Archive for the ‘Blog’ Category

New Employee

Monday, October 2, 2017 // Blog, News

We are pleased to have hired a new nurse Amber Allen. Amber was born in Oakland, California and raised in the Bay area. She moved to Texas in 1990.

Amber graduated from St. Philips Nursing School in 2010. Prior to joining us, she worked as a nurse at Haven for Hope.

She has a 9-year-old son named Caleb who plays baseball and football. Amber loves the water, floating the river and taking her son to concerts. They are also big football fans especially the Dallas Cowboys.

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Words written in italic are directly from Mark L. Thornton, M.D., F.A.C.P.

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Lifestyle Modification Reduces Heart Disease Risk

Monday, October 2, 2017 // Blog, Blood Pressure, News, Prevention

Nature versus Nurture: Even though people may have inherited genes that confer an increased risk of cardiovascular disease that doesn’t mean that there isn’t something that they can do about it. Not smoking, maintaining a normal weight, exercise and healthy eating will reduce that risk. Below is a summary of a study published in the New England of Journal Medicine in December.

Cardiovascular Disease: Genetics versus Lifestyle NEJM

December 15, 2016, Original Article:

Genetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease

Amit V. Khera, M.D., Connor A. Emdin, D.Phil., Isabel Drake, Ph.D., Pradeep Natarajan, M.D., Alexander G. Bick, M.D., Ph.D., Nancy R. Cook, Ph.D., Daniel I. Chasman, Ph.D., Usman Baber, M.D., Roxana Mehran, M.D., Daniel J. Rader, M.D., Valentin Fuster, M.D., Ph.D., Eric Boerwinkle, Ph.D., Olle Melander, M.D., Ph.D., Marju Orho-Melander, Ph.D., Paul M Ridker, M.D., and Sekar Kathiresan, M.D.

N Engl J Med 2016; 375:2349-2358December 15, 2016DOI: 10.1056/NEJMoa1605086


Both genetic and lifestyle factors contribute to an individual-level risk of coronary artery disease. The extent to which increased genetic risk can be offset by a healthy lifestyle is unknown.


Using a polygenic score of DNA sequence polymorphisms, we quantified genetic risk for coronary artery disease in three prospective cohorts — 7814 participants in the Atherosclerosis Risk in Communities (ARIC) study, 21,222 in the Women’s Genome Health Study (WGHS), and 22,389 in the Malmö Diet and Cancer Study (MDCS) — and in 4260 participants in the cross-sectional BioImage Study for whom genotype and covariate data were available. We also determined adherence to a healthy lifestyle among the participants using a scoring system consisting of four factors: no current smoking, no obesity, regular physical activity, and a healthy diet.


The relative risk of incident coronary events was 91% higher among participants at high genetic risk (top quintile of polygenic scores) than among those at low genetic risk (bottom quintile of polygenic scores) (hazard ratio, 1.91; 95% confidence interval [CI], 1.75 to 2.09). A favorable lifestyle (defined as at least three of the four healthy lifestyle factors) was associated with a substantially lower risk of coronary events than an unfavorable lifestyle (defined as no or only one healthy lifestyle factor), regardless of the genetic risk category. Among participants at high genetic risk, a favorable lifestyle was associated with a 46% lower relative risk of coronary events than an unfavorable lifestyle (hazard ratio, 0.54; 95% CI, 0.47 to 0.63). This finding corresponded to a reduction in the standardized 10-year incidence of coronary events from 10.7% for an unfavorable lifestyle to 5.1% for a favorable lifestyle in ARIC, from 4.6% to 2.0% in WGHS, and from 8.2% to 5.3% in MDCS. In the BioImage Study, a favorable lifestyle was associated with significantly less coronary-artery calcification within each genetic risk category.


Across four studies involving 55,685 participants, genetic and lifestyle factors were independently associated with susceptibility to coronary artery disease. Among participants at high genetic risk, a favorable lifestyle was associated with a nearly 50% lower relative risk of coronary artery disease than was an unfavorable lifestyle. (Funded by the National Institutes of Health and others.

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Words written in italic are directly from Mark L. Thornton, M.D., F.A.C.P.

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Prostate Cancer Screening Revisited

Monday, October 2, 2017 // Blog, News, Prostate

Opinions in medicine change over time. “Every dogma shall have its day,” I tell my medical students. Two years ago the United services Preventive Task Force (USPSTF) recommended against screening for prostate cancer because the risk and expense of screening were felt to outweigh the benefits. Now they have revised that recommendation as follows:

The USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA)–based screening for prostate cancer.

The decision about whether to be screened for prostate cancer should be an individual one. Screening offers a small potential benefit of reducing the chance of dying of prostate cancer. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and impotence. The USPSTF recommends individualized decision making about screening for prostate cancer after discussion with a clinician so that each man has an opportunity to understand the potential benefits and harms of screening and to incorporate his values and preferences into his decision.

We will ask men age 45-69 if they wish to be screened for prostate cancer. For those interested in additional information here is a related article for National Public Radio.

Federal Task Force Softens Opposition To Routine Prostate Cancer Screening

April 11, 2017 – Rob Stein

A common blood test checks for elevated levels of prostate-specific antigens (PSA) in a man’s blood, as an indicator that he may have prostate cancer.

An influential federal task force is relaxing its controversial opposition to routine screening for prostate cancer.

In the proposed revised guidelines released Tuesday, the U.S. Preventive Services Task Force says men ages 55 to 69 should decide individually with their doctors whether and when to undergo prostate-specific antigen (PSA) testing.

The task force would continue to recommend against PSA testing for men age 70 and older, saying the potential harms continue to outweigh benefits of routine screening in this age group.

The proposal, which isn’t yet final, pending input from the public, comes five years after the task force surprised many men and their doctors by recommending against the routine use of the commonly used blood test. That 2012 guidance prompted a significant drop in PSA testing.

Almost 180,000 American men are diagnosed with prostate cancer each year, and at least 26,000 die from the disease, making it one of the most common and deadly cancers among men.

The task force decided to adjust its screening recommendations based on new research.

“The new evidence allowed us to say that, on balance, we think now the benefits do outweigh the harms,” says Dr. Kirsten Bibbins-Domingo, a professor of medicine at the University of California, San Francisco, who chairs the task force. The latest research also suggests a small net benefit from screening, she says.

“Therefore,” Bibbins-Domingo says, “what we are recommending is that doctors and patients talk together about whether screening is right for them.”

While PSA tests can detect prostate tumors at their smallest, most treatable stage, the testing has some risks, she says.

The harms include stressful false alarms that often lead to painful and sometimes dangerous biopsies. And even if the test detects an actual malignancy, many prostate cancers grow so slowly that they never become life-threatening. Nonetheless, many men undergo surgery and radiation, which can leave them incontinent or impotent.

Why Prostate Cancer Screening Is So Tricky

“The PSA test is not a great test,” Bibbins-Domingo says. “It doesn’t help us distinguish the types of cancers that are going to kill you from those cancers that are going to not progress over time and will not cause a man health problems.”

So when the task force last issued guidelines in 2012, the panel decided the potential harms of screening outweighed the benefits.

But the results of research from the last five years have changed that equation, the task force says.

Specifically, the European Randomized Study of Screening for Prostate Cancer (ERSPC) found PSA testing cuts the chances of developing advanced prostate cancer by about 30 percent and the risk of dying from the disease by about 20 percent.

