Archive for the ‘News’ 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

Background

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.

Methods

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.

Results

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.

Conclusions

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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New Pneumonia Vaccine Guidelines for Patients Over 65

Friday, January 23, 2015 // News, Vaccines

These recommendations have been in the works for a long time. What the CDC didn’t mention is that Medicare hasn’t decided whether to pay for the PCV13 vaccine or not. Patients anxious to get the vaccine are getting confusing information from pharmacies. Some are trying to give them the PPSV23 when the ask for the PCV13 which goes by the brand name Prevnar. Until the dust settles, I’m not ordering any.

The Advisory Committee on Immunization Practices (ACIP) recommends that the 13-valent pneumococcal conjugate vaccine (PCV13,Prevnar) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23,Pneumovax) should be routinely administered in series to all adults who are at least 65 years of age, the CDC announced last week.

Adults in this age group who have not previously received a pneumococcal vaccine or who do not know their vaccination history should receive a dose of PCV13, followed by a dose of PPSV23 6 to 12 months later. The 2 vaccines should not be administered together, and the minimum acceptable interval between them is 8 weeks, the ACIP said.

Adults in this age group who have previously received 1 or more doses of PPSV23 should receive a dose of PCV13 if they not already done so. This dose should be given at least 1 year after the most recent PPSV23 dose was received. Patients in whom another dose of PPSV23 is indicated should receive it 6 to 12 months after PCV13 and 5 or more years after the most recent dose of PPSV23.

The recommendations were published in the Sept. 19 Morbidity and Mortality Weekly.

 

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Vicodin

Friday, January 23, 2015 // Medication, News

Vicodin (hydrocodone/APAP) a potent pain killer has been changed by the Federal government from a Class III drug for which a prescription can be written or called in to a special prescription which can’t be called in and has to be written on a special prescription. This is in an effort to reduce abuse of prescription drugs. There is also a reduction in the number of days for which a prescription can be written. It goes from 180 days to 90 days. A prescription for it will now necessitate a trip to the doctor’s office.

We’ll see how this plan works. It will be challenging for patients with chronic conditions which necessitate the regular use of this medication.

 

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Stress Testing

Friday, January 23, 2015 // News

Stress testing may be useful to screen for heart disease, assess exercise tolerance and blood pressure response to exercise, but the American College of Cardiology does not recommend doing it in patients at low risk for coronary artery disease because a positive test, which may indicate underlying heart disease, is more likely to be a false positive in these individuals.  The patient may then have to go through additional testing to prove what isn’t wrong with them.  It may be useful in stratifying risk is patients who have multiple risk factors for heart disease.  I will continue to utilize it in those select individuals.

 

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Flu Vaccine

Friday, January 23, 2015 // Flu, News

Most patients have received their flu vaccine by now. Unfortunately, it’s not a great match with the strain that is circulating now as the following article from Journal Watch outlines, but it is all we have available and offers some protection.

 

Flu Vaccine Not a Perfect Match to Circulating Viruses

By Kelly Young Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS Roughly half of the circulating influenza A (H3N2) viruses collected in the U.S. early this flu season are antigenically different from the H3N2 virus included in this year’s vaccine, prompting CDC officials to remind healthcare providers about using neuraminidase inhibitors to treat and prevent influenza. H3N2 has been present in about 90% of influenza-positive tests this flu season. Years with high H3N2 activity tend to see higher flu morbidity and mortality. The World Health Organization recommended components for the Northern Hemisphere vaccine in February. Antigenically drifted H3N2 viruses were detected in March and became more prevalent in September, too late to change the vaccine. “They’re different enough that we’re concerned that protection from vaccination … may be lower than we usually see,” CDC Director Tom Frieden told reporters on Thursday.The CDC is still recommending that people get vaccinated against the flu because it provides partial protection and the B strains are well matched. But Frieden said that if clinicians suspect influenza in high-risk patients, they should start neuraminidase inhibitor treatment without waiting for confirmatory test results. – See more here.

I was very surprised by the recommendation of the Tamiflu-like medications (neuraminidase inhibitors) given recent articles on their lack of efficacy. Again, from Journal Watch.

 

Tamiflu, Relenza Data Show Little Clinical Benefit Against Flu
By Joe Elia

The neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) have only marginal benefits in the treatment and prevention of influenza, a series of BMJ articles concludes. Investigators reviewed documents submitted to regulatory agencies concerning both drugs. Tamiflu data showed it reduced symptom duration by roughly 17 hours but made no difference in hospital admissions or rates of carefully defined pneumonia. Tamiflu increased nausea and vomiting. As prophylaxis, it greatly reduced symptomatic (but not asymptomatic) cases. The Relenza analysis similarly showed a modest reduction in symptom duration (14 hours) and no effect on pneumonia. As prophylaxis, it acted like Tamiflu and had fewer side effects. Editorialists observe that the analyses show “with greater clarity than ever” that the current system for drug regulation is broken. And one commented that, given these results, “it is difficult to conceive that many patients would actively seek treatment.”. NEJM Journal Watch Infectious Diseases associate editor Stephen Baum wrote: “Clean out your medicine cabinet: these reviews call into question the drugs’ efficacy and side effects, as well as the ways in which data were selectively used to promote them.” – See more here

Still, most people who are sick would gladly shorten their sickness by 17 hours. If you have headache, fever and a cough you can call, email or text. Make sure to do it in the first 48 hours. It is not considered good medical practice to prescribe medications for people who are not your patients. It is also a big liability to prescribe drugs with potential side effects for people with whose medical history you are not familiar.. For those reasons I don’t call in Tamiflu for non patients, and recommend calling their physician.

 

 

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New Associate: Dr. Jennifer Wallace

Friday, January 23, 2015 // News

When I opened this practice 12 years ago, I designed the space for two physicians. I felt confident that I would locate someone who would be a good match. That didn’t happen, I got used to the quiet along with the patients and staff and I didn’t actively seek another physician. Now, I have finally identified someone who is a good fit. I worked with Dr. Jennifer Wallace in my old practice and she has agreed to come on board starting in the spring of 2015. Dr. Wallace graduated from Texas A+M. She received her medical degree from the University of Texas Health Science Center at San Antonio and did her residency there in Internal Medicine. She is board certified in Internal Medicine. She is married, is a stepmother and plays the piano.

She is currently accepting new patients so if you wish to refer a friend or family member to Dr. Wallace, you can call Sieglinde at 210-822-2004. Her email address is [email protected]. Forms are available on this page. She will start April 1st. No fooling. I think having another physician in the office will improve coverage when I am out of town and will allow us to take care of more of our existing patients, families and friends than we would otherwise have been able to.

 

 

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