Archive for January, 2013

Smoking is Deadlier than HIV?

Wednesday, January 30, 2013 // Uncategorized

 This is a summary of an article from Journal Watch.  Smoking shortened lives more than HIV did.

For HIV-Infected Patients, Smoking Is Deadlier Than HIV

The striking numbers: 12.3 life-years lost from smoking, compared with 5.1 lost from HIV infection

Smoking is extremely common among HIV-infected patients. To quantify the contribution of smoking to mortality in HIV patients, researchers analyzed a median of 4 years of follow-up data from 2921 patients (78% men, 77% on antiretroviral therapy at baseline) in a Danish national HIV cohort and from 10,642 matched controls in the Danish general population. Each patient’s smoking status — current (any weekly tobacco use), previous, or never — was assessed at time of enrollment and held constant for purposes of analysis. Duration of smoking was not considered. Outcomes data came from Danish national registries.

In the HIV-infected cohort, analyses adjusted for HIV-related and other clinical variables revealed that all-cause mortality was more than fourfold higher, and non–AIDS-related mortality was more than fivefold higher, among current smokers than among never smokers. Some 12.3 life-years were lost from smoking, compared with 5.1 life-years lost from HIV infection.

The population-attributable risk for death related to smoking was about 62% in the HIV cohort and 34% in the control group. Compared with controls, HIV patients had roughly triple the excess mortality and life-years lost from smoking. The relative risk for death associated with smoking did not differ significantly between the two groups.

Comment: This study offers a striking message: HIV-infected smokers lose more life-years to smoking than to HIV. Whether smoking is merely a “traditional” risk factor or a pro-inflammatory factor that acts synergistically with HIV, it clearly influences life expectancy among HIV patients who are engaged in care. The findings underscore the importance of smoking-cessation efforts in HIV care; those include raising general awareness, promoting counseling and pharmacologic intervention, training providers, and designing interventions tailored to HIV patients. These compelling data may make it easier for clinicians to persuade patients that smoking poses an even greater risk than HIV infection.

— Virginia A. Triant, MD, MPH

Dr. Triant is an Instructor in Medicine at Harvard Medical School and an Infectious Diseases Specialist at Massachusetts General Hospital. She reports no conflicts of interest.

Published in Journal Watch HIV/AIDS Clinical Care January 28, 2013

Citation(s):

Helleberg M et al. Mortality attributable to smoking among HIV-1–infected individuals: A nationwide, population-based cohort study. Clin Infect Dis 2012 Dec 18; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/cis933)

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Annual Exams Unnecessary

Monday, January 21, 2013 // Uncategorized

A friend forwarded this blog post from the New York Times.  It includes information from a recent study that showed that annual physicals don’t improve longevity.  It is hard to make a blanket statement regarding the periodic health exam.  It’s not clear whether all the studies included the same exams.  It certainly adds more fuel to the debate about unnecessary screening exams.  This article covers the pros and the cons. 
 The most important part of an exam is having one’s blood pressure checked. 
January 21, 2013, 12:01 am

A Check on Physicals

“Go Beyond Your Father’s Annual Physical. Live Longer, Feel Better”

This sales pitch for the Princeton Longevity Center’s “comprehensive exam” promises, for $5,300, to take “your health beyond the annual physical.” But it is far from certain whether this all-day checkup, and others less inclusive, make a meaningful difference to health or merely provide reassurance to the worried well.

Among physicians, researchers and insurers, there is an ongoing debate as to whether regular checkups really reduce the chances of becoming seriously ill or dying of an illness that would have been treatable had it been detected sooner.

No one questions the importance of regular exams for well babies, children and pregnant women, and the protective value of specific exams, like a Pap smear for sexually active women and a colonoscopy for people over 50. But arguments against the annual physical for all adults have been fueled by a growing number of studies that failed to find a medical benefit.

Some experts note that when something seemingly abnormal is picked up during a routine exam, the result is psychological distress for the patient, further testing that may do more harm than good, and increased medical expenses.

