Should You Stay Home When You Are Ill

Symptoms of being sick with the flu or a cold are designed genetically to protect the rest of the population from catching the disease according to researchers at the Weizmann Institute of Science in Israel. Their research findings have been published in PLos Biology. This is cold and flu season and individuals wake up daily feeling ill and miserable and wonder if they should take their antivirals and some acetaminophen and tough it out at work?

The study authors note that feeling sick is a multi-system event involving the endocrine system, the nervous system the immune system, the respiratory system and others. They cite the fact that behavior associated with being ill has been preserved over millennia of evolution. They give an example of an infectious illness which causes the patient to isolate themselves from others. While the patient may not survive the illness, the isolation behavior favors them not passing it on to others. Appetite loss prevents the disease from spreading through shared sources of food and water. Fatigue and weakness reduce the sick individuals’ independence and mobility reducing the distance and “radius” of possible infection. Other symptoms such as lost interest in others and less sexual desire and contact also reduce the transmission of disease. They cite changes in body language and personal grooming that send the message, “I am sick! Don’t come near.”

Professor G. Shakhar of the Immunology Department at Weizmann Institute made it clear that despite available medications to ease the symptoms, you are still ill and infectious and should stay home! We routinely advise patients to stay home until their temperature is less than 100.8 for 24 hours. If you have an upper respiratory tract infection with copious nasal discharge and cough related phlegm stay home to prevent getting everyone else at the office ill as well.

CDC and ACP: Stop Prescribing Antibiotics for Common Respiratory Infections

The Affordable Health Care Act has created patient satisfaction surveys which can affect a physician’s reimbursement for services rendered plus their actual employment by large insurers and health care systems. This has created a fear of not giving patients something or something they want at visits for colds, sore throats and other viral illnesses. Aaron M Harris, MD, MPH, an internist and epidemiologist with the CDC noted that antibiotics are prescribed at 100 million ambulatory visits annually and 41% of these prescriptions are for respiratory conditions. The unnecessary use of antibiotics has resulted in an increasing number of bacteria developing resistance to common antibiotics and to a surge in Emergency Department visits for adverse effects of these medications plus the development of antibiotic related colitis. To address the issue of overuse of antibiotics, Dr Harris and associates conducted a literature review of evidence based data on the use of antibiotics and its effects and presented guidelines for antibiotic use endorsed by the American College of Physicians and the Center for Disease Control.

  1. Physicians should not prescribe antibiotics for patients with uncomplicated bronchitis unless they suspect pneumonia are present”. Acute bronchitis is among the e most common adult outpatient diagnoses, with about 100 million ambulatory care visits in the US per year, more than 70% of which result in a prescription for antibiotics.” The authors suggested using cough suppressants, expectorants, first generation antihistamines, and decongestants for symptom relief.
  2. Patients who have a sore throat (pharyngitis) should only receive an antibiotic if they have confirmed group A streptococcal pharyngitis. Harris group estimates that antibiotics for adult sore throats are needed less than 2% of the time but are prescribed at most outpatient visits for pharyngitis. Physicians say it is quicker and easier to write a prescription than it is to explain to the patient why they do not need an antibiotic.
  3. Sinusitis and the common cold result in overprescribing and unnecessary use of antibiotics often. Over four million adults are diagnosed with sinusitis annually and more than 80% of their ambulatory visits result in the prescribing of an antibiotic unnecessarily. “ Treatment with antibiotics should be reserved for patients with acute rhinosinusitis who have persistent symptoms for more than ten days, nasal discharge or facial pain that lasts more than 3 consecutive days and signs of high fever with onset of severe symptoms. They also suggest patients who had a simple sinusitis or cold that lasted five days and suddenly gets worse (double sickening) qualified for an antibiotic

Last year two patients in the practice who were treated with antibiotics prescribed elsewhere for situations outside the current guidelines developed severe antibiotic related colitis. They presented with fever, severe abdominal pain and persistent watery bloody diarrhea. Usual treatment with oral vancomycin and cholestyramine did not cure the illness. One patient lost thirty pounds, the other sixty pounds. Fecal transplants were required to quell the disease. At the same time community based urine infections now require a change in antibiotic selection because so many of the organisms are now resistant to the less toxic, less expensive , less complicated antibiotics that traditionally worked.

