Need To Expand the Recommendations for Screening for Lung Cancer in Former Smokers

In 1976 when I began my internship in internal medicine almost all cigarette smokers 35 years of age or older received an annual chest x ray to screen for lung cancer. In the 1990’s as managed care and insurers’ stopped paying for these screenings, we were told by the experts that the cost of saving one life by looking at every smoker was not cost effective. Insurance companies stopped paying for these films at the same time that medical advisory boards insisted on clinicians sending their chest x-rays out to be read by radiologists, adding extra costs to each film.

The practice of routine screening virtually disappeared. With it came a large increase in the number of smoking related deaths from lung cancer. It took the “experts” almost two decades to realize the errors of their decision.

In 2014 the US Preventive Services Task Force endorsed performing low dose computed tomography (CT Scans) in patients who were a high risk for lung cancer. This group was defined as individuals aged 55 to 80 years who had smoked at least 30 pack years (computed as number of packages of cigarettes smoked per day times the years the individual smoked) in individuals who continued to smoke or had quit within the last 15 years. The data to back up this recommendation came from Ping Yang, MD, PhD and colleagues at the Mayo Clinic. Their research and the new recommendations have helped reduce lung cancer deaths by 20%.

Since these recommendations were instituted, Dr. Yang and colleagues have continued to evaluate the guidelines. They found that individuals who quit smoking 15 -30 years ago are being diagnosed with lung cancer at a rate of 12-17 % of the newly diagnosed cases. They consequently are now recommending that we screen all adults 55- 80 with a 30 pack year history even if they quit more than 15 years ago.

The US Preventive Services Task Force which produces the recommendations that insurers consider has not yet endorsed this suggestion. In our practice we will be recommending low dose CT lung scanning annually on all our smokers who meet the Mayo Clinic criteria. If you, as my patient, fall into that group and have not been getting annual low dose CT Scanning of the lung for lung cancer detection please let us know so that we may set up a surveillance program. We understand the increased cost and ionizing radiation exposure that CT Scans involve but Dr Wang’s research suggests that the benefits outweigh the costs and risks.

End of Life Decisions Are Tougher Than We Think

As an internist and geriatrician I deal with elderly patients all the time. We always end up talking about end of life issues such as “Should I be resuscitated if my heart stops and I stop breathing?”. “Do I want a feeding tube or gastrostomy tube if I stop eating and require nutrition?” “Should I be kept alive on machines and for how long if there is no reasonable hope of recovery?” “When should we refuse tests for diagnosis and subsequent treatments due to frailty, age and quality of life.” These are all immensely difficult decisions for patients and their loved ones. We have documents available such as living wills and medical directives and we appoint health care surrogates to carry out our wishes when we cannot direct care ourselves due to health reasons. Despite this, disagreement often happens between family members and loved ones when the time comes to institute the plans outlined by the incapacitated patient. There are different interpretations of “living”, “terminal condition”, “life prolonging treatment”, etc. Is having a heartbeat and a spontaneous respiration truly living if you cannot eat by mouth, walk to the bathroom, recognize your loved one?

I faced these decisions as a caregiver and co-healthcare surrogate earlier this year and, despite being a professional, felt the decision making was extraordinarily painful and difficult. I share decision making with my brother who lives out of state but will hop on a plane at a moment’s notice to help out. He is an extraordinary son to my chronically ill mom. Widowed a few years back, and suffering from severe and chronic lower extremity issues, she became wheel chair bound and incontinent in the last year. Mom has been living in a highly rated senior facility with its own on-site medical staff in a complex supported by a religious philanthropic organization. Her doctor is a “fellowship trained geriatrician” from an Ivy League institution supported by a team of nurse practitioners. For this reason I decided to interact strictly as her son, not her doctor. Since dad passed away several years ago, she became withdrawn, angry and stopped participating in facility functions. The care team brought in psychiatrists who prescribed medications that left her calmer but clearly hallucinating frequently.