“Part of the problem of looking for abnormalities in perfectly well people is that rather a lot of us have them,” Dr. Margaret McCartney, a Scottish physician, wrote in The Daily Mail, a British newspaper. “Most of them won’t do us any harm.”

She cited the medical saga of Brian Mulroney, former prime minister of Canada. A CT scan performed as part of a checkup in 2005 revealed two small lumps in Mr. Mulroney’s lungs. Following surgery, he developed an inflamed pancreas, which landed him in intensive care. He spent six weeks in the hospital, then was readmitted a month later for removal of a cyst on his pancreas caused by the inflammation.

The lumps on his lungs, by the way, were benign. But what if, you may ask, Mr. Mulroney’s lumps had been cancer? Might not the discovery during a routine exam have saved his life?

Logic notwithstanding, the question of benefits versus risks from routine exams can be answered only by well-designed scientific research.

Defining the value of a routine checkup – determining who should get one and how often – is especially important now, because next year the Affordable Care Act will add some 30 million people to the roster of the medically insured, many of whom will be eligible for government-mandated preventive care through an annual exam.

Dr. Ateev Mehrotra of the University of Pittsburgh School of Medicine, who directed a study of annual physicals in 2007, reported that an estimated 44.4 million adults in the United States undergo preventive exams each year. He concluded that if every adult were to receive such an exam, the health care system would be saddled with 145 million more visits every year, consuming 41 percent of all the time primary care doctors spend with patients.

There is already a shortage of such doctors and not nearly enough other health professionals – physician assistants and nurse practitioners – to meet future needs. If you think the wait to see your doctor is too long now, you may want to stock up on some epic novels to keep you occupied in the waiting room in the future.

Few would challenge the axiom that an ounce of prevention is worth a pound of cure. Lacking incontrovertible evidence for the annual physical, this logic has long been used to justify it:

¶ If a thorough exam and conversation about your well-being alerts your doctor to a health problem that is best addressed sooner rather than later, isn’t that better than waiting until the problem becomes too troublesome to ignore?

¶ What if you have a potentially fatal ailment, like heart disease or cancer, that may otherwise be undetected until it is well advanced or incurable?

¶ And wouldn’t it help to uncover risk factors like elevated blood sugar or high cholesterol that could prevent an incipient ailment if they are reversed before causing irreparable damage?

Even if there is no direct medical benefit, many doctors say that having their patients visit once a year helps to maintain a meaningful relationship and alert doctors to changes in patients’ lives that could affect health. It is also an opportunity to give patients needed immunizations and to remind them to get their eyes, teeth and skin checked.

But the long-sacrosanct recommendation that everyone should have an annual physical was challenged yet again recently by researchers at the Nordic Cochrane Center in Copenhagen.

The research team, led by Dr. Lasse T. Krogsboll, analyzed the findings of 14 scientifically designed clinical trials of routine checkups that followed participants for up to 22 years. The team found no benefit to the risk of death or serious illness among seemingly healthy people who had general checkups, compared with people who did not. Their findings were published in November in BMJ (formerly The British Medical Journal).

In introducing their analysis, the Danish team noted that routine exams consist of “combinations of screening tests, few of which have been adequately studied in randomized trials.” Among possible harms from health checks, they listed “overdiagnosis, overtreatment, distress or injury from invasive follow-up tests, distress due to false positive test results, false reassurance due to false negative test results, adverse psychosocial effects due to labeling, and difficulties with getting insurance.”

Furthermore, they wrote, “general health checks are likely to be expensive and may result in lost opportunities to improve other areas of health care.”

In summarizing their results, the team said, “We did not find an effect on total or cause-specific mortality from general health checks in adult populations unselected for risk factors or disease. For the causes of death most likely to be influenced by health checks, cardiovascular mortality and cancer mortality, there were no reductions either.”

What, then, should people do to monitor their health?