“My doctor always gives me an antibiotic and I know my body and what it needs,” can no longer be the criteria for antibiotic use.

Aspirin Use for Targeted Breast Cancer

The indication to take aspirin to prevent various diseases has certainly been confusing over the last few years. A Veterans Administration (VA) study in the 1950’s noted that men over 45 years of age who took an aspirin per day had fewer heart attacks and strokes. The exact dosage of aspirin to take to prevent heart attacks and strokes has been the subject of many studies and much disagreement. In more recent times researchers have questioned whether aspirin should only be taken by those individuals who already have survived a heart attack or stroke for secondary prevention.

Taking aspirin is not risk free with users having a higher risk of gastrointestinal bleeding and cerebral hemorrhage especially if head trauma was involved. Recent studies have made it even more confusing with some experts not wanting patients to take aspirin for primary prevention of a first heart attack or stroke unless their 10 year risk of an event was 6% or greater. Others thought 6% was too high a figure and suggested 3%. The guidelines and suggestions for aspirin use to prevent cardiovascular disease have certainly become more confusing and have made the decision to use it far more complicated.

As a result of the use of aspirin in prevention of vascular and heart disease, researchers noted that people who took aspirin had fewer pre-cancerous adenomatous colon polyps and less skin cancer. In a 2010 study in the Journal of Clinical Oncology, Drs. Michelle Holmes and Wendy Chen of the Harvard Medical School noticed that women with breast cancer who took one aspirin per week had a 50% lower chance of dying from breast cancer. This observational study required a more detailed sophisticated double blind study to prove the point but the authors did not receive the necessary funding to begin the research study. This left the relationship between aspirin use and breast cancer development very unclear.

In the December 22, 2015 edition of the Mayo Clinic Proceedings, Bardia A, Keenan TE, and Ebbert JO and associates published data hinting that aspirin use was associated with a lower incidence of breast cancer for women with a history of breast cancer and those with a personal history of benign breast disease. This study of 26,580 postmenopausal women followed the study participants for three years. In the online journal Internal Medicine News, Neil Skolnik, MD talked about the exciting possibility of decreasing breast cancer in this specific group of women by 30 – 40% by taking a daily aspirin.

There is no question that aspirin therapy increases the risk of bleeding especially in the GI tract and the brain. Trauma and cuts will lead to increased bleeding and blood loss. Individuals will need to discuss with their physician the pros and cons of preventive aspirin therapy for heart disease prevention, skin cancer prevention, colon cancer prevention and now breast cancer prevention based on their personal and family medical history and balance it with the risk of bleeding.

High Disability and Death Rates in Bleeds Associated with New Oral Anticoagulants

In the trailer for the movie Jaws 2 they show a swimmer in the ocean with a deep voice saying, “Just when you thought it was safe to go back into the water…” followed by the classic music associated with a shark attack and a big fin approaching the unsuspecting swimmer. I feel much the same way upon reading a Medpage Today online journal review of an article in JAMA Neurology published on December 14, 2015. Jan C. Purrucker, MD and colleagues looked at 61 consecutive patients with non-trauma related cerebral hemorrhages due to the newer oral anticoagulants Pradaxa, Xarelto and Eliquis. Overall there was a death rate of 28% at three months and “two out of 3 survivors had an unfavorable outcome.”

