SPRINT Study Supports More Aggressive Blood Pressure Targets

For several years now there has been a growing controversy over how low to lower blood pressure to reduce health risks. The most recent recommendations were to lower systolic BP to 140 or lower in men and women less than 60 years old, with a higher systolic blood pressure of 150 in those over 60 years older. There has been much recent concern that if we lower systolic blood pressure too much in senior citizens we fail to perfuse the brain with needed blood supply carrying oxygen and nutrients. The end result is a clinical appearance of dementia or cognitive impairment. Researchers recognize that to achieve a systolic blood pressure of less than 140 most patients need to take at least two blood pressure pills. There has been a great deal of difficulty convincing patients to consistently take those two blood pressure pills so the thought of adding a third medication to achieve a systolic BP of 120 or less is quite challenging.

To answer the question of how low to optimally lower blood pressure, the National Heart and Lung Institute instituted the SPRINT study looking at 9300 men and women over age 50 that had high blood pressure. One group was attempting to lower systolic blood pressure to 120 or less. The other to 140 or less. The study was scheduled to run through 2016 and conclude in 2017. The goal was to see if the lower blood pressure reduced the number of heart attacks and strokes. Last week the Federal government announced that the reduction in heart attacks and strokes in the aggressively treated group was so pronounced that they were stopping the study early. With the lower systolic BP the heart attack and stroke risk was reduced by nearly a third and the death risk by 25%. To achieve the desired systolic blood pressure of 120 or less required the daily use of three distinct blood pressure medications per patient.

In the process of cutting the study short to announce the results for the public’s benefit, the researchers were not able to answer the question of whether senior citizens would suffer more falls from getting dizzy with the lower pressure or if the lower pressure resulted in more cognitive impairment and dementia due to hypoperfusion of the brain. The only question they answered is that a lower target blood pressure will result in less death due to heart attacks and strokes. They did not address the issue of whether lower blood pressures would result in less chronic kidney disease either.

There are many academic researchers who hail the SPRINT study as cutting edge in further reducing cardiovascular injury and death. Other researchers are peeved at the failure to look at the effects on dizziness, falls, dementia like symptoms and kidney function with the lower blood pressure in our elderly population. As a practicing clinician I will look at each patient situation individually. I will suggest maximizing lifestyle issues such as smoking cessation, weight reduction, lipid control and sensible exercise before adding additional medications to lower blood pressure even more. We will recognize that many of you are already on two blood pressure medicines, an antiplatelet agent, a lipid lowering agent plus other medications before we add a third class of blood pressure medicine to get your systolic blood pressure even lower. With the side effect profile of most blood pressure medications including electrolyte imbalances, fatigue, effects on frequency of urination and sexual function, we must consider the individual pros and cons of further lowering BP by additional medication very carefully.

Fish Oils in Osteoarthritis – Low Dose vs. High Dose

Using the common sense approach that if a little bit is good then more is better in the treatment of “rheumatism” Catherine Hill, M.D., of the University of Adelaide in Australia and colleagues looked at the effect of taking low dose fish oil supplements versus high dose fish oil supplements. When one looks at the adult population of Australia, one third of them take fish oil supplements and had within a month of this study. The typical dose is one ml of fish oil per day. Experts say the dose for anti-inflammatory effect for arthritis is considerably higher at 2.7 gram or 10 ml per day. Dr Hill’s theory was that high dose fish oil for symptomatic and structural outcomes in people with knee osteoarthritis was better.

She enrolled 202 symptomatic patients in a double blind study. High dose group patients received 4.5 g EPA/HPA per day. The low dose group were given a blended of fish oil containing 0.45 g EPA /DHA per day in combination with Sunola oil. Both supplements were flavored with citrus oil.

All patients received a baseline MRI of the knee at inception of the study and at two years. The patients mean age was 61 years and body mass index was 29kg/meter squared. Both groups showed x-ray evidence of arthritis in the knee at inception and both groups were allowed to take non-steroidal anti-inflammatory medications and acetaminophen for arthritic pain during the course of the study.

At two years there was no difference in the MRI findings or cartilage volume loss between the high dose and low dose groups. Each group took similar amounts of NSAIDs and acetaminophen for pain on a regular basis. The high dose had no benefit over the low dose.

The researchers concluded that there was no benefit in their study to high dose versus low dose fish oil supplementation for arthritis. They reasoned that since patients in the study were permitted to take additional fish oils on their own during the study this may have altered the findings. The researchers additionally had little control over how much fish the participants ate.

In reviewing the data it seems to indicate that fish oil played a minor role in slowing down arthritis in the knee joint. Low dosage had as good of an effect as high dosage but the studies lack of a true control group who did not take fish oil at all made the conclusions hard to accept.

I will suggest to my patients that they continue to eat two fleshy fish meals per week to get their fish oils for arthritis and cardiovascular protection, rather than purchasing and taking low dose or high dose fish oil supplements.

