More Anti-Oxidants Provide No Benefit for Aging Eyes

Eye Glasses, Older WomanTwo papers presented at the Association for Research in Vision (ARVO) conference in Seattle emphasized that in a population of patients with adequate nutrition the addition of more antioxidants, vitamins and supplements do not help your vision or prevent progression or development of eye disease. In fact, not only did they not help but there was a significant concern that the addition of lutein and beta carotene to the diet of smokers and former smokers actually increased the risk of those individuals developing carcinoma of the lung. The studies were published in JAMA Ophthalmology and the Journal of the American Medical Association.

The study, known as Age-Related Eye Disease Study 2 (AREDS2), concluded that adding lutein, zeaxanthin, and fish oil to daily multivitamin supplements does not boost prevention of age related macular degeneration or cataracts in high risk individuals.

The original AREDS study showed that adding high doses of Vitamin C and Vitamin E, beta carotene and zinc slowed and lowered progression of early and intermediate age related macular degeneration and associated vision loss. That original study suggested that the addition of more antioxidants might help. This was the basis for the follow-up study AREDS2.  The follow up study randomized patients to receive lutein plus zeaxanthin, or omega 3 fatty acids, plus DHA and EPA, both, or a placebo. No benefit of adding these antioxidants was noted except in patients with extreme nutritional deprivation situations.

Vitamin C is a water soluble vitamin.  You keep what you need and the rest is eliminated harmlessly through the kidneys. Vitamin E is a fat soluble vitamin and excess intake is stored in the cells of your body.  Toxicity can occur from ingesting too much of Vitamin E or Vitamin A.  Beta Carotene has been postulated to have an effect on lung cancer in other studies.   The bottom line, too much of anything is not good for you. 

Patients should be asking their ophthalmologists about the constituents of the supplements being recommended to them for eye health.  If they are a cigarette smoker or former smoker they should question the need for beta carotene and lutein because of the association with lung cancer. They should review their total Vitamin A, E, D and K intake from their ophthalmologic vitamins and supplements and their other vitamins and supplements to insure that their total daily intake does not exceed recommended levels.

Where Do You Go To Die?

Question Mark v3A long-time patient in his mid-nineties, who lived an independent and full life style, became acutely ill six weeks ago. He lost his equilibrium and was unable to get up from a chair without having his blood pressure plummet and him faint.  When we could keep his blood pressure up, and he tried to walk, he ambulated like an intoxicated individual, swaying from side to side slapping his feet down like Goofy in Disney World.  CT scans of the brain, neck and spine, MRI scans of the brain, neurological testing, cardiac testing and multiple consultants in cardiology, neurology, and endocrinology could not find the cause of his problems. He did develop an aggressive and fastidious urine infection which improved with antibiotics.  It was hoped that with time, good nutrition and help from a team of occupational and physical therapists at a skilled nursing facility, we could return this sweet gentleman to his previous state of life. It did not work out that way.  Instead of improving he declined. He refused to eat or drink. He refused to consider intravenous nutrition or a feeding tube. He was judged by psychiatry to be sane and competent to make those decisions.   Trials of mood and appetite stimulants did not work. The decline occurred over a five day period at the SNF during which I called on him at least daily.

The patient and I had discussions about end of life issues yearly which we documented on his chart. The last discussion in January 2013 revealed that he did not want to be kept alive by machines but was not ready to sign a Do Not Resuscitate (DNR) order. He was against artificial feeding measures such as NG tubes and PEG’s.  As he declined clinically, I reintroduced that discussion to his wife and children.  I suggested we execute a DNR form and begin comfort measures. I asked them to consider a consult with Hospice but assured them we could provide comfort measures without them as well. They declined all help saying they were beginning to consider it but were not quite ready yet to make a decision. The SNF charge nurse was present at one of these discussions and to my surprise called me aside and said, “That man cannot die here. People cannot die here unless they execute a DNR or are in a hospice bed.”   I could not believe what I was hearing. We were in an old age home in a geriatric community with multiple custodial care patients plus the post-hospital rehab type patients.  The charge nurse then brought in the administrator who emphasized the same message. “He cannot die here.”

If the patient’s demise was imminent, the SNF wanted him transferred to the acute care hospital or else they threatened to call 911.    Where then are deteriorating patients supposed to die?  Hospice has become a bureaucracy unto itself and, while their efforts and works are admirable, the cost to Medicare is extraordinary.  Why can’t a deteriorating patient who is not uncomfortable or in distress expire quietly surrounded by family in a SNF?  Ideally this patient should be at home but sometimes the family just cannot provide the support and care in their home?  Is the only alternative an acute care hospital via 911 or Hospice?