At the same time, an increasing number of men confronted with a diagnosis of prostate cancer are skipping treatment, according to recent research. Instead, they and their doctors are opting for “watchful waiting” or active surveillance of the malignancy. That less aggressive approach to treatment minimizes the harms of screening, the task force says.

So, in its proposed revision, the task force drops its “D” recommendation against PSA testing for men ages 55 to 69 and replaces it with a “C” recommendation that each man in that age group make the decision about whether to get screened individually — in consultation with his doctor.

Bibbins-Domingo stresses that the task force has stopped short of urging screening for all young men.

“There are some men who might say, ‘You know, I really want to avoid dying of prostate cancer. That’s the most important thing to me. So even if there’s a small likelihood this will work I want to do it,’” Bibbins-Domingo says. Screening saves an estimated one or two lives out of every 1,000 men who get screened.

And with treatment’s risk of impotence or incontinence, it’s also a reasonable choice for some men to decide, “ ‘I’m not willing to risk the things that may happen along the way,’ “ Bibbins-Domingo notes.

Doctors who have long advocated aggressive PSA testing are praising the new guidelines.

“I’m very pleased. I view this as a victory for PSA screening for prostate cancer,” says Dr. William Catalona, a professor of urology at the Northwestern University Feinberg School of Medicine.

“PSA screening saves lives,” he says. “And having the U.S. Preventive Services Task Force discourage PSA screening has sort of created a whole generation of family practitioners and internists who feel that PSA screening is a bad thing to do for patients. If this were to continue, we would lose all these gains in reducing the prostate cancer death rate.” He says he wishes the group had gone further and recommended that doctors actively encourage PSA screening beginning at age 40 and continuing past age 70.

Dr. David Penson, a urologist at Vanderbilt-Ingram Cancer Center, agrees with the task force’s decision. “The idea of letting men make their own decision, I think, is a really terrific thing,” he says, noting that the new draft guidelines are in line with those of other medical groups.

But other doctors fear the task force’s recommendation will be oversimplified into a recommendation for screening.

Dr. Dan Merenstein, a family medicine physician at Georgetown University, doesn’t think the new evidence warrants a change. And he worries the new guidelines are confusing.

“What I’m afraid of is that rather than having this discussion — because it’s a difficult and long discussion — physicians will just order this test like they do… a cholesterol panel,” Merenstein says. “And that will cause much more harm than good.”

Meanwhile, Dr. Otis Brawley, the chief medical officer for the American Cancer Society, believes the guidelines strike the right balance.

“I really do think that there is a pendulum in a lot of things that we do in medicine,” Brawley says. “And the pendulum here may be getting to the right place where we realize there are harms and there are benefits and individuals need to weigh these harms and benefits and tailor a decision that’s right for them.”

And the latest word from The Annals of Internal Medicine:

More Support for Prostate Cancer Screening?

By Amy Orciari Herman

A reanalysis of U.S. and European data seems to offer more support for prostate-specific antigen (PSA)-based screening for prostate cancer. The findings appear in the Annals of Internal Medicine.

Researchers re-examined data from the European Randomized Study of Screening for Prostate Cancer, which originally showed a reduction in prostate cancer mortality with screening, and the U.S. Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, which showed no reduction. In the new analysis, the researchers attempted to account for the high rate of PSA screening that contaminated the control group of the U.S. trial. Ultimately, they concluded that the results of both screening trials could be consistent with roughly a 25%–30% reduction in prostate cancer mortality over 11 years’ follow-up.

Dr. Allan S. Brett, editor-in-chief of NEJM Journal Watch General Medicine, weighed in: “I’d like to see a critical analysis of this report by other groups with sophisticated statistical expertise. But in the end, it doesn’t really matter whether the U.S. data legitimately can be interpreted as supporting the European data. We already know (from the European trial) that screening likely confers a small absolute reduction in prostate cancer mortality, but that many men must be treated (or subjected to repeated testing and biopsy) to benefit one person. So this latest analysis doesn’t change anything: We’re still left with the same debate about benefit vs. harm in PSA screening.”

We will screen men 45-69 years of age if they want. We won’t screen older men unless there extenuating circumstances.

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Words written in italic are directly from Mark L. Thornton, M.D., F.A.C.P.

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Flu Vaccine 2017

Sunday, October 1, 2017 // Blog, Flu, Prevention, Vaccines

Information for 2017-2018

Getting an annual flu vaccine is the first and best way to protect yourself and your family from the flu. Flu vaccination can reduce flu illnesses, doctors’ visits, and missed work and school due to flu, as well as prevent flu-related hospitalizations. The more people who get vaccinated, the more people will be protected from flu, including older people, very young children, pregnant women and people with certain health conditions who are more vulnerable to serious flu complications. This page summarizes information for the 2017-2018 flu season.

What viruses will the 2017-2018 flu vaccines protect against?

There are many flu viruses, and they are constantly changing. The composition of U.S. flu vaccines is reviewed annually and updated to match circulating flu viruses. Flu vaccines protect against the three or four viruses that research suggests will be most common. For 2017-2018, three-component vaccines are recommended to contain:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus
  • an A/Hong Kong/4801/2014 (H3N2)-like virus
  • a B/Brisbane/60/2008-like (B/Victoria lineage) virus

Four-component vaccines, which protect against a second lineage of B viruses, are recommended to be produced using the same viruses recommended for the trivalent vaccines, as well as a B/Phuket/3073/2013-like (B/Yamagata lineage) virus.

We will be giving the Quadrivalent Flu Vaccine this fall.  A high dose vaccine will be available for those 65 and over.  It is marginally more effective and does not appear to have any greater risk of side effects.  If you have a scheduled appointment this fall, we will give it then.  Otherwise, you can call to schedule an appointment.  The optimal time is late October and early November.  Think pumpkins when thinking of the optimal time.  It is readily available, so if it is more convenient for you to get it at your pharmacy, work or school, it is fine to get it there.

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Words written in italic are directly from Mark L. Thornton, M.D., F.A.C.P.

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Preventing Falls Among Older Adults

Friday, August 5, 2016 // Prevention



We all want to protect our older family members and help them stay safe, secure, and independent. Knowing how to reduce the risk of falling, a leading cause of injury, is a step toward this goal.

The Reality

Each year, one in every three adults ages 65 or older falls and 2 million are treated in emergency departments for fall-related injuries. And the risk of falling increases with each decade of life. The long-term consequences of fall injuries, such as hip fractures and traumatic brain injuries (TBI), can impact the health and independence of older adults. Thankfully, falls are not an inevitable part of aging. In fact, many falls can be prevented. Everyone can take actions to protect the older adults they care about.

Prevention Tips

You can play a role in preventing falls. Encourage the older adults in your life to:

  • Get some exercise. Lack of exercise can lead to weak legs and this increases the chances of falling. Exercise programs such as Tai Chi can increase strength and improve balance, making falls much less likely.
  • Be mindful of medications. Some medicines—or combinations of medicines—can have side effects such as dizziness or drowsiness. This can make falling more likely. Having a doctor or pharmacist review all medications can help reduce the chance of risky side effects and drug interactions.
  • vision
    Keep their vision sharp.
    Poor vision can make it harder to get around safely. Older adults should have their eyes checked every year and wear glasses or contact lenses with the right prescription strength to ensure they are seeing clearly.
  • Eliminate hazards at home. About half of all falls happen at home. A home safety check can help identify potential fall hazards that need to be removed or changed, such as tripping hazards, clutter, and poor lighting.