With isolation came increasing cognitive dysfunction with poor decision making and extremely fuzzy thinking. Four months ago she complained to me about having foot pain. I reported it to the nurse rather than undress her and examine her. The LPN reported it to the nurse practitioner. She was seen by a podiatrist several days later and several hours after that visit a nursing aide called my brother in NYC to ask permission to apply betadine (iodine solution) to an infection on her toes. He granted it. Several weeks later while visiting her I smelled decaying flesh. I noticed that when she moved her feet under her sheets she grimaced. I walked over and lifted the sheets and gasped. I was looking at seven gangrenous toes with a blue cool foot and absent pulses in both feet. No one had told my brother or me that mom had vascular insufficiency with gangrenous feet and toes. I called in the nurse and she called the nurse practitioner. The nurse practitioner had no answer as to why no one had told my brother or me that mom had a serious vascular problem going on for months. We had participated in the monthly team telephone conference calls where we listened to social workers, dietitians and therapists discuss her eating habits, socialization and participation. No one discussed gangrene.

Mom had a living will and a State of Florida DNR form. At best she enjoyed holiday trips to my home for family dinners, reading a book and watching TV. Injuries to her hands from repeated falls had made reading a book difficult. Sensitivity about wearing adult diapers and having an accident while visiting my home or out to a restaurant had made those trips a thing of the past. No one at the facility or care team discussed gangrene, evaluation and care for it or the option of palliative care. The Nurse Practitioner said that they hoped the iodine applied to the toes would stem an infection and the bloodless toes would just fall off.

I had numerous discussions with my brother about asking Hospice to intervene and provide comfort measures only at that point. My thinking was colored by my experiences as a resident at a big city hospital where a man with a gangrenous leg chose not to amputate it for religious reasons. We treated his infection but packed his gangrenous leg in ice so the decaying tissue would not rapidly deteriorate and to reduce the horrible odor. I did not want my mother to become that gentleman dying a horrible death, packed in dry ice while caregivers avoided her room due to the horrible odor.

A kind vascular surgeon in the area with excellent credentials offered to see her and offer an opinion. He said that without a diagnostic angiogram he would recommend an amputation above the knee on one side and below the knee on the other. I could not see amputating two legs. Had mom been rational and competent she would not have wanted that. Hospice seemed like the rational decision but that decision required two health care surrogates to reach agreement. “Steve I called her on the phone yesterday and the nurse brought her the phone. We had a wonderful conversation about your nephew and your kids. She seemed with it.” Grandchildren called her and had rational conversations with her. There was resistance to calling in Hospice within the family and their concerns created seeds of doubt in me. I am not blaming my relatives at all. I never stood up to them and strongly said, “She is infirm, with a miserable quality of life and no hope of improvement and you are all crazy for wanting to intervene.” So she went for an angiogram and they opened up three arteries in the right leg and then two on the left. The vascular doctor recommended amputating the gangrenous toes while the circulation was good and creating a clean margin of tissue receiving blood. That procedure took about an hour and was done right after the angiogram. All looked well when I saw her back in her room and snuck in a forbidden corned beef sandwich and kosher pickle. One week later the pain returned to the left foot. It looked dusky and pale. Noninvasive vascular studies showed the arteries that had been opened were now closed. The vascular surgeon recommended above the knee amputation. During this period of time my brother had made multiple trips back and forth from NYC to visit Nana. Our children had flown in from out of town to rally her and support her. They saw her deterioration. They saw her go from recognizing them to confusing them for our wives and her mother and sister. The decision to call Hospice this time met with no family resistance. Hospice arrived as Hurricane Matthew bore down on this area. We went home to prepare our homes for the storm and mom died during it.

Her death clearly relieved her of suffering with a horrible quality of life. That fact is comforting. Losing a mom is an irreplaceable loss. Should I have been more forceful in demanding palliative care earlier? I am still not sure. I am very comfortable with the effort to restore blood circulation to her feet to relieve pain and suffering. I would make that decision again. Other families and clinicians might not have decided that was the best course of action for their loved ones. I will say I had no guidance or help from her medical care team. I think patients and families need guidance at times like these because the choices are not black and white. There is much grey and much pain and many life experiences and emotion coloring your decisions.

I still sit down with my patient’s families and review the end of life options. We talk more about what “living” actually means to their loved ones. The decisions are never easy.