Whenever you see your doctor, for any reason, make sure your blood pressure is checked and get new blood tests, if a year or more has elapsed since your last ones.

Keep immunizations up to date, and get the screening tests specifically recommended based on your age, gender and known risk factors, including your family and personal medical history.

And if you develop a symptom, like unexplained pain, shortness of breath, digestive problems, a lump, a skin lesion that doesn’t heal, or unusual fatigue or depression, consult your doctor without delay. Seek further help if the initial diagnosis and treatment fails to bring relief.

 
 
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The Myth of Tamiflu

Tuesday, January 15, 2013 // Uncategorized

Here is an article from Forbes on Tamiflu.  It restates some of the information that I had blogged about previously.  Bottom Line:  There is still a lot we don’t know about this drug.  It may shorten the duration of the flu by a day.
1/08/2013 @ 6:48AM |42,508 views

The Myth of Tamiflu: 5 Things You Should Know

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TamifluTamiflu (Photo credit: ahisgett)

Influenza-like-illness is sweeping the country with the Centers for Disease Control & Prevention reporting that most areas of the country experiencing high rates. I should know, my family is in the midst of it despite having been vaccinated. This year may rival some of the worst years in recent history.

These illnesses are more than uncomfortable – they can cause life-threatening complications. Worries about complications lead many people to want to be prepared with a treatment. I have a friend who once stockpiled Tamiflu, an antiviral agent sold by Roche, wanting to be prepared to protect his friends and family. He was not alone. The US actually reportedly stockpiled $1.5 billion of the drug prior to the global outbreak of H1N1 influenza and while the vaccine was being prepared.

The problem is that we actually know little about the effectiveness and safety of Tamiflu – and Roche is not willing to share all the relevant data they have. Last year the Cochrane group, the world’s most respected organization devoted to synthesizing evidence and providing assessments on medical interventions, updated their review of the Tamiflu studies. If you are enamored by the idea of Tamiflu, then here are 5 things you should know from their report.

1. The manufacturer of the drug sponsored all the trials and the reviewers found evidence of publication and reporting biases. With so much at stake I was surprised that there had been no prospective, placebo-controlled trials conducted that were funded by an independent source. Industry trials can be well conducted, but there are many situations where a lack of independence has had an influence on the way the study was designed and the results that are released. At the very least, it is worth noting that they were probably designed to have the best chance of showing benefit. And that the reviewers had concerned about whether all the information was released. In addition the experts found evidence of reporting bias. According to Tom Jefferson, one of the authors of the Cochrane study: 60% of randomized data from the Tamiflu treatment trials (i.e. in people with influenza-like-illness symptoms) have never been published including the biggest trial ever conducted (which was done in the US, so it’s of great relevance to you).”

2. The studies did not show that Tamiflu reduced the risk of hospitalization. One of the reasons people might take an antiviral is to prevent the illness progressing to the point where they would need to be hospitalized. Unfortunately there was no evidence that the drug produced that benefit.

3. The studies were inadequate to determine the effect of Tamiflu on complications. Even though the drug did not reduce hospitalizations, some people may think it would prevent less severe complications. Unfortunately, the reviewers found that limitations in the design of the trials, their conduct, and the way they were reported precluded any conclusions about the effect of the drug on complications. To expect that Tamiflu can reduce complications would be a leap of faith currently unsupported by the available evidence. You should also know that the FDA requires Roche to print on the label: “Tamiflu has not been shown to prevent such complications [serious bacterial infections].”

4. The studies were inadequate to determine if Tamiflu reduced transmission of the virus. Same story. Some people might prescribe the drug to prevent the spread of the virus. The expert reviewers simply said that with what information they had available; they could not assess the effect of the drug on transmission. I asked Peter Doshi, one of the authors of the Cochrane report about this issue of transmission and here is what he wrote me: “Roche’s prophylaxis trials were not designed to answer the question of transmission. The prophylaxis trials – and FDA approval of Tamiflu for prophylaxis – is based on its proven ability to reduce the chances of symptomatic influenza. (But since we don’t know anything about asymptomatic influenza infections, we cannot say anything about whether or not Tamiflu reduces actual transmission of virus.)”