In October of 2015 the FDA approved the use of the antibody fragment idarucizumab (Praxbind) to reverse anticoagulation in patients bleeding from the administration of the oral anticoagulant Pradaxa. There are currently no medications to reverse the bleeding from the drugs Xarelto or Eliquis but we are promised that new products are in development. The article goes on to discuss how physicians have been forced to improvise when patients on these medications show up bleeding. They have tried fresh frozen plasma, 3-factor, 4-factor and activated prothrombin complex concentrates prothrombin complex concentrates, recombinant factor VIIa and cryoprecipitate alone or in combination with marginal success at best.

Despite there being no antidote to these blood thinners, the massive direct to consumer advertising continues on television prime time and magazines as if the products are no more dangerous than an antacid for heartburn. Coumadin or warfarin is the prototype anticoagulant working by inhibiting vitamin K dependent clotting factors. Its effects are reversible with administration of Vitamin K and clotting factors if bleeding occurs. Coumadin requires periodic blood tests (INR) to check on its efficacy and there is a long list of medications and foods that need to be avoided or adjusted while taking it. It is less convenient but safer in the sense that its effects can be reversed with medication.

The newer oral anticoagulants were championed by several studies that suggested that they were more effective in preventing embolic strokes in patients with the heart rhythm atrial fibrillation. Many experts in the field felt that those conclusions were flawed because the Coumadin group was not tightly regulated to keep their INR in a therapeutic non-clotting range thus unfairly biasing the results in favor of the newer agents.

There is no question that the newer agents are more convenient than warfarin treatment, but until there are readily available antidotes, complications seem to be more difficult to limit and control.

Does Not Testing the PSA Lead to More Advanced Prostate Cancer?

Mortality from prostate cancer has diminished by almost 40% since the introduction of the PSA test in the late 1980’s. Much of this is due to the use of the PSA blood test for screening purposes. In 2011 The US Preventive Screening Task Force strongly condemned the use of PSA screening. They felt that we were finding too many inconsequential early malignancies that would not lead to death and were being over treated. In their eyes, prostate cancer treatment with surgery and or radiation carried a high price tag with multiple long term complications and the benefit of screening was not worth the risk. Prior to the USPSTF”s 2011 recommendation against screening for prostate cancer with a PSA there were 9000 – 12,000 new cases of prostate cancer diagnosed per month. In the month following the USPSTF recommendation not to screen with PSA the number of new cases dropped by almost 1400 a month or over 12%. Over the next year the decline in prostate cancer diagnosis was 37.9 % for low-risk prostate cancer, 28.1% for intermediate risk, 23.1 5 for high risk and 1.1% for non-localized cancer. Clearly if you do not look for a disease you will not find it.

In the December issue of the Journal of Urology, Daniel Barocas, MD, of Vanderbilt University and colleagues discussed the PSA testing controversy. They too noted that the consequences of not screening for intermediate and high risk prostate cancer by performing the PSA test may lead to individuals presenting with far more advanced disease that is more difficult to treat, has more complications and ultimately leads to disease related deaths. His position was debated by two major urologists in the editorial section of the journal with no firm conclusion being reached.

In an unrelated article, the Center for Medicare Services or CMS announced that it is considering penalizing physicians who test the PSA for screening in Medicare patients beginning in 2018 as part of their paying for value and quality. They said that physicians need to present their patients with an ABN (advanced beneficiary notice) stating that Medicare will not pay for this test, before the blood is drawn or face fines and penalties.

Men in their forties and older have been put in an uncomfortable and inappropriate position by health policy leaders. The truth is we are currently unsure how and when to test for prostate cancer in men with a normal digital rectal exam (DRE). The consequences of not paying for screening will not be known or understood for easily ten to fifteen years. It is clear that early stage disease has the option to be observed for progression with minimal consequences in the short term. Not enough time has elapsed for anyone to know the long term effects of this policy change. Unfortunately, men in this age group are all guinea pigs in the public health policy laboratory while the data to reach a firm scientific conclusion is assembled. The predominant policy today is spending less and doing less. With this in mind, it is best for men to see their doctor, have an annual digital rectal exam, discuss their family history of prostate disease and reach an individual decision on PSA screening appropriate for their unique situation rather than one based on large population policy.