Water versus Diet Drinks for Dieting and Weight Loss

Water and many diet beverages quench your thirst and are listed as providing no energy or calories to your daily intake. With this in mind, researchers at the University of Nottingham in the United Kingdom set up a definitive study to assess the effect of water on weight loss after a meal versus a diet beverage’s effect on weight loss.

Ameneh Madjid, PharmD and associates looked at 81 overweight and obese women with Type II Diabetes Mellitus. Members of the group were either asked to continue drinking diet beverages five times per week after lunch or substitute water for the diet beverages. The researchers found that over a 24 week period, the water group had greater decreases in weight, body mass index, fasting plasma glucose, fasting insulin homeostasis and two hour post-meal glucose readings compared with the diet beverage group.

A similar study published in the American Journal of Clinical Nutrition looking at 89 obese women found that after six months the water group had lost an extra three pounds compared to the diet beverage group.

As a clinician, the idea of putting water into your body as opposed to diet drink chemicals makes great sense. There have been some researchers who felt that diet beverages eliminated calories in soft drinks but that users consumed more dietary food and calories when drinking diet beverages as opposed to water.

I will suggest to my patients that they try water instead of diet beverages but remind them that an occasional diet beverage probably will not hurt their long term goals.

News on Newer Oral Anticoagulants (NOAC)

For most of my adult medical career, warfarin or Coumadin has been the gold standard for achieving anticoagulation to prevent deep vein thrombosis, pulmonary embolism, embolic strokes and other hypercoaguable conditions. Taking warfarin required monitoring your INR or Prothrombin Time by taking blood from a vein or puncturing your finger and using the finger stick blood on a strip to calculate the INR. Our goal was to keep the INR level therapeutic between 2 and 3. The safe dose of warfarin (Coumadin) is affected by dietary intake of foods containing Vitamin K (green leafy vegetables and fruits) and medications that either makes the warfarin more or less potent. These dietary and medication interferences either made your blood more coaguable increasing your risk of an embolic event, or made the blood less coaguable and contributed to bleeding events. These could include intracranial bleeds leading to permanent neurological damage and or death or gastrointestinal or retroperitoneal bleeding which could be life threatening. Warfarin or Coumadin’s anticoagulant effect could be reversed quickly by administering an antidote, fresh frozen plasma (FFP) and or replacing Vitamin K.

Within the last decade, pharmaceutical manufacturers developed and released newer oral anticoagulants such as Pradaxa (dabigatran), Xarelto (rivaroxaban) and Eliquis (apixaban). These medications were advertised as safe and did not require blood tests to monitor their effectiveness while eliminating interactions with healthy foods and most medicines. They were embraced by cardiologists trying to prevent embolic strokes in patients with the arrhythmia atrial fibrillation. The major drawback was that if you started to bleed, there was no antidote to stop the bleeding available. In the introductory period the drug could only be reversed by removing the drug via hemodialysis. There were additional questions about whether the drug was actually as or more effective than warfarin when the warfarin dosage was monitored and regulated at reputable and established medical centers in the United States.

At the European Society of Cardiology meetings in Rome, Italy, Stuart J Connelly, MD, from McMaster University in Hamilton, Ontario Canada reported this week on the results of the ANNEXA – 4 Study. They reported being able to reverse the effects of Xarelto and Eliquis using a newly created chemical. According to their report they had achieved a safe and effective antidote for these two drugs which would complement another product already approved by the FDA and in use to reverse the anticoagulant effects of Pradaxa. Their presentation of the data was accompanied by the simultaneous publication of the results in the New England Journal of Medicine. Despite the papers presentation and warm reception and publication in a respected peer review journal, the FDA has yet to approve this medication for use in the United States.

At the same meeting, Dutch researchers presented data showing that the NOAC’s (Pradaxa, Xarelto, Eliquis) provide at least the same degree of embolic stroke prevention as warfarin with less chance of intracranial bleeding. Clearly if this study is reproducible and if the antidote for bleeding with Xarelto and Eliquis receives FDA approval, it will be far easier for patients and clinicians to work with these NOAC’s then to continue treatment with Coumadin. The NOAC’s are far more expensive than warfarin (Coumadin) but their ease of use and reversibility with the newly approved agents, will make them the drugs of choice when an oral anticoagulant is required.