5. The use of Tamiflu did reduce the duration of symptoms by about a day. The reviewers found 5 studies that assessed the effect of Tamiflu on the duration of symptoms. They were fairly consistent in their findings – though the duration of the symptoms varied quite a lot across the studies.

After conducting this review the reviewers felt that they needed access to more information to make firm conclusions about the drug. They asked Roche for full clinical study reports, with study protocols, the reporting analysis plan, the statistical analysis plan and individual patient data so that all they could more fully determine what could be concluded from the studies. Unfortunately, Roche has not complied .

People face decisions every day about this drug – and more than ever this season – so it would seem reasonable that the company would share all that they know about the drug.

Unfortunately the company has not complied. There remains substantial uncertainty about whether this drug is worth taking. Meanwhile, it is worth asking – why are they unwilling to share the information they have? And should doctors keep prescribing medicines when some potentially vital information is being kept out of view?

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Weather and Disease

Monday, January 14, 2013 // Uncategorized

A lot has been written about the effect of weather conditions on the outbreak of West Nile virus this past summer. You can search my blog for previous postings on this.  This is the first article (or letter) that I have read which suggests that Hurricane Sandy was involved with the early flu outbreak this year.

Date: Sun, 13 Jan 2013 18:10:04 -0500 (EST)
From: ProMED-mail <[email protected]>
Subject: PRO> Influenza (06): 2013 season early start hypothesis

INFLUENZA (06): 2013 EARLY START HYPOTHESIS
*******************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Sat 12 Jan 2013
From: Michael Olesen <[email protected]> [edited]

I have been thinking about the influenza season this year [season
2012-2013], particularly what would account for the number of cases
and its early start. I have an idea that I would like to propose and
hear some feedback about.

My hunch is that we can tie some of the impact of influenza this year
[2012-2013] to Hurricane Sandy. I started thinking about this during a
meeting with my MN1-DMAT [Minnesota-1, Disaster Medical Assistance
Team]. It was triggered by a comment about an outbreak of norovirus at
the medical shelter that my team was staffing.

I started thinking that maybe the use of shelters during the hurricane
brought a lot of people in much closer proximity to each other at a
time when influenza was just starting to ramp up for the year but not
at a time when it was symptomatic. There was clear evidence of
transmission of Spanish flu during the 1918 pandemic over the summer
and that it had mutated substantially during those months. I am not
arguing that there was any mutation due to Hurricane Sandy but
strictly that there was probably a lot of transmission in those close
quarters.

The next piece of the puzzle has to do with response teams, such as
mine, who provided support to those who were affected. The virus was
being amplified in the shelter populations, and response teams were
coming in from all over the country to help those in need. They, too,
would have been exposed to the virus in the shelter settings and could
have played the role of a vector in bringing the virus to airports,
where they could have spread it still further, and also back to their
communities of origin. Assuming that is the case, then the virus could
have taken a foothold in schools, which would have increased its
prevalence in other municipalities. Since this happened before the 2
main travel holidays (Thanksgiving and Christmas), this would account
for its presence in such large numbers and so early this year
[2012-2013].

If this is the course of the influenza epidemic this year [2012-2013],
there is a pretty strong argument to be made for both early
vaccinations but also for mandating vaccination for kids in school and
for health care workers. In both cases under the scenario I’ve
described, it would have had a major impact on the prevalence of
influenza we are seeing in the United States today.

– —
Michael Olesen
Safety Officer, MN-1 DMAT
Instructional Faculty,
St. Catherine University,
St. Paul, MN
USA

[Michael Olesen’s hypothesis is supported in addition by the
situations in the Northern European Region and North America as
recorded in recent ProMED-mail influenza updates. – Mod.CP]

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Overweight People Live Longer?