Steps for Home Safety

The following checklist can help older adults reduce their risk of falling at home:

  • Remove things you can trip over (such as papers, books, clothes, and shoes) from stairs and places where you walk.
  • Install handrails and lights on all staircases.
  • Remove small throw rugs or use double-sided tape to keep the rugs from slipping.
  • Keep items you use often in cabinets you can reach easily without using a step stool.
  • Put grab bars inside and next to the tub or shower and next to your toilet.
  • Use non-slip mats in the bathtub and on shower floors.
  • Improve the lighting in your home. As you get older, you need brighter lights to see well. Hang lightweight curtains or shades to reduce glare.
  • Wear shoes both inside and outside the house. Avoid going barefoot or wearing slippers.

More Information

CDC offers various materials and resources for all audiences about older adult falls and what can be done to prevent them. These resources are for the general public, public health officials, and anyone interested in programs that aim to prevent falls.


25th Year of Precepting

This marks my 25th year of serving as a community preceptor for medical students at the University of Texas Health Science Center at San Antonio.  My thanks to those patients who have taken time to meet with students.  Here is a comment from one of them:


The past 4 weeks with Dr. Thornton was probably one of my favorite rotations of 3rd year. There is an ample amount of diversity in the types of medical problems seen from routine follow ups to vaccinations needed for world travel as well as more chronic conditions. Dr. Thornton’s attentiveness and laid back personality make him a great instructor. He often provided me with articles he found interesting and we had many conversations about medicine and life in general. He really made me feel like I was part of the treatment team. His staff is extremely nice and personable. I feel very fortunate to have had this rotation.

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Protection against Mosquitoes, Ticks, & Other Arthropods

Friday, August 5, 2016 // Prevention

Roger S. Nasci, Robert A. Wirtz, William G. Brogdon

Vaccines or chemoprophylactic drugs are available to protect against some vectorborne diseases such as yellow fever, Japanese encephalitis, and malaria; however, travel health practitioners should advise travelers to use repellents and other general protective measures against biting arthropods. The effectiveness of malaria chemoprophylaxis is variable, depending on patterns of drug resistance, bioavailability, and compliance with medication, and no similar preventive measures exist for other mosquitoborne diseases such as dengue, chikungunya, Zika, and West Nile encephalitis or tickborne diseases such as Lyme borreliosis, tickborne encephalitis, and relapsing fever.

The Environmental Protection Agency (EPA) regulates repellent products in the United States. CDC recommends that consumers use repellent products that have been registered by EPA. EPA registration indicates the materials have been reviewed and approved for both efficacy and human safety when applied according to the instructions on the label.


Avoid outbreaks. To the extent possible, travelers should avoid known foci of epidemic disease transmission. The CDC Travelers’ Health website provides updates on regional disease transmission patterns and outbreaks (

Be aware of peak exposure times and places. Exposure to arthropod bites may be reduced if travelers modify their patterns or locations of activity. Although mosquitoes may bite at any time of day, peak biting activity for vectors of some diseases (such as dengue and chikungunya) is during daylight hours. Vectors of other diseases (such as malaria) are most active in twilight periods (dawn and dusk) or in the evening after dark. Avoiding the outdoors or taking preventive actions (such as using repellent) during peak biting hours may reduce risk. Place also matters; ticks and chiggers are often found in grasses, woodlands, or other vegetated areas. Local health officials or guides may be able to point out areas with increased arthropod activity.

Wear appropriate clothing. Travelers can minimize areas of exposed skin by wearing long-sleeved shirts, long pants, boots, and hats. Tucking in shirts, tucking pants into socks, and wearing closed shoes instead of sandals may reduce risk. Repellents or insecticides, such as permethrin, can be applied to clothing and gear for added protection. (Additional information on clothing is below.)

Check for ticks. Travelers should inspect themselves and their clothing for ticks during outdoor activity and at the end of the day. Prompt removal of attached ticks can prevent some infections. Showering within 2 hours of being in a tick-infested area reduces the risk of some tickborne diseases.

Bed nets. When accommodations are not adequately screened or air conditioned, bed nets are essential in providing protection and reducing discomfort caused by biting insects. If bed nets do not reach the floor, they should be tucked under mattresses. Bed nets are most effective when they are treated with a pyrethroid insecticide. Pretreated, long-lasting bed nets can be purchased before traveling, or nets can be treated after purchase. Effective, treated nets may also be available in destination countries. Nets treated with a pyrethroid insecticide will be effective for several months if they are not washed. Long-lasting pretreated nets may be effective for much longer.

Insecticides and spatial repellents. More spatial repellent products are becoming commercially available. These products, containing active ingredients such as metofluthrin and allethrin, augment aerosol insecticide sprays, vaporizing mats, and mosquito coils that have been available for some time. Such products can help to clear rooms or areas of mosquitoes (spray aerosols) or repel mosquitoes from a circumscribed area (coils, spatial repellents). Although many of these products appear to have repellent or insecticidal activity under particular conditions, they have not yet been adequately evaluated in peer-reviewed studies for their efficacy in preventing vectorborne disease. Travelers should supplement the use of these products with repellent on skin or clothing and using bed nets in areas where vectorborne diseases are a risk or biting arthropods are noted. Since some products available internationally may contain pesticides that are not registered in the United States, it may be preferable for travelers to bring their own. Insecticides and repellent products should always be used with caution, avoiding direct inhalation of spray or smoke.

Optimum protection can be provided by applying the repellents described in the following sections to clothing and to exposed skin (Box 2-03).

Box 2-03. Maximizing protection from mosquitoes and ticks

To optimize protection against mosquitoes and ticks and reduce the risk of diseases they transmit:

  • Wear a long-sleeved shirt, long pants, and socks.
  • Treat clothing with permethrin or purchase pretreated clothing.
    • Permethrin-treated clothing will retain repellent activity through multiple washes.
    • Repellents used on skin can also be applied to clothing but provide shorter duration of protection (same duration as on skin) and must be reapplied after laundering.
  • Apply lotion, liquid, or spray repellent to exposed skin.
  • For Mosquitoes
    • Ensure adequate protection during times of day when mosquitoes are most active.
    • Dengue, yellow fever, and chikungunya vector mosquitoes bite mainly from dawn to dusk.
    • Malaria, West Nile, and Japanese encephalitis vector mosquitoes bite mainly from dusk to dawn.
    • Use common sense. Reapply repellents as protection wanes and mosquitoes start to bite.
  • For Ticks
    • Check yourself daily (your entire body) and remove attached ticks promptly.


CDC has evaluated information published in peer-reviewed scientific literature and data available from EPA to identify several types of EPA-registered products that provide repellent activity sufficient to help people reduce the bites of disease-carrying mosquitoes. Products containing the following active ingredients typically provide reasonably long-lasting protection:

  • DEET (chemical name: N,N-diethyl-m-tolua-mide or N,N-diethyl-3-methyl-benzamide). Products containing DEET include, but are not limited to, Off!, Cutter, Sawyer, and Ultrathon.
  • Picaridin (KBR 3023 [Bayrepel] and icaridin outside the United States; chemical name: 2-(2-hydroxyethyl)-1-piperidinecarboxylic acid 1-methylpropyl ester). Products containing picaridin include, but are not limited to, Cutter Advanced, Skin So Soft Bug Guard Plus, and Autan (outside the United States).
  • Oil of lemon eucalyptus (OLE) or PMD (chemical name: para-menthane-3,8-diol), the synthesized version of OLE. Products containing OLE and PMD include, but are not limited to, Repel and Off! Botanicals. This recommendation refers to EPA-registered repellent products containing the active ingredient OLE (or PMD). “Pure” oil of lemon eucalyptus (essential oil not formulated as a repellent) is not recommended; it has not undergone similar, validated testing for safety and efficacy, is not registered with EPA as an insect repellent, and is not covered by this recommendation.
  • IR3535 (chemical name: 3-[N-butyl-N-acetyl]-aminopropionic acid, ethyl ester). Products containing IR3535 include, but are not limited to, Skin So Soft Bug Guard Plus Expedition and SkinSmart.