To Floss or Not To Floss? Making Recommendations Without Data

The U.S. Department of Health has announced that there is no data that flossing your gums has any benefit.  This has led to an Associated Press review of the paucity of randomly controlled trials with evidence that flossing is beneficial. The result is a new recommendation that flossing daily is not necessary. We are living in an era where the only justification for research and observational studies seems to be to justify saving money by not teaching patients something or encouraging them not to do something. Cost containment is the key as the US Government tries to lower the percentage of dollars spent on health care as a percentage of the Gross National Product.

Experts at the Cleveland Clinic spurred on by the “Bale and Doneen” philosophy that inflammation in arterial vessels leads to acute heart attacks and strokes have pushed for greater periodontal care and health. Flossing is part of that philosophy. Cleaning in-between your teeth with hand held pics or water pics provides cleaning of the gums and spaces between teeth as well.  There are few or any studies on this subject because the benefit is so obvious that there has been no need to perform them.  Dentists assure me that proper tooth and gum care is essential to your general health and wellbeing.  This is common sense like not crossing a busy street against the light, not drinking alcohol and driving a car or truck or not jumping out of an airplane without a parachute. It’s time for our dental schools to organize and perform these studies but I suggest you keep caring for your gums and teeth while the data is being accumulated.

Pneumococcal Vaccine in Development May Fight All Strains of the Disease

Community acquired pneumonia (CAP) plus other infections attributable to the Pneumococcus bacteria account for 15 million infections per year including pneumonia, meningitis and bronchitis. The organism is the leading cause of death in children less than five years old.  Over the last 30 years pharmaceutical companies have developed Pneumovax 23 which covers 23 unique bacteria that cause CAP in adults and Prevnair 13 which covers 13 pneumococcal bacterial strains.  Twelve of the bacteria in Prevnair 13 are identical to the Pneumovax 23 with only one unique bacterial type included.

A group at the State University of New York at Buffalo led by Blaine Pfeifer, specializing in chemical and bacterial engineering; has developed a new approach to pneumococcal vaccination. Working with computer modeling and animals to this point, they have developed a successful vaccine that attacks pathogenic pneumococcal bacteria while leaving the beneficial and non-pathogenic subtypes alone. The vaccine reads proteins on the surface of the bacterial cells and destroys only those that show aggressive activity. The vaccine has been 100% effective against the 12 most virulent pneumococcal bacterial strains existing in animal studies.    The vaccine is being prepared for human testing in the near future.  The preliminary work was discussed in the medical magazine Medical Economics

Telomeres and Healthy Aging. The Tufts Perspective

Telomeres are bits of DNA genetic material that sit atop DNA strands and keep vital genetic material intact when cells divide or replicate. Think of them as the little plastic piece on top of the shoe laces. When they fall off or become damaged the shoelaces get damaged or frayed. Healthier older individuals have longer DNA strands with intact telomeres compared to people with shorter life spans and chronic diseases who have smaller and shorter telomeres. Whether the shorter telomeres are the “chicken or egg” is unclear but clearly those with shorter telomeres are more likely to die from heart disease or infectious processes.

There does seem to be a relationship between telomere size and nutritional and vitamin levels. Ligi Paul Pottenplackel is a researcher at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts New England Medical Center. She has looked extensively at the humans’ intake and concentration of folate and telomere length and health. She found that those with an exceptionally high folate level and intake have shorter telomeres and worse health. While many researchers believe that folate being water soluble is flushed out if you don’t need it and causes no cumulative toxicity, she believes the short telomeres may be the result of excessive folate intake.

Physical exercise seems to keep telomeres from eroding. In an article in the journal Medicine & Science in Sports and Exercise, researchers showed that telomeres were longer in those who were active. Over time, all participants telomeres shortened but less so in the physically active groups.

While Tufts takes a closer look at nutrition and healthy aging we urge all to stay physically active while eating a balanced diet