Thursday, January 3, 2013 // Uncategorized

Here’s a Physicians First Watch summary of a recent controversial JAMA article followed by the abstract from JAMA and a commentary on it from the Atlantic.  As the Gershwin song from Porgy and Bess says, “It ain’t necessarily so.”

Overweight Seems Associated with Lower All-Cause Mortality, Meta-Analysis Finds

 

Being overweight is associated with lower all-cause mortality than being normal weight, according to a JAMA meta-analysis, but editorialists are cautious in their interpretation.

 Researchers examined BMI and its relation to mortality in nearly 100 studies, altogether including 2.9 million people. People with higher levels of obesity (that is, with BMIs of 35 and above) had higher hazard ratios for all-cause mortality than those of normal weight (BMIs between 18.5 and 25).

However, BMIs between 25 and 30 were associated with a significantly lower risk (hazard ratio, 0.94) than normal weight, and BMIs of 30 to 35 did not show higher risks.

Editorialists say the reduced risk seen in overweight people could be an artifact, since the lower end of the normal BMI range has been found to confer a higher risk of mortality than the upper end of normal. They conclude: “Establishing BMI is only the first step toward a more comprehensive risk evaluation.”

Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories:  A Systematic Review and Meta-analysis FREE

Katherine M. Flegal, PhD; Brian K. Kit, MD; Heather Orpana, PhD; Barry I. Graubard, PhD
[+-] Author Affiliations

Author Affiliations: National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland (Drs Flegal and Kit); School of Psychology, University of Ottawa, Ottawa, Ontario, Canada (Dr Orpana); and Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland (Dr Graubard).

 

JAMA. 2013;309(1):71-82. doi:10.1001/jama.2012.113905.
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Published online
 
 
Article
Figures
Tables
References
 
 
CME
 
 

Importance  Estimates of the relative mortality risks associated with normal weight, overweight, and obesity may help to inform decision making in the clinical setting.

Objective  To perform a systematic review of reported hazard ratios (HRs) of all-cause mortality for overweight and obesity relative to normal weight in the general population.

Data Sources  PubMed and EMBASE electronic databases were searched through September 30, 2012, without language restrictions.

Study Selection  Articles that reported HRs for all-cause mortality using standard body mass index (BMI) categories from prospective studies of general populations of adults were selected by consensus among multiple reviewers. Studies were excluded that used nonstandard categories or that were limited to adolescents or to those with specific medical conditions or to those undergoing specific procedures. PubMed searches yielded 7034 articles, of which 141 (2.0%) were eligible. An EMBASE search yielded 2 additional articles. After eliminating overlap, 97 studies were retained for analysis, providing a combined sample size of more than 2.88 million individuals and more than 270 000 deaths.

Data Extraction  Data were extracted by 1 reviewer and then reviewed by 3 independent reviewers. We selected the most complex model available for the full sample and used a variety of sensitivity analyses to address issues of possible overadjustment (adjusted for factors in causal pathway) or underadjustment (not adjusted for at least age, sex, and smoking).

Results  Random-effects summary all-cause mortality HRs for overweight (BMI of 25-<30), obesity (BMI of ≥30), grade 1 obesity (BMI of 30-<35), and grades 2 and 3 obesity (BMI of ≥35) were calculated relative to normal weight (BMI of 18.5-<25). The summary HRs were 0.94 (95% CI, 0.91-0.96) for overweight, 1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity. These findings persisted when limited to studies with measured weight and height that were considered to be adequately adjusted. The HRs tended to be higher when weight and height were self-reported rather than measured.

Conclusions and Relevance  Relative to normal weight, both obesity (all grades) and grades 2 and 3 obesity were associated with significantly higher all-cause mortality. Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality. The use of predefined standard BMI groupings can facilitate between-study comparison.