There is No Hope for Ending Medicare Fraud

South Florida is apparently a hotbed for criminal Medicare fraud. It is easy theft with crime rings accessing Medicare numbers of the elderly in Dade County and Broward and setting up durable medical equipment companies that bill our local Medicare subsidiary for equipment that doesn’t exist. Having said that, yesterday I received a Medicare Summary of Benefits letter for my mother at my home. She is almost 90 years old and my brother and I are her legal guardians and handle all her financial affairs while she resides in a skilled nursing facility in northern Palm Beach County, Florida. We moved her to this excellent campus in May of 2015 from a facility in Broward County and by submitting a change of address notice to the US Post Office, all her mail now comes to me. The official Medicare Benefits Summary stated that on September 11, 2015 a claim had been received for a wheelchair for my mom for $280 from a durable medical equipment company in Miami, Florida. The ordering physician was her former physician at her former Broward County skilled nursing facility. I thought it was strange that a bill would be submitted for a wheelchair four months after she was gone from that facility so I tried to reach the doctor. I was told that he was no longer at that facility. I next called my mom and asked her if she had received a new wheelchair in the last few months and she just did not remember if she had or not. I had no knowledge of it but the move from one facility to another accompanied by closing down her apartment in the assisted living section had been tumultuous and disorderly.

I then called the Medicare Fraud number listed on the piece of mail, 1-800- Medicare. The call was answered by an automated attendant who did not list “Fraud Report” as one of the choices so I pressed 5 for “other.” I was placed on hold for five minutes and a pleasant gentleman asked me why I was calling. I explained and he politely asked me to please hold on. Another five minutes elapsed before he got back on the line and apologized for the delay. He started asking me personal questions about my mother for security purposes such as her address, phone number, date of birth, Medicare number. He then asked me to hold on while he prepared a report and another seven minutes elapsed. He told me he would be transferring my call to a supervisory claims officer and I held on again.

It took five or more minutes before a woman got on the phone and repeated the same questions I had already been asked and answered. I tried to explain the purpose of the call and my relationship to my mother but she politely silenced me and told me that she had the original agent’s summary and knew the reason for the call. She asked me to hold on while she looked up the claim and another ten minutes elapsed. When she returned she told me that Medicare paid durable medical equipment claims monthly for up to twelve months and possibly this was a late claim for a 13th month. I then asked her what type of non-motorized wheelchair could possibly cost 12 X $280. I explained to her that all I was interested in was reporting a suspicious claim. She told me that without me forwarding her a copy of my Power of Attorney form she would not be able to reveal any claims history information to me. I told her I wasn’t asking for her to reveal any information but was just trying to report a suspicious Medicare claim. She responded that the claim had been denied and not paid so why was I making such a fuss in the first place. Having invested almost an hour trying to be a responsible citizen I gave up. If this is the type of system we as citizens put in place and tolerate then we deserve to be ripped off!

Two Handoffs with Different Outcomes

My 66 year old professional athletic patient had a history of a scar tissue related small bowel obstruction seven years ago related to a previous appendectomy. He now had similar symptoms with cramping, lower abdominal pain, and some nausea. Since his office was next door to his longtime friend and gastroenterologist he called over there. He was given an appointment with the junior partner since his buddy was out of town. Thirty years earlier I had referred him to that practice. The junior partner examined him, thought it was a self-limited viral illness and sent him home. The next day the two met in the Emergency Department for similar symptoms and once again the patient was sent home. The symptoms continued for 48 hours, and at the end of one of his long workdays he again saw the junior partner. This time the gastroenterologist sent him over to the hospital for a CT scan at about 6PM. Two hours later he received a phone call that the patient had a small bowel obstruction and the radiologist inquired of the GI specialist; “What should I do with him?” He was told to send him to the Emergency Department. When the physician in the ED called the GI doctor for admitting orders, he responded,” call his PCP (primary care physician) I am a consultant and I do not admit patients. “Forty five minutes later I received a call from the emergency department informing me for the first time of my patient’s problem and asking me to come in and admit the patient to the hospital. I asked him why the GI doctor was not taking ownership of the problem. I was told that the gastroenterologist said he was a specialist and did consulting not admissions. When I called the gastroenterologist directly I reached one of the covering partners who told me, “We are only gastroenterologists and we have not kept up our certification in internal medicine so we are really not qualified to admit a patient with a bowel obstruction or provide the day to day medical care.”

