tedious explanation of a pneumothorax or why a chest tube was necessary when I was covering the story. “My dad was a doctor,” I would explain.

“Ah, yes,” they would say.

Attending autopsies with homicide detectives, I would point to the transverse colon and note a bullet hole. The medical examiner didn’t need to explain the connection between a hyoid fracture and ocular petechiae in a suspected strangulation death.

“Doc’s kid?” he asked me early on. “Ah, yes.”

Much later, as a Crohn’s patient undergoing periodic colonoscopies, I would decline sedation to watch the monitor. A nurse once marveled at that. “Why not take the drugs?” she wondered.

My gastroenterologist, snatching biopsies from the cecum, laughed. “Doc’s kid,” he said through his mask.

Ah, yes. It stays with you. It marks and shapes and molds you in a way that no other parental profession can.

More than 35 years after my father’s death, I was watching televised coverage of the medical briefing by the neurosurgery team that salvaged wounded Arizona Congresswoman Gabrielle Giffords. Two things about that broadcast were striking. One was the calm, professional demeanor of the lead neurosurgeon. He answered every question, even the frequently foolish ones, with clarity and assurance. Only a fine physician, tempered by decades of meticulous training and experience, could handle both the intricate surgery he had just performed and the baying media corps he was now taming. He was, I thought, the best man in that room.

My second thought was that no one in the pack of reporters had the sense to ask the obvious question beyond survival: This is a woman who talks for a living . . . was Broca’s area affected?

Of course, none of them was a doctor’s kid.

I have no idea if today’s children of physicians feel the same, but I hope they do. Doctor’s kids should feel a bit special. Not smug or superior or better than, but proud. I was, and I still am, proud to be a doctor’s kid.

Author Information

  1. Author Affiliation: Oklahoma City, Oklahoma ([email protected]).

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor.

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The Straight Skinny on Fat Doctors

Wednesday, February 1, 2012 // Uncategorized

Your physician’s size may influence his/her advice on whether or not you should lose weight according to a new study from John’s Hopkins.

January 26, 2012

Physician’s Weight May Influence Obesity Diagnosis and Care

A patient’s body mass index (BMI) may not be the only factor at play when a physician diagnoses a patient as obese. According to a new study led by researchers at the Johns Hopkins Bloomberg School of Public Health, the diagnosis could also depend on the weight of your physician. Researchers examined the impact of physician BMI on obesity care and found that physicians with a normal BMI, as compared to overweight and obese physicians, were more likely to engage their obese patients in weight loss discussions (30 percent vs. 18 percent) and more likely to diagnose a patient as obese if they perceived the patient’s BMI met or exceed their own (93 percent vs. 7 percent). The results are featured in the January issue of Obesity.

“Our findings indicate that physicians with normal BMI more frequently reported discussing weight loss with patients than overweight or obese physicians. Physicians with normal BMI also have greater confidence in their ability to provide diet and exercise counseling and perceive their weight loss advice as trustworthy when compared to overweight or obese physicians,” said Sara Bleich, PhD, lead author of the study and an assistant professor with the Bloomberg School’s Department of Health Policy and Management. “In addition, obese physicians had greater confidence in prescribing weight loss medications and were more likely to report success in helping patients lose weight.”

Using a national cross-sectional survey of 500 primary care physicians, Bleich and colleagues from the Johns Hopkins School of Medicine assessed the impact of physician BMI on obesity care, physician self-efficacy, perceptions of role modeling and perceptions of patient trust in weight loss advice. Physicians with a self-reported BMI below 25 kg/m2 were considered to be of normal weight and physicians reporting a BMI at or above 25 kg/m2 were considered overweight or obese.

According to the Centers for Disease Control and Prevention (CDC) obesity affects more than one-third of the U.S. adult population and is estimated to cost $147 billion annually in related health care costs. Obesity increases the risk of many adverse health conditions including type 2 diabetes, coronary heart disease, stroke and high blood pressure. Despite guidelines for physicians to counsel and treat obese patients, previous studies have found only one-third of these patients report receiving an obesity diagnosis or weight-related counseling from their physicians.

“While our results suggest that obesity practices and beliefs differ by physician BMI, more research is need to understand the full impact of physician BMI on obesity care,” suggest the study’s authors.

“Physician self-efficacy to care for obese patients, regardless of their BMI, may be improved by targeting physician well-being and enhancing the quality of obesity-related training in medical school, residency or continuing medical education,” adds Bleich.

”Impact of Physician BMI on Obesity Care and Beliefs” was written by Sara N. Bleich, Wendy L. Bennett, Kimberly A. Gudzune and Lisa A. Cooper.

The research was supported by in part by the National Heart, Lung and Blood Institute and the Health Resources and Services Administration.

Media contact for Johns Hopkins Bloomberg School of Public Health: Natalie Wood-Wright at 410-614-6029 or [email protected].

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