EPA characterizes the active ingredients DEET and picaridin as “conventional repellents” and OLE, PMD, and IR3535 as “biopesticide repellents,” which are either derived from or are synthetic versions of natural materials.

Repellent Efficacy

Published data indicate that repellent efficacy and duration of protection vary considerably among products and among mosquito and tick species. Product efficacy and duration of protection are also markedly affected by ambient temperature, level of activity, amount of perspiration, exposure to water, abrasive removal, and other factors. In general, higher concentrations of active ingredient provide longer duration of protection, regardless of the active ingredient. Products with <10% active ingredient may offer only limited protection, often 1–2 hours. Products that offer sustained-release or controlled-release (microencapsulated) formulations, even with lower active ingredient concentrations, may provide longer protection times. Studies suggest that concentrations of DEET above approximately 50% do not offer a marked increase in protection time against mosquitoes; DEET efficacy tends to plateau at a concentration of approximately 50%. CDC recommends using products with ≥20% DEET on exposed skin to reduce biting by ticks that may spread disease.

Recommendations are based on peer-reviewed journal articles and scientific studies and data submitted to regulatory agencies. People may experience some variation in protection from different products. Regardless of what product is used, if travelers start to get insect bites they should reapply the repellent according to the label instructions, try a different product, or, if possible, leave the area with biting insects.

Ideally, repellents should be purchased before traveling and can be found online or in hardware stores, drug stores, and supermarkets. A wide variety of repellents can be found in camping, sporting goods, and military surplus stores. When purchasing repellents overseas, look for the active ingredients specified above on the product labels; some names of products available internationally have been specified in the list above.

Repellency Awareness Graphic

The Environmental Protection Agency (EPA) allows companies to apply for permission to include a new repellency awareness graphic on the labels of insect repellents that are applied to the skin (Figure 2-01( The graphic helps consumers easily identify the time a repellent is effective against mosquitoes and ticks. EPA reviews products that apply to use the graphic to ensure that their data meet current testing protocols and standard evaluation practices. Use of this graphic by manufacturers is voluntary. For more information, visit

Repellents and Sunscreen

Repellents that are applied according to label instructions may be used with sunscreen with no reduction in repellent activity; however, limited data show a one-third decrease in the sun protection factor (SPF) of sunscreens when DEET-containing insect repellents are used after a sunscreen is applied. Products that combine sunscreen and repellent are not recommended, because sunscreen may need to be reapplied more often and in larger amounts than needed for the repellent component to provide protection from biting insects. In general, the recommendation is to use separate products, applying sunscreen first and then applying the repellent. Due to the decrease in SPF when using a DEET-containing insect repellent after applying sunscreen, travelers may need to reapply the sunscreen more frequently.

Repellents and Insecticides for Use on Clothing

Clothing, hats, shoes, bed nets, jackets, and camping gear can be treated with permethrin for added protection. Products such as Permanone and Sawyer, Permethrin, Repel, and Ultrathon Permethrin Clothing Treatment are registered with EPA specifically for use by consumers to treat clothing and gear. Alternatively, clothing pretreated with permethrin is commercially available, marketed to consumers in the United States as Insect Shield, BugsAway, or Insect Blocker.

Permethrin is a highly effective insecticide-acaricide and repellent. Permethrin-treated clothing repels and kills ticks, chiggers, mosquitoes, and other biting and nuisance arthropods. Clothing and other items must be treated 24–48 hours in advance of travel to allow them to dry. As with all pesticides, follow the label instructions when using permethrin clothing treatments.

Permethrin-treated materials retain repellency or insecticidal activity after repeated laundering but should be retreated, as described on the product label, to provide continued protection. Clothing that is treated before purchase is labeled for efficacy through 70 launderings. Clothing treated with the other repellent products described above (such as DEET) provides protection from biting arthropods but will not last through washing and will require more frequent reapplications.

Precautions when Using Insect Repellents

Travelers should take the following precautions:

  • Apply repellents only to exposed skin or clothing, as directed on the product label. Do not apply repellents under clothing.
  • Never use repellents over cuts, wounds, or irritated skin.
  • When using sprays, do not spray directly on face—spray on hands first and then apply to face. Do not apply repellents to eyes or mouth, and apply sparingly around ears.
  • Wash hands after application to avoid accidental exposure to eyes or ingestion.
  • Children should not handle repellents. Instead, adults should apply repellents to their own hands first, and then gently spread on the child’s exposed skin. Avoid applying directly to children’s hands. After returning indoors, wash your child’s treated skin and clothing with soap and water or give the child a bath.
  • Use just enough repellent to cover exposed skin or clothing. Heavy application and saturation are generally unnecessary for effectiveness. If biting insects do not respond to a thin film of repellent, apply a bit more.
  • After returning indoors, wash repellent-treated skin with soap and water or bathe. Wash treated clothing before wearing it again. This precaution may vary with different repellents—check the product label.

If a traveler experiences a rash or other reaction, such as itching or swelling, from an insect repellent, the repellent should be washed off with mild soap and water and its use discontinued. If a severe reaction has occurred, a local poison-control center should be called for further guidance, if feasible. Travelers seeking health care because of the repellent should take the repellent to the doctor’s office and show the doctor. Permethrin should never be applied to skin but only to clothing, bed nets, or other fabrics as directed on the product label.

Children and Pregnant Women

Most repellents can be used on children aged >2 months. Protect infants aged <2 months from mosquitoes by using an infant carrier draped with mosquito netting with an elastic edge for a tight fit. Products containing OLE specify that they should not be used on children aged <3 years. Other than the safety tips listed above, EPA does not recommend any additional precautions for using registered repellents on children or on pregnant or lactating women.

Useful Links


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There has been a recent resurgence in bedbug infestations worldwide, particularly in developed countries. Although bedbugs do not transmit diseases, their bites may be a nuisance. Travelers can take measures to avoid bedbug bites and avoid transporting them in luggage and clothing (Box 2-04).

Box 2-04. Bedbugs and international travel

A recent resurgence in bedbug infestations worldwide, particularly in developed countries, is thought to be related to the increase in international travel, pest control strategy changes in travel lodgings, and insecticide resistance. Bedbug infestations have been increasingly reported in hotels, theaters, and any locations where people congregate, even in the workplace, dormitories, and schools. Bedbugs may be transported in luggage and on clothing. Transport of personal belongings in contaminated transport vehicles is another means of spread of these insects.

Bedbugs are small, flat insects that are reddish-brown in color, wingless, and range from 1 to 7 mm in length. Although bedbugs have not been shown to transmit disease, their bites can produce strong allergic reactions and considerable emotional stress.

