Coffee Consumption Lowers Mortality Risk

The online edition of the Annals of Internal Medicine, July 11, 2017 edition published an article from MJ Gunter using data from the European Prospective Investigation into Cancer and Nutrition that concluded that coffee consumption lowered patient mortality. The study looked at more than 520,000 patients from 10 different countries that were followed for 16.4 years. In a side study they looked at a group of 14, 800 patients and examined the correlation between coffee consumption and biomarkers of liver inflammation, function and health.

Patients who drank the most coffee had statistically significant lower all-cause mortality than individuals who did not consume coffee.  Patients in the highest group of coffee consumption tended to have significantly lower risk for mortality related to digestive diseases. Women coffee drinkers had a lower risk for cerebrovascular disease mortality and circulatory disease mortality but were at higher risk for ovarian cancer related mortality.

The researchers concluded, “Coffee drinking was associated with reduced risk for death from various causes.”

I will enjoy my coffee even more now. If only I could lay off the bagels and donuts that go with it.

Advertisements

Physical Therapy as Effective as Surgery in Lumbar Spinal Stenosis

Anthony Delitto, PT, PhD and colleagues at the University of Pittsburgh published an article in the April 7, 2015 Annals of Internal Medicine documenting that at the two year mark, physical therapy was as effective as surgical decompression in spinal stenosis of the lumbar spine. The study involved 169 patients diagnosed with spinal stenosis with imaging confirmation by either CT scan or MRI. These patients all met the accepted criteria for surgical intervention, all had agreed to and signed consent for surgery and all had leg pain with walking (neurogenic claudication). None of the patients had previous back surgery.

After all had consented to surgery they were randomly assigned to a surgical group or a physical therapy group that had exercise sessions twice a week for six weeks. They were then followed for two years. The physical therapy exercises included general conditioning plus lumbar flexion exercises.

All the participants charted their course with a self- reported survey of physical function which consisted of scores from zero to 100 on topics such as pain, function and mental health. The patients were all reassessed at 10 weeks, 6 months, 12 months and 24 months.

There was no difference between the surgical group and the physical therapy groups in the category of physical function at any time during the follow-up. Despite this 47 of the 82 patients assigned to the physical therapy group crossed over and had surgery with nearly a third in the first ten weeks. Patients crossed over to surgery for both medical and financial reasons citing the high cost of copays for physical therapy. Jeffrey Katz, MD, director or the Orthopedic and Arthritis Center at the Brigham and Women’s Hospital in Boston felt that the paper “suggests that a strategy of starting with an active, standardized physical therapy regimen results in similar outcomes to immediate decompressive surgery over the first several years.”

This paper gives us excellent data on the belief that surgery of the back should be a last resort. Since the study only looks at two years, it is hoped that continued follow-up over time will allow us to see the real life situation we see in our patients who live with this condition for decades not months.

Physical Therapy as Effective as Surgery in Lumbar Spinal Stenosis

Physical TherapyAnthony Delitto, PT, PhD and colleagues at the University of Pittsburgh published an article in the April 7, 2015 Annals of Internal Medicine documenting that at the two year mark, physical therapy was as effective as surgical decompression in spinal stenosis of the lumbar spine. The study involved 169 patients diagnosed with spinal stenosis with imaging confirmation by either CT Scan or MRI. These patients all met the accepted criteria for surgical intervention, all had agreed to and signed consent for surgery and all had leg pain with walking (neurogenic claudication). None of the patients had previous back surgery.

After all had consented to surgery they were randomly assigned to a surgical group or a physical therapy group that had exercise sessions twice a week for 6 weeks. They were then followed for two years. The physical therapy exercises included general conditioning plus lumbar flexion exercises.

All the participants charted their course with a self- reported survey of physical function which consisted of scores from zero to 100 on topics such as pain, function and mental health. The patients were all reassessed at 10 weeks, 6 months, 12 months and 24 months.

There was no difference between the surgical group and the physical therapy groups in the category of physical function at any time during the follow-up. Despite this 47 of the 82 patients assigned to the physical therapy group crossed over and had surgery with nearly a third in the first ten weeks. Patients crossed over to surgery for both medical and financial reasons citing the high cost of copays for physical therapy. Jeffrey Katz, MD, director or the Orthopedic and Arthritis Center at the Brigham and Women’s Hospital in Boston felt that the paper “suggests that a strategy of starting with an active, standardized physical therapy regimen results in similar outcomes to immediate decompressive surgery over the first several years.”

This paper gives us excellent data on the belief that surgery of the back should be a last resort. Since it doesn’t follow the patients for more than two years it is hoped that continued follow-up over time will allow us to see the real life situation we see in our patients who live with this condition for decades not months.