Are Non-Steroidal Anti-inflammatory Drugs Safe?

In recent months patients and physicians have been challenged to find safe medications to relieve pain. Nonsteroidal anti-inflammatory drugs such as ibuprofen, naproxen and others were once the mainstay of simple pain relief. We knew that they could irritate the lining of your stomach and possibly cause gastrointestinal bleeding so we suggested that you take them with food in your stomach. We knew they could injure your kidneys so we reduced the dosage and frequency to individuals with kidney issues. When reports came out that these effective pain medications were contributing to acute heart attacks through coronary artery spasm, we grew leery of prescribing them. In recent years after a pharmaceutical industry push to use narcotics for pain relief we are confronted with addiction and all its negative connotations to deal with if we use opioids to relieve pain. What then is available to prescribe for pain?

The SCOT (Standard Care vs Celoxicab Study), championed by, Thomas M MacDonald, MD, of the University of Scotland Dundee helped provide an answer. The study was discussed at the meetings of the European Society of Cardiology this week with results that show that older patients with no heart disease history had no increased risk of heart attack or stroke while using NSAID drugs for extended treatment. They followed 7297 patients 60 years of age or older for three years who were prescribed celecoxib (Celebrex) or another nonsteroidal drug. The endpoint of the study was a heart attack, a stroke or the discovery of new cardiovascular disease. The number of new heart attacks or strokes was actually far lower than predicted proving that these drugs do not cause heart attacks or strokes in cardiovascular disease free individuals. The study did not look at these drugs effect on individuals with documented heart or cardiovascular disease.

In recent months the Food and Drug Administration has insisted that manufacturers of NSAID’s specifically inform and warn consumers of the increased risk of a heart attack within weeks of starting the drug and increasing with time. This study will now allow us to relieve the pain of the young athletic individual with musculoskeletal pain without fearing we are setting them up for a cardiovascular calamity.

Cold and Flu Season Coming

As we head into fall and winter we see an increase in the number of viral respiratory illnesses in the community. Most of these are simple self-limited infections that healthy individuals can weather after a period of a few days to a week of being uncomfortable from runny noses, sinus congestion, sore throats, coughs, aches and pains and sometimes fever. There are studies out of Scandinavia conducted in extreme cold temperature environments that show that taking an extra gram of Vitamin C per day reduces the number of these infections and the severity and duration in elite athletes and Special Forces military troops. Starting extra vitamin C once you develop symptoms does little to shorten the duration or lessen the intensity of the illness. Vigorous hand washing and avoidance of sick individuals helps as well. Flu shots prevent viral influenza and should be taken by all adults unless they have a specific contraindication to influenza. A cold is not the flu or influenza. Whooping cough or pertussis vaccination with TDap should be taken by all middle aged and senior adults as well to update their pertussis immunity. We often see pictures of individuals wearing cloth surgical masks in crowded areas to prevent being exposed to a viral illness. Those cloth surgical masks keep the wearers secretions and “germs” contained from others but do nothing to prevent infectious agents others are emitting from getting through the pores of the mask and infecting them. If you wish to wear a mask that is effective in keeping infectious agents out then you need to be using an N95 respirator mask.

Once you exhibit viral upper respiratory tract symptoms care is supportive. If you are a running a fever of 101 degrees or higher taking Tylenol or a NSAID will bring the fever down. Staying hydrated with warm fluids, soups and broths helps. Resting when tired helps. Most adults do not “catch” strep throat unless they are exposed to young children usually ages 2-7 that have strep throat. Sore throats feel better with warm fluids, throat lozenges and rest.

You need to see your doctor if you have a chronic illness such as asthma , COPD, heart failure or an immunosuppressive disease which impairs your immune system and you develop a viral illness with a fever of 100.8 or higher. If your fever is 101 or greater for more than 24 hours it is the time to contact your doctor. Breathing difficulty is a red flag for the need to contact your physician immediately.

Most of these viral illnesses will make you feel miserable but will resolve on their own with rest, common sense and plenty of fluids.

Medical Students Return for Clinical Experience

The Charles F. Schmidt College of Medicine medical students who learn history taking, physical examinations and patient care skills have returned to the office for their second year of training. Danielle Chang Klein will be seeing patients with Dr. Reznick on Wednesday afternoons this year. Dr. Levine’s student, Tyler Anderson, will be seeing patients with him on Monday afternoons. If you prefer not being seen by a medical student then please let us know and we will make sure you are seen just by your physician. I understand that being seen by a student is not for everyone. I also understand that it presents a unique opportunity for our patient’s in a relaxed clinical setting to teach our future doctors’ how they wish to be treated as patients.