Protective Measures against Bedbugs

Travelers should be encouraged to take the following precautions to avoid or reduce their exposure to bedbugs:

  • Inspect the premises of hotels or other sleeping locations for bedbugs on mattresses, box springs, bedding, and furniture, particularly built-in furniture with the bed, desk, and closets as a continuous structural unit. Travelers who observe evidence of bedbug activity—whether it be the bugs themselves or physical signs such as blood-spotting on linens—should seek alternative lodging.
  • Keep suitcases closed when they are not in use and try to keep them off the floor.
  • Remove clothing and personal items (such as toiletry bags and shaving kits) from the suitcase only when they are in use.
  • Carefully inspect clothing and personal items before returning them to the suitcase.
  • Keep in mind that bedbug eggs and nymphs are very small and can be easily overlooked.

Prevention is by far the most effective and inexpensive way to protect oneself from these pests. The costs of ridding a personal residence of these insects are considerable, and efforts at control are often not immediately successful even when conducted by professionals.


  1. Barnard DR, Xue RD. Laboratory evaluation of mosquito repellents against Aedes albopictus, Culex nigripalpus, and Ochlerotatus triseriatus (Diptera: Culicidae). J Med Entomol. 2004 Jul;41(4):726–30.
  2. Fradin MS, Day JF. Comparative efficacy of insect repellents against mosquito bites. N Engl J Med. 2002 Jul 4;347(1):13–8.
  3. Goodyer LI, Croft AM, Frances SP, Hill N, Moore SJ, Onyango SP, et al. Expert review of the evidence base for arthropod bite avoidance. J Travel Med. 2010 May–Jun;17(3):182–92.
  4. Lupi E, Hatz C, Schlagenhauf P. The efficacy of repellents against Aedes, Anopheles, Culex and Ixodes—a literature review. Travel Med Infect Dis. 2013 Nov–Dec;11(6):374–411.
  5. Montemarano AD, Gupta RK, Burge JR, Klein K. Insect repellents and the efficacy of sunscreens. Lancet. 1997 Jun 7;349(9066):1670–1.
  6. Murphy ME, Montemarano AD, Debboun M, Gupta R. The effect of sunscreen on the efficacy of insect repellent: a clinical trial. J Am Acad Dermatol. 2000 Aug;43(2 Pt 1):219–22.
  7. Pages F, Dautel H, Duvallet G, Kahl O, de Gentile L, Boulanger N. Tick repellents for human use: prevention of tick bites and tick-borne diseases. Vector Borne Zoonotic Dis. 2014 Feb;14(2):85–93.
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Injury Prevention

Friday, August 5, 2016 // Prevention

David A. Sleet, David J. Ederer, Michael F. Ballesteros

According to the World Health Organization (WHO), injuries are among the leading causes of death and disability in the world, and they are the leading cause of preventable death in travelers. Among travelers, data show that injuries are one of the leading causes for consulting a physician, hospitalization, repatriation, and death. Worldwide, injuries are the leading cause of death for young people aged 15–29 years. Estimates have reported that 18%–24% of deaths among travelers in foreign countries are caused by injuries. Infectious diseases accounted for only 2% of deaths to travelers abroad. Contributing to the injury toll while traveling are exposure to unfamiliar and perhaps risky environments, differences in language and communications, less stringent product safety and vehicle standards, unfamiliar rules and regulations, a carefree holiday or vacation spirit leading to more risk-taking behavior, and overreliance on travel and tour operators to protect one’s safety and security.

From 2011 through 2013, an estimated 2,466 US citizens died from non-natural causes, such as injuries and violence, while in foreign countries (excluding deaths occurring in the wars in Iraq and Afghanistan). Motor vehicle crashes—not crime or terrorism—are the number 1 killer of healthy US citizens living, working, or traveling in foreign countries. From 2011 through 2013, 621 Americans died in road traffic crashes abroad (25% of all non-natural deaths to US citizens abroad). Another 555 were victims of homicide (23%), 392 committed suicide (16%), and 309 were victims of drowning (13%) (Figure 2-02( Other less common but serious injuries are related to natural disasters, aviation accidents, drugs, terrorism, falls, burns, and poisoning.

If a traveler is seriously injured, emergency care may not be available or acceptable by US standards. Trauma centers capable of providing optimal care for serious injuries are uncommon outside urban areas in many foreign destinations. Travelers should be aware of the increased risk of certain injuries while traveling or residing abroad, particularly in developing countries, and be prepared to take preventive steps.


Globally, an estimated 3,300 people are killed each day, including 720 children, in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks, and pedestrians. Annually, 1.24 million are killed and 20–50 million are injured in traffic crashes—a number likely to double by 2030. Although only 53% of the world’s vehicles are in developing countries, >90% of road traffic casualties occur in these countries.

International efforts to combat road deaths command a tiny fraction of the resources deployed to fight diseases such as malaria and tuberculosis, yet the burden of road traffic injuries is comparable. In response to this crisis, in March 2010 the 64th General Assembly of the United Nations described the global road safety crisis as “a major public health problem” and proclaimed 2011–2020 as “The Decade of Action for Road Safety.” On April 19, 2012, the United Nations General Assembly adopted a new resolution (A/66/PV.106) to improve global road safety by implementing plans for the decade, setting ambitious targets, and monitoring global road traffic fatalities.

According to Department of State data, road traffic crashes are the leading cause of injury deaths to US citizens while abroad (Figure 2-02( Of the 621 US citizens killed in road traffic crashes from 2011 through 2013, approximately 110 (18%) deaths involved motorcycles. Unlike in the United States, in many countries, 2- and 3-wheeled vehicles outnumber cars, and travelers unfamiliar with driving or riding motorcycles may be at higher risk of crashing. Most non-natural American deaths in Thailand and Vietnam, popular travel destinations, were related to motorcycle use. Motorcycle use is also dangerous for travelers in countries where motorcycles are not the primary mode of transportation. The reported rate of motorbike injuries in Bermuda is much higher in tourists than in the local population, and the rate is highest in people aged 50–59 years. Motor vehicle rentals in Bermuda and some other small Caribbean islands are typically limited to motorbikes for tourists, possibly contributing to the higher rates of motorbike injuries. Loss of vehicular control, unfamiliar equipment, and inexperience with motorized 2-wheelers contributed to crashes and injuries, even at speeds <30 miles per hour.

Road traffic crashes are common among foreign travelers for a number of reasons: lack of familiarity with the roads, driving on the opposite side of the road, lack of seat belt use, the influence of alcohol, poorly made or maintained vehicles, travel fatigue, poor road surfaces without shoulders, unprotected curves and cliffs, and poor visibility due to lack of adequate lighting. In many developing countries, unsafe roads and vehicles and an inadequate transportation infrastructure contribute to the traffic injury problem. In many of these countries, motor vehicles often share the road with vulnerable road users, such as pedestrians, bicyclists, and motorcycle users. The mix of traffic involving cars, buses, taxis, rickshaws, large trucks, and even animals increases the risk for crashes and injuries.

Millions of US citizens travel to Mexico each year, and >150,000 people cross the US–Mexico border daily. Travelers should be particularly cautious in Mexico; from 2011 through 2013, 27% of all deaths of US citizens abroad occurred in that country, where >200 Americans died in road traffic crashes.

Strategies to reduce the risk of traffic injury are shown in Table 2-12( The Association for International Road Travel ( and Make Roads Safe ( have useful safety information for international travelers, including road safety checklists and country-specific driving risks. The Department of State has safety information useful to international travelers, including road safety and security alerts, international driving permits, and travel insurance (

Figure 2-02. Leading causes of injury death for US citizens in foreign countries, 2011-20131,2


View Larger Figure

1Data from US Department of State. Death of US citizens abroad by non-natural causes. Washington, DC: US Department of State; 2014 [cited 2014 March 26]. Available from:

2Excludes deaths of US citizens fighting wars in Afghanistan or Iraq, and deaths that were not reported to the nearest US embassy or consulate.