Another patient, 67 Hispanic and female was being treated for depression. She was under the care of a psychiatrist and in the middle of a medication adjustment. Her husband brought her to me because she was hallucinating, talking to her deceased father, acting violent and sexually inappropriate. I called her psychiatrist and then her neurologist who both answered the phone call immediately and suggested we schedule a CT scan of the brain. It showed a large brain frontal lobe tumor with much swelling around it and a hint of hemorrhage. I met with the patient and informed her of the problem and called the local university medical center to speak to the director of their brain tumor department. The university center is traditionally difficult to communicate with and receive information from. This time the young new department chair took my phone call, reviewed the clinical scans and data sent to him by fax and said, “She seems like she needs our help. If she can come down now I will have our team meet her and begin her evaluation. Later that night she clinically deteriorated. I text messaged the surgeon. He responded within minutes and said, “Send her down now; my team will meet her in the Emergency Department. “ I received daily clinical updates from this department chairman and prior to discharge he called me with a complete review, medication list, things to look for and emergency contact numbers if the patient had a problem. The professionalism, thoroughness and collegial communication was outstanding and far safer for the patient than for my local patient with a bowel obstruction. I was treated as a professional colleague asking for help with a patient rather than a generalist medical doctor expected to whatever the procedural specialist did not want to do.

I thought the gastroenterologist was both rude and dismissive of primary care physicians. I believe he abandoned his patient and created a safety issue by not calling me directly if he wanted me to assume the patient’s care. I was so upset that I brought the matter to the attention of the Chairperson of the hospital department of medicine and the associate chair of our medical executive committee. Both told me that similar things had happened to them. One told me of a nephrologist performing dialysis on a mutual patient who sent a patient unannounced to the Emergency Department because his vascular access was amiss and never called him about it but expected him to admit the patient and obtain appropriate specialty help to deal with the infection. The other doctor told of a cardiology patient who saw a cardiologist in an office that was across the street from the hospital. The patient was in dire straits with florid pulmonary edema and great distress so he sent him by ambulance to the Emergency Department. When he got there and the Emergency Department called him he said, “I don’t admit. Call his PCP for that.” He never called the patient’s PCP either to tell him he was sending this mutual patient who was critically ill to the hospital. Both medical staff officers told me that I could not hope to change a national culture which dumps on the PCPs and the patients. They told me it was not a hospital staff problem but one I needed to solve with the individual consulting groups.

Failure to communicate and take responsibility for care you have begun especially when the problem is in your area of expertise is a safety issue. It will come back to harm a patient someday. When these same gentlemen are sitting in court testifying in that medical malpractice case they will say the system is not fair rather than recognize that their inactions contributed to the problem. Hospital administrators and hospital boards using physicians they now employ and a limited number of local private physicians they can control have created a culture of poor communication between caregivers at a time when the technology exists to make communication far simpler and easy. They choose physicians for committee positions that are easy to influence. Community and public input into the policies of local hospitals and health care delivery systems has been eliminated or limited so that the driving force for policy is profits whether you are dealing with a for profit or nonprofit facility. In this setting the probability of errors occurring and patients’ being harmed because of lack of communication is greatly increased. There is institutional indifference to this problem and the safety organizations responsible for inspecting hospitals have not addressed it yet.

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.