Low Dose Aspirin Cuts Colon Cancer Risk in Women

AspirinNancy Cook, SCD of Brigham and Women’s Hospital in Boston and colleagues reported in the July 16, 2013 issue of the Annals of Internal Medicine that data from the Women’s Health Initiative including 39,876 women 45 years or older, who were randomly assigned to take 100 mg of aspirin every other day for ten years, experienced a 20% reduction in the risk of colorectal cancer. The study did not show that there was an all-cause reduction in mortality .

The very conservative US Preventive Services Task Force currently recommends aspirin in Women 55 – 79 only if potential benefits are greater than harms. The aspirin group did have more bleeding from peptic ulcers and gastrointestinal bleeding. The article was accompanied by an editorial comment by Peter Rothwell, MD, PhD of the University of Oxford. He felt that the risk of bleeding and the fact that there was no all-cause mortality reduction, or risk in all cause cancer reduction, should result in a tempering of suggestions for widespread use of aspirin in healthy middle-aged women. MedPage Today, the online Journal of the University Of Pennsylvania School Of Medicine, ran a comment from Dr. Randal Burt, MD, a gastroenterologist at the Huntsman Cancer Institute who felt that this was one more piece of evidence that aspirin can reduce colorectal cancer.

It is clear that there are multiple studies showing that aspirin can reduce the risk of colorectal cancer. There are studies showing it reduces the risk of a stroke in women as well.

Like all decisions to take or prescribe a medication, the risks and benefits must be examined first. It is clear to me that in a woman with a strong family history of colorectal cancer, and little or no history of gastrointestinal or systemic bleeding, an aspirin with close monitoring should seriously be considered.

Lipid Testing Continues After LDL Target Met

A study performed at a Veterans Affairs medical center in Houston, Texas claims that physicians are ordering too many lipid levels on patients with coronary artery disease who have met the LDL (low density lipoprotein) guidelines of <70mg/dl. They looked at 35,191 patients and found that 9200 of these patients had already achieved the desired lipid levels however their clinic physicians ordered a repeat lipid panel on subsequent tests. The researchers cited the Institute of Medicine guidelines which suggest testing your lipid levels only once a year once you have achieved goal levels. If that annual test reveals an elevation of your lipids outside guidelines and it leads to an intensification of your treatment, then they believe it is acceptable to recheck your cholesterol and its subtypes to assess the effectiveness of the treatment.

The study was published in the online edition of the Journal of the American Medical Association (JAMA) by Salim S. Virani, MD PhD of the Michael DeBakey VA and Baylor College of Medicine in Houston. They concluded and an accompanying editorial questioned whether this was an overuse of resources and wasteful spending that was not being discussed by health policy experts because this was low expense non procedural waste and not a big ticket item. They stressed the need to get this wasteful spending under control if we expect to reduce overall health care costs.

In my internal medicine practice, an individual who achieves goal levels of lipids by losing weight, or eating a different diet, or exercising more vigorously or by taking a medicine may in fact alter their habits over a 3-6 month period. They may gain back the weight they lost. They may reduce their exercise due to scheduling conflicts or physical injury and health problems. They may alter their medication regimens or be placed on medicines by other doctors that influence their lipid levels. There are very few patients in my practice that are static and have no changes from quarter to quarter of the calendar year. I make no money sending off blood tests. The lab makes a great deal of money. They have a very high fee schedule for uninsured patients. Their fee schedule for private insurances and Medicare is still far higher than the fee they will charge your doctor if the doctor charges the patient directly and pays the wholesale cost to the lab for that test. Maybe the researchers and cost effective analysts should be looking at the actual cost to the lab of performing the test and insuring that the profit they make is appropriate not price gouging instead of worrying about an additional two or three lipid panels per patient per year. When I send your blood to a reference lab I earn no money on it but do bear the responsibility for interpreting the result and conveying it to you. It seems to me some of the research on cost effectiveness is getting very penny wise and pound foolish.

A Large Review Proves Statins Are Safe

StatinsThe online version of Circulation: Cardiovascular Quality and Outcome published a review of the safety of statin drugs. The study looked at 135 randomized research trials including 246,955 participants. Medications examined included atorvastatin (Lipitor), fluvastatin (Lescol), simvastatin (Zocor), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and trials of pitavastatin.

They found there were no differences in the rates of discontinuation of the statins because of adverse events compared with discontinuation of placebo. The same applied to elevation of the muscle enzyme creatine kinase, muscle aches or myalgias and/or the development of cancer. As the doses of these medicines increased they found the participants reported more adverse effects.

Christie Ballantyne, MD of the Baylor College of Medicine reviewed the study for MedPage, the online journal of the University Of Pennsylvania School Of Medicine, and felt the study certainly confirmed the tolerability of the statins as a class of drugs to lower cholesterol and reduce cardiovascular events. He reaffirmed the very small increased risk of statin use and developing Type II Diabetes and the need to monitor liver function blood tests while taking the drugs. He concluded these risks were well worth taking in view of the benefits to your health statins provided.