Table 2-12. Recommended strategies to reduce injuries while abroad

Road Traffic Crashes
Lack of seat belts and child safety seats Always use safety belts and child safety seats. Rent vehicles with seat belts; when possible, ride in taxis with seat belts and sit in the rear seat; bring child safety seats and booster seats from home for children to ride properly restrained.
Driving hazards When possible, avoid driving at night in developing countries; always pay close attention to the correct side of the road when driving in countries that drive on the left.
Country-specific driving hazards Check the Association for Safe International Road Travel website for driving hazards or risks by country (
Motorcycles, motor bikes, and bicycles Always wear helmets (bring a helmet from home, if needed). When possible, avoid driving or riding on motorcycles or motorbikes, including motocycle and motorbike taxis. Traveling overseas is a bad time to learn to drive a motorcycle or motorbike.
Alcohol-impaired driving Alcohol increases the risk for all causes of injury. Do not drive after consuming alcohol, and avoid riding with someone who has been drinking.
Cellular telephones Do not use a cellular telephone or text while driving. Many countries have enacted laws banning cellular telephone use while driving, and some countries have made using any kind of telephone, including hands-free, illegal while driving.
Taxis or hired drivers Ride only in marked taxis, and try to ride in those that have safety belts accessible. Hire drivers familiar with the area.
Bus travel Avoid riding in overcrowded, overweight, or top-heavy buses or minivans.
Pedestrian hazards Be alert when crossing streets, especially in countries where motorists drive on the left side of the road. Walk with a companion or someone from the host country.
Other Tips
Airplane travel Avoid using local, unscheduled aircraft. If possible, fly on larger planes (>30 seats), in good weather, during the daylight hours, and with experienced pilots. Children <2 years should sit in a child safety seat, not on a parent’s lap. Whenever possible, parents should travel with a safety seat for use before, during, and after a plane ride.
Drowning Avoid swimming alone or in unfamiliar waters. Wear life jackets while boating or during water recreation activities.
Burns In hotels, stay below the sixth floor to maximize the likelihood of being rescued in case of a fire. Bring your own smoke alarm.



Drowning accounts for 13% of all deaths of US citizens abroad. Although risk factors have not been clearly defined, these deaths are most likely related to unfamiliarity with local water currents and conditions, inability to swim, and the absence of lifeguards on duty. Rip currents can be especially dangerous, as are sea animals such as urchins, jellyfish, coral, and sea lice. Alcohol also contributes to drowning and boating mishaps.

Drowning was the leading cause of injury death to US citizens visiting countries where water recreation is a major activity, such as Fiji, the Bahamas, Jamaica, and Costa Rica. Young men are particularly at risk of head and spinal cord injuries from diving into shallow water, and alcohol is a factor in some cases.

Boating can be a hazard, especially if boaters are unfamiliar with the boat, do not know proper boating etiquette or rules for watercraft navigation, or are new to the water environment in a foreign country. From 2011 through 2013, maritime accidents accounted for 8% of deaths to healthy Americans abroad. Many boating fatalities result from inexperience or failure to wear lifejackets.

Scuba diving is a frequent pursuit of travelers in coastal destinations. The death rate among all divers worldwide is thought to be 15–20 deaths per 100,000 divers per year. Travelers should either be experienced divers or dive with a reliable dive shop and instructors. See the Scuba Diving( section later in this chapter for a more detailed discussion about diving risks and preventive measures.


From 2011 through 2013, aviation incidents, drug-related incidents, and deaths classified as “other unintentional injuries” accounted for 22% of deaths to healthy US citizens abroad (Figure 2-02( Fires can be a substantial risk in developing countries where building codes do not exist or are not enforced, there are no smoke alarms, there is no access to emergency services, and the fire department’s focus is on putting out fires rather than on fire prevention or victim rescue.

Travel by local, lightweight aircraft in many countries can be risky. From 2011 through 2013, an estimated 82 US citizens abroad were killed in aircraft crashes. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with inexperienced pilots carries the highest risk.

Before flying with children, parents and caregivers should check to make sure that their child restraint system is approved for use on an aircraft. This approval should be printed on the system’s information label or on the device itself. The Federal Aviation Administration (FAA) recommends that a child weighing <20 lb use a rear-facing child restraint system. A forward-facing child safety seat should be used for children weighing 20–40 lb. FAA has also approved a harness-type device for children weighing 22–44 lb.

Travel health providers, vendors of travel services, and travelers themselves should consider the following:

  • Purchasing special travel health and medical evacuation insurance if their destinations include countries where there may not be access to good medical care (see the Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance section later in this chapter).
  • Because trauma care is poor in many countries, victims of injuries and violence can die before reaching a hospital, and there may be no coordinated ambulance service available. In remote areas, medical assistance and modern drugs may be unavailable, and travel to the nearest medical facility can take a long time.
  • Adventure activities, such as mountain climbing, skydiving, whitewater rafting, dune-buggying, and kayaking, are popular with travelers. The lack of rapid emergency trauma response, inadequate trauma care in remote locations, and sudden, unexpected weather changes that compromise safety and hamper rescue efforts can delay access to care.
  • Travelers should avoid using local, unscheduled, small aircraft. If available, choose larger aircraft (>30 seats), as they are more likely to have undergone more strict and regular safety inspections. Larger aircraft also provide more protection in the event of a crash. For country-specific airline crash events, see
  • When traveling by air with young children, consider bringing a child safety seat approved for use on an aircraft.
  • To prevent fire-related injuries, travelers should select accommodations no higher than the sixth floor. (Fire ladders generally cannot reach higher than the sixth floor.) Hotels should be checked for smoke alarms and preferably sprinkler systems. Travelers may want to bring their own smoke alarm. Two escape routes from buildings should always be identified. Crawling low under smoke and covering one’s mouth with a wet cloth are helpful in escaping a fire. Families should agree on a meeting place outside the building in case a fire erupts.
  • Improperly vented heating devices may cause poisoning from carbon monoxide. Carbon monoxide at the back of boats near the engine can be especially dangerous. Travelers may want to carry a personal detector that can sound an alert in the presence of this lethal gas.
  • Travelers should consider learning basic first aid and CPR before travel overseas with another person. Travelers should bring a travel health kit, which should be customized to the anticipated itinerary and activities (see the Travel Health Kits section later in this chapter).
  • Suicide is the third-leading cause of injury death to US citizens abroad, accounting for 16% of non-natural deaths. For longer-term travelers (such as missionaries and volunteers), social isolation and substance abuse, particularly while living in areas of poverty and rigid gender roles, may increase the risk of depression and suicide. See the Mental Health( section later in this chapter for more detailed information.