Adult Sore Throats 2015 – 2016 Flu Season

Robert Centor, M.D., of the University of Alabama at Birmingham, performed the definitive study on adult sore throats showing that 10% or less of adult sore throats are caused by bacteria particularly Group A Streptococcus . He went on to prove that bacterial Strep throats were accompanied by a cough, large swollen and tender lymph nodes, a temperature greater than 100.4 and an exudate on your tonsils. The disease is primarily seen in children age 2-7 and those who care for them and play with them. In adults who did not meet the criteria of having a cough, swollen and enlarged lymph nodes, a temperature of 100.4 and a tonsillar exudate, a rapid streptococcus throat swab was accurate 100 % of the time. If the quick strep analysis is negative you do not have a strep throat and do not require an antibiotic. We had two patients this past fall who did not meet the criteria of Dr. Centor, did not have the physical findings consistent with a strep throat, had a negative quick strep throat swab but upon performing a traditional throat culture were found to be positive for Group a Beta Hemolytic Streptococcus requiring antibiotics. Why did the discrepancy occur? According to the manufacturer they had to recall a batch of diagnostic material that was ineffective. Both patients were placed on antibiotics soon after their clinical course did not follow the path of a viral infection and both did well.

Most adult sore throats and colds do not require antibiotics. We reserve them for patient with debilitating chronic illnesses especially advanced pulmonary, cardiac and neurologic disease patients. With influenza season on the horizon we will continue to assess patient’s clinically using history, exam, quick strep throat swabs and traditional microbiological throat cultures where appropriate. I will continue to prescribe antibiotics where necessary but must admit, last years’ experience opened my eyes to a more liberal approach with the prescribing of antibiotics for simple sore throats.

2015 Changes in Medicine for Medicare Patients

CMS, the parent organization for the Medicare program has decided to reduce health care costs. One method for reducing health care costs is to pay a flat bundled fee for services to one entity and let that entity worry about how to pay for all the services and equipment. CMS first venture into this practice in the State of Florida begins shortly with Medicare deciding to pay one flat fee for knee and hip replacements. In our local area they will pay Boca Raton Regional Hospital (BRRH) one time. The hospital is expected to provide physicians, nurses, pharmaceutical goods, the orthopedic appliance (the hip and knee) and all related costs including your postoperative stay in a rehabilitation facility and physical therapy. If a patient has a medical complication of the surgery, or the surgeon needs consultative physician assistance, that too is covered in the bundled fee.

This means that your orthopedic surgeon will either need to be an employee of Boca Raton Regional Hospital or a contracted physician at an agreed upon price for that service. For several years now, CMS has been encouraging hospitals and health care organizations to organize into Accountable Care Organizations (ACO’s) which would receive the bundled payments and distribute them according to a formula they devise internally. The ACO’s have formed in most parts of the country, but Florida remains as a stronghold of fiercely independent physicians primarily in the medical and surgical specialties that are procedure oriented and generate large revenue streams. They have seen hospital systems like Boca Raton Regional Hospital purchase physician practices and try to run them at least twice in the last 25 years. In each case the hospitals lost large sums of money, the practices ran inefficiently and were returned to the physician owners as a means of cutting their losses. Over the last few years, in addition to building many new facilities , BRRH has been buying up local physician practices and employing the doctors in primary care ( Boca Care), hematology oncology ( Lynn Regional Cancer Group), plus their hospitalist service, emergency department physicians ( who additionally staff their community Urgent Care Centers) pathologists , anesthesiologists and others. By accumulating so many of the formerly private physicians’ as employees or contracted help, they were able to change the structure and bylaws of the medical staff rules and regulations and bylaws allowing the hospital administration to effectively eliminate a checks and balances arm of decision making that protected patient and physician interests.

When you enter the hospital for a knee or hip replacement, it is unclear if your personal physician will be paid by Medicare for seeing you if that physician is not a member of the Accountable Care Organization or an employee of the hospital. A non-employed, non-contracted consulting doctor may possibly bill the patient privately for their services but it is unclear whether Medicare will pay the doctor if they accept assignment, or reimburse the patient if they pay privately and submit the receipt to their insurances for reimbursement. CMS plans to bundle payments for 30% of existing conditions by 2017 and over 70% by 2023. These changes are part of the Affordable Care Act or “ObamaCare”.

I will continue to see my patients who need a hip or knee replacement and develop a fair payment option for them. This will apply to any future bundled service CMS implements as well. My patients will continue to be cared for by me! Experienced local physicians have a healthy distrust of the hospital as an employer based on their past track record. Younger physicians coming out of training with large educational debt and a desire to balance their lives by working regular shifts are more willing to accept employment positions and work for the ACO’s. The goal of the Federal Government is to reduce health care spending by fiat rather than by natural market forces. As the Baby Boomers age and develop more chronic conditions and require more care It seems to me that physicians will need to spend more time with these complex patients rather than less time in short conveyor belt type visits being advocated CMS and current health care policy makers. Feel free to contact me if you wish to discuss any of this.


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