 

 

The Problem With The ‘Overweight People Live Longer’ Study

Lindsay AbramsThe Atlantic | Jan. 3, 2013, 9:43 AM | 1,832 | 3
 
 
Fat

Shutterstock

Yes, to some degree, having a higher BMI has been associated with a lower risk of death. But interpreting these new findings to mean anything more than that, and precisely that, is dangerous.

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The counterintuitive findings that people who are overweight live longer, published today in the Journal of the American Medical Association, couldn’t have been more perfectly timed, coming as it has right when people are resolving to be healthier — which involves, for many, losing weight.

 

In many places where this story has been picked up, including The New York TimesThe Wall Street Journal, and Time, the implication seems to be that the push to get people down to a “healthy” weight has been overblown.

But that being overweight is associated with increased lifespan isn’t new. It’s called the “obesity paradox,” and studies documenting it have lead to widespread speculation about the potential “protective benefits” of excess body fat.

For some health advocates, the implication is downright offensive. Walter Willett of the Harvard School of Public Health, for example, lost his cool this morning on NPR, declaring, “This study is really a pile of rubbish and no one should waste their time reading it.”

But the study’s author, Katherine Flegal of the Centers for Disease Control and Prevention, mounted a solid defense: “It’s statistically significant.” Those three words carry weight — if an association has been found to be significant, it tells us that if nothing else, we need to acknowledge that the results are in some way legitimate and warrant our attention.

The findings are without doubt interesting, which on its own makes the study worth reading. The problem is that despite the grandness of the meta-analysis — it takes into account over 3 million people! — it still has an extremely limited scope. It looks at BMI, and only BMI, in relation to death, regardless of cause. It’s impossible to report on its baseline conclusion without taking into account substantial caveats. 

This can be said of any study where one thing is found to be associated with another, but in this case the findings are particularly amenable to being mistakenly interpreted as instructions, along the line of: “You should gain weight to live longer.” In this case, its real value is that it highlights the problems we always run into when attempting to talk about weight and healthy living.

Aside from the obvious limitations — people who pass away after a lengthy period of disease, for example, will likely be thinner than they might have been had they died unexpectedly — the study fails to take into account any of the various other measures used to assess health. It ignores blood pressure, blood sugar, and cholesterol — high levels of all are directly associated with a variety of chronic conditions and diseases — not to mention mental health and life satisfaction scores. As another large-scale study recently pointed out, longevity isn’t everything. The population as a whole is living longer than it was twenty years ago, but the number of those years spent in poor health are increasing as well. 

That BMI is an imperfect measure of body size is emphasized here as well. The simple calculation of height and weight ignores gender, age, and muscle mass — I remember being hopelessly confused the first time a guy told me his goal was to gain weight. Where on the body fat is located is important as well (belly fat, for example, poses a greater health risk than excess weight that’s more evenly distributed). A BMI in the “overweight” range, from 25 to just below 30, encompasses a broad sweep of body diversity: A frequently cited argument is that Michael Jordan, at his prime, would have been classified as overweight. By almost any other measure but BMI, we would almost certainly put him in the range of ideal health. 

Just as BMI glosses over such variance, so, too, have news outlets reporting on the study.

While in the most basic of ways, it makes sense to pay attention to the number on the scale, it only gives us one metric of health that, if not understood in context, is basically useless. If we could get used to looking at weight more holistically, in terms of overall health, the link between BMI and longevity wouldn’t be so shocking.

From TheAtlantic – shaping the national debate on the most critical issues of our times, from politics, business, and the economy, to technology, arts, and culture.

SOME OF THE CONTROVERSY INVOLVES THE FACT THAT THIS IS A META-ANALYSIS OR CRUNCHING OF DATA FROM MULTIPLE STUDIES.  THESE TYPES OF STUDIES ARE ONLY AS GOOD AS THEIR INDIVIDUAL COMPONENTS.  SOME OF THE STUDIES ALLOWED SELF REPORTING OF HEIGHT AND WEIGHT.  BOTTOM LINE: BMI DOESN’T TELL THE WHOLE STORY.

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