  1. Ball DJ, Machin N. Foreign travel and the risk of harm. Int J Inj Contr Saf Promot. 2006 Jun;13(2):107–15.
  2. Cortes LM, Hargarten SW, Hennes HM. Recommendations for water safety and drowning prevention for travelers. J Travel Med. 2006 Jan–Feb;13(1):21–34.
  3. FIA Foundation for the Automobile and Society. Make roads safe report: a decade of action for road safety. FIA Foundation for the Automobile and Society; 2009 [cited 2014 Aug 8]. Available from:
  4. Guse CE, Cortes LM, Hargarten SW, Hennes HM. Fatal injuries of US citizens abroad. J Travel Med. 2007 Sep–Oct;14(5):279–87.
  5. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet. 2002 Oct 5;360(9339):1083–8.
  6. Lawson CJ, Dykewicz CA, Molinari NA, Lipman H, Alvarado-Ramy F. Deaths in international travelers arriving in the United States, July 1, 2005 to June 30, 2008. J Travel Med. 2012 Mar–Apr;19(2):96–103.
  7. Leggat PA, Fischer PR. Accidents and repatriation. Travel Med Infect Dis. 2006 May–Jul;4(3–4):135–46.
  8. McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a review. J Travel Med. 2002 Nov–Dec;9(6):297–307.
  9. Sleet DA, Balaban V. Travel medicine: preventing injuries to children. Am J Lifestyle Med. 2013 Mar 10;7(2):121–9.
  10. World Health Organization. WHO global status report on road safety 2013: supporting a decade of action Geneva: World Health Organization; 2013 [cited 2014 Sep 19]. Available from:
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Blood Pressure: How Low Do You Go? Our Four Cents from Dr. Thornton and Dr. Wallace

Wednesday, December 23, 2015 // Blood Pressure, Medication

Choosing the optimal blood pressure target to shoot for in managing hypertension requires that we apply the art of medicine, rather than just a cookbook approach. Over recent years, we have gotten dizzy keeping up with various recommendations which have swung back and forth between lower versus higher blood pressure goals. Last year a Joint National Committee on Hypertension recommended higher blood pressure targets: <140/90, but <150/90 in adults over 60 years old. Now we have a new large study published in November (the SPRINT study) which has caused the pendulum to swing back toward a goal of lower blood pressures, specifically in individuals at least 50 years old who already have cardiovascular disease, or who have at least one risk factor for developing it. The SPRINT study found that treating these patients aggressively, with a goal of achieving a systolic (top number) blood pressure <120, rather than to a more conservative target of <140, resulted in a significant decrease in the risk of cardiovascular events such as stroke or heart attack, and of death in general.

As usual, nothing is ever black or white. Getting to the lower target required more blood pressure medications (an average of 3, vs. 2 for the higher target), which increases the chance of side effects. The target of <120 also caused more incidence of blood pressure going too low, as one might expect. This increases the possibility of dizziness and falls which can be devastating, especially in our older patients.

So we must once again apply the art of medicine, treating each patient as an individual, and keeping new information in mind as we attempt to balance the risk of medication side effects against the risk of future adverse events.

Below is a summary published in Journal Watch of the findings of the SPRINT study, followed by some published comments:
SPRINT: A Trial of Intensive Blood Pressure Lowering Allan S. Brett, MD reviewing The SPRINT Research Group. N Engl J Med 2015 Nov 9. Chobanian AV. N Engl J Med 2015 Nov 9.Allan S. Brett, MD

Allan S. Brett, MDTreating to a systolic target of 120 mm Hg lowered the incidence of adverse cardiovascular events in a high-risk population. Allan S. Brett, MD

Treating to a systolic target of 120 mm Hg lowered the incidence of adverse cardiovascular events in a high-risk population. Allan S. Brett, MDFor years, clinicians have debated how far to lower blood pressure (BP) in hypertensive patients. The multicenter Systolic Blood Pressure Intervention Trial (SPRINT) now provides some guidance. SPRINT researchers enrolled 9361 patients (age, ≥50) with systolic BP of 130 to 180 mm Hg and high cardiovascular (CV) risk (defined as one or more of these: known symptomatic or asymptomatic CV disease, chronic kidney disease [CKD] with glomerular filtration rate ( a measure of kidney function) [GFR] 20–59 mL/minute/1.73 m2, 10-year Framingham CV risk ≥15%, or age ≥75). Patients with diabetes and stroke were excluded. Patients were randomized to either intensive or standard treatment (systolic BP targets, 120 or 140 mm Hg, respectively). The protocol included general guidelines for choice of antihypertensive agents, but researchers were permitted discretion in choosing drug regimens. Diuretics, angiotensin-converting–enzyme inhibitors or angiotensin-receptor blockers, calcium-channel blockers, and β-blockers were used extensively. During the trial, intensive- and

For years, clinicians have debated how far to lower blood pressure (BP) in hypertensive patients. The multicenter Systolic Blood Pressure Intervention Trial (SPRINT) now provides some guidance. SPRINT researchers enrolled 9361 patients (age, ≥50) with systolic BP of 130 to 180 mm Hg and high cardiovascular (CV) risk (defined as one or more of these: known symptomatic or asymptomatic CV disease, chronic kidney disease [CKD] with glomerular filtration rate ( a measure of kidney function) [GFR] 20–59 mL/minute/1.73 m2, 10-year Framingham CV risk ≥15%, or age ≥75). Patients with diabetes and stroke were excluded. Patients were randomized to either intensive or standard treatment (systolic BP targets, 120 or 140 mm Hg, respectively). The protocol included general guidelines for choice of antihypertensive agents, but researchers were permitted discretion in choosing drug regimens. Diuretics, angiotensin-converting–enzyme inhibitors or angiotensin-receptor blockers, calcium-channel blockers, and β-blockers were used extensively. During the trial, intensive- and standard-treatment patients required averages of three and two drugs, respectively. The trial was terminated early after median follow-up of 3.3 years, during which participants’ average systolic BPs were 121.5 mm Hg and 134.6 mm Hg in the intensive- and standard-treatment groups, respectively. The primary composite outcome (myocardial infarction [MI], non-MI acute coronary syndrome, stroke, heart failure, or CV-related death) occurred in 5.2% of intensive-treatment patients and 6.8% of standard-treatment patients (P<0.001). Relative reductions in this outcome were similar in subgroups of patients with CKD and of patients older than 75. Two individual components of the composite outcome were significantly lower with intensive treatment — heart failure (1.3% vs. 2.1%) and CV-related death (0.8% vs. 1.4%). All-cause mortality also was significantly lower with intensive treatment (3.3% vs. 4.5%).Several serious adverse events were significantly more common with intensive than with standard treatment: Incidences of hypotension (low blood pressure), syncope (passing out), and electrolyte abnormalities were each about 1 percentage point higher, and incidence of acute kidney injury was about 2 percentage points higher. Among patients without CKD at baseline, the incidence of a >30% decline in GFR was significantly greater with intensive treatment (3.8% vs. 1.1%).Comment — General Medicine Allan S. Brett, MD

Comment — General Medicine Allan S. Brett, MDSPRINT has demonstrated that aiming for a systolic BP of 120 mm Hg can lower the rate of adverse cardiovascular events; to prevent 1 event, 61 patients had to be treated for 3.3 years. Keep in mind that SPRINT was limited to middle-aged and older patients at above-average CV risk and that diabetic patients were excluded because the ACCORD BP researchers had examined this question (and showed no significant lowering of adverse CV events with intensive treatment; NEJM JW Cardiol Apr 2010 and N Engl J Med 2010; 362:1575). Whether the decline in GFR (kidney function) associated with intensive treatment represents a harmless hemodynamic effect or

SPRINT has demonstrated that aiming for a systolic BP of 120 mm Hg can lower the rate of adverse cardiovascular events; to prevent 1 event, 61 patients had to be treated for 3.3 years. Keep in mind that SPRINT was limited to middle-aged and older patients at above-average CV risk and that diabetic patients were excluded because the ACCORD BP researchers had examined this question (and showed no significant lowering of adverse CV events with intensive treatment; NEJM JW Cardiol Apr 2010 and N Engl J Med 2010; 362:1575). Whether the decline in GFR (kidney function) associated with intensive treatment represents a harmless hemodynamic effect or more-serious renal injury is unclear. Because this trial will change practice, clinicians must understand how BP was measured in the study. At each visit, patients were seated in a quiet area for 5 minutes. Then, BP was recorded by a commercially available automated unit that recorded three readings, separated by several minutes, with no clinician in the room. Decisions were based on the average of the three readings. Other studies have shown that this method of BP measurement yields substantially lower readings than does the single rushed measurement typical in many practices. If SPRINT is applied without attention to proper BP measurement, substantial overtreatment — with a higher rate of adverse events — likely will occur .Finally, note that the average achieved systolic BP in the intensive-treatment group (121.5 mm Hg) remained higher than the 120 mm target. This likely represents judicious balancing by treating clinicians who tried to approximate the 120 mm goal while avoiding side effects and excessive polypharmacy. Thus, an editorialist concludes reasonably that “the results from SPRINT warrant reducing the treatment goal for systolic blood pressure to less than 130 mm Hg” in patients who meet SPRINT’s enrollment criteria. – See more at:

Generalizability of the SPRINT Results

Harlan M. Krumholz, MD,

SM reviewing Bress AP et al. J Am Coll Cardiol 2015 Nov 9.

An analysis of NHANES data shows how many U.S. adults with hypertension meet SPRINT eligibility criteria. Harlan M. Krumholz, MD, SMThe SPRINT trial (N Engl J Med 2015 Nov 9; [e-pub]), which tested a blood pressure goal of <120 mm Hg against the standard goal of <140 mm Hg, was released amid much fanfare, but a relevant question is its generalizability. Non-SPRINT investigators used data from the National Health and Nutrition Examination Survey to estimate the prevalence, number, and characteristics of U.S. adults who would meet SPRINT inclusion criteria.They found that in the years 2007–2012, an estimated 7.6% of U.S. adults (17 million people) — including 16.7% of those with treated hypertension (8 million) and 5.0% of those not being treated (8.5 million) — met SPRINT eligibility criteria. Among all U.S. adults with hypertension, an estimated 20% met eligibility criteria.

Comment : Many Americans meet SPRINT eligibility criteria and might benefit from the blood pressure goal of <120 mm Hg. However, importantly, 5 of 6 people with treated hypertension do not meet the eligibility criteria. Decisions about treatment goals for these patients will be based on greater uncertainty than for the patients who meet the eligibility criteria. – See more at:

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Prostate Cancer Screening

Wednesday, December 23, 2015 // Cancer, Prostate

PSA Police?

Screening for prostate cancer is controversial for reasons outlined in this article from the Wall Street Journal, but now the controversy is taking a new turn. The government is becoming more aggressive in determining what high-quality care is. In the past, Medicare and private insurers would not pay for certain tests or medications that were unapproved. Now, Medicare will actually penalize doctors for ordering such tests. This goes way beyond educating the public. It interferes with shared decision making by patients and their doctors.

Doctors Could be Penalized for Ordering This Test

Wall Street Journal
November 20, 2015
By Melinda Beck

Medicare officials are considering a measure that would penalize doctors who order routine prostate-cancer screening tests for their patients, as part of a federal effort to define and reward quality in health-care services.The proposal, which hasn’t been widely publicized, has prompted a flurry of last-minute comments to the Centers for Medicare and Medicaid Services, including more than 200 in the past two days, virtually all in opposition. The official comment period began Oct. 26 and ends Friday.

The proposal, which hasn’t been widely publicized, has prompted a flurry of last-minute comments to the Centers for Medicare and Medicaid Services, including more than 200 in the past two days, virtually all in opposition. The official comment period began Oct. 26 and ends Friday.Many of those commenting said the measure would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.

Many of those commenting said the measure would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. “To make it a quality measure would say, ‘You’re a poor quality doctor if your patients get this test.’ ”

“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. “To make it a quality measure would say, ‘You’re a poor quality doctor if your patients get this test.’ ”The proposed measure is part of continuing federal efforts to develop ways to identify and reward value in health care. The Obama administration has said it plans to tie 50% of Medicare payments to such quality measures by 2018.

The proposed measure is part of continuing federal efforts to develop ways to identify and reward value in health care. The Obama administration has said it plans to tie 50% of Medicare payments to such quality measures by 2018.Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits don’t outweigh the harms.

Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits don’t outweigh the harms.Studies have shown that screening reduces the risk of death from prostate cancers only minimally, if atStudies have shown that screening reduces the risk of death from prostate cancers only minimally, if at all, because most grow so slowly they effectively are harmless.

Yet many men diagnosed with prostate cancer undergo surgery and radiation, which can have lifelong side effects.

Meanwhile, about 28,000 U.S. men die annually from aggressive prostate cancers, often despite getting regular PSA tests and fast treatment. (This is not substantiated).

Both the rate of PSA testing, and diagnoses of early-stage prostate cancer, have declined significantly in the U.S. in recent years, according to studies published in the Journal of the American Medical Association this week. But whether treating fewer cancers early results in more deaths from late-stage prostate cancer later won’t be known for many years.

A CMS official said that as currently drafted, the proposed measure addresses only “non-recommended PSA screenings”—that is, “men who get PSA screening when, under current clinical guidelines, it is not recommended for them.” She said it wouldn’t restrict needed or medically necessary PSA tests.

“Physicians can still order PSA tests if they feel the test is recommended or if the patient requests it,” she said.

The proposal lists some categories of men who would be excluded from the measure, including those with a history of prostate cancer or enlarged prostate, prior elevated PSA levels, or those taking certain medications for prostate issues. It doesn’t mention men at high risk for prostate cancer due to family history or African-American heritage. Some experts say the benefits of screening may outweigh the harms for such patients.

Wanda Flier, president of the American Academy of Family Physicians, which is working with CMS on other quality measures, said it planned to urge the agency to adopt a more flexible measure for PSA screening that would allow for shared decision-making between a patient and physician based on individual circumstances.

“Our goal, as we move to value-based care, is to get to a system that is based on evidence and individual circumstances and not create harm to the patient or undue economic harm to the country,” she said.

Here is the bottom line on prostate cancer screening from the most recent Annals of Internal Medicine:

Clinical Bottom Line: Screening

Screening for prostate cancer and active treatment may prevent some prostate cancer deaths, mostly a decade or more later. However, screening also produces false-negative and false-positive results and over diagnosis. Cancer treatments cause sexual dysfunction in most men and distinct patterns of urinary and bowel symptoms. Therefore, harm is much more likely than benefit. Because men differ in how they weigh these outcomes, a shared decision-making process that reviews benefits and harms is essential to any informed decision to screen. However, providers should recommend against screening for men who have no risk factors and are younger than 50 years, most men older than 69 years, and those with a life expectancy less than 10 years.

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Flu Vaccine

Wednesday, December 16, 2015 // Flu, Vaccines

Everyone over the age of 6 months should get the flu vaccine. It used to be so simple; there was just one flu vaccine.  Now we have high dose, trivalent, quadrivalent, intranasal and intradermal, to name a few.  Here is a list of the vaccines available and their indications:


To avoid ordering multiple types of flu vaccine we have chosen the vaccine that would suit the needs of the majority of our patients, the standard dose trivalent vaccine.  Some patients have asked about the high dose vaccine–it contains much more antigen than the standard dose, but studies so far show that it is no more effective, or may be only marginally better, depending on which study one reads.

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