American College of Physicians Rejects “Heart Screening in Adults at Low Risk”

Heart screeningI am often asked by potential new patients, “What do you consider a complete annual checkup?” When I tell them it is a detailed history session reviewing their personal medical history and family history followed by a comprehensive medical physical examination they inquire about testing. We generally perform a urinalysis and a blood panel measuring things such as the blood sugar, the cholesterol and lipid profile, kidney and liver function plus thyroid function. In addition to that we personalize the testing based on the information presented by the patient during the history session and exam. Despite having few risk factors for the development of heart disease, peripheral arterial vascular disease or cerebrovascular disease they ask how often they can have a nuclear stress test, an echocardiogram and imaging of their hearts and blood vessels. When I tell them they probably do not need such testing they tell me about their highly fit and athletic friend with no symptoms who just had a stress test and ended up with a three vessel coronary bypass procedure “saving“ their life.

An article in the Annals of Internal Medicine the American College of Physicians (ACP) supported that position saying that individuals with a Framingham cardiovascular risk assessment of <10% over the next 10 years should not be tested. “These recommendations are based on the lack of evidence showing that screening improves clinical outcomes.” They went on to say that screening has unclear effects on risk reclassification and the use of risk reducing therapies and noted that while abnormalities discovered via resting or exercise EKG were associated with an increased risk of subsequent cardiovascular events, they had no effect on clinical outcomes. According to the authors, “even if a cardiac abnormality is uncovered via screening, the most effective treatment may be adjustments in diet, exercise and other modifiable CHD risk factors that would be recommended regardless of screening results.”

I am frequently asked about the health conscious individual who had the testing and was found surprisingly to have critical disease requiring a lifesaving procedure. The ACP cited a thorough Coronary Artery Surgery Study in which cardiac catheterization on patients with “nonspecific“ or unclear chest pain revealed atherosclerosis in 40% of men and 24% of women, but only 3% of men and 0.6% of women had severe enough disease to benefit from a revascularization procedure.

The ACP paper cited the harm done by screening low risk individuals including excessive radiation exposure and the cost and morbidity of doing additional testing and or procedures to follow up false positive test results. The group stated that a nuclear stress test exposed an individual to an effective radiation dose that is twice the dose of an abdominal CT scan (15.6 mSV) which is the equivalent of ten years’ worth of chest x-ray irradiation. They also projected an increased risk of 2 -25 cancer cases per 10,000 nuclear medicine stress tests in people age 50 or older.

What is clear from the ACP recommendations is that the decision to perform cardiovascular screening should be based on the personal and individual patient history and physical exam findings which indicate a significant possibility of their being cardiac or vascular disease. If in fact the risk is low then testing for the sake of wanting to know causes more problems than solutions.

The Benefits of Exercise and Fitness

Woman with DumbbellsThe highly acclaimed Cooper Clinic has been following 20,000 patients’ fitness levels for the last 40 years. They recently published an article in the Annals of Internal Medicine proclaiming that fitness in the middle years of life lowers your risk of developing dementia in your senior years. The Cooper Clinic has been following these patients for evaluation of cardiovascular fitness and development of heart disease but decided to use the same data to review who, if any, developed dementia by their 70th, 75th, 80th and 85th birthdays. All participants initially were screened with exercise treadmill testing. They found that those who were the fittest were 36% less likely to be diagnosed with dementia after age 65 than the least fit.

David Geldmacher, MD, of the University of Alabama at Birmingham, told MedPage Today that the potential benefit of exercise to reduce dementia risk is worth bringing up with patients, even though recommendations for exercise are made routinely for cardiovascular health reasons. Many patients are willing to forego exercise with the belief that sudden death by a heart related illness isn’t such a bad way to expire. On the other hand the thought of living with a chronic debilitating disease like dementia is highly undesirable and exercise might be an acceptable lifestyle change to prevent that process. Knowing that fitness can reduce the Alzheimer risk may give them further motivation to follow through with an exercise and fitness plan.

In an unrelated but equally fascinating study, researchers at the Durham Veterans Affairs Medical Center in Durham, North Carolina found that Caucasian men who participated in regular exercise at a moderate level were less likely to have prostate cancer on biopsy of suspicious areas of the prostate. If the biopsy did reveal prostate cancer the grade of the cancer tended to be lower indicating a more favorable prognosis. This study of 164 Caucasian men and 143 black men did not show any fitness protection for black men who exercised regularly. The authors went on to point out the small size of the study and the fact that the level and frequency of exercise was self-reported not measured or monitored by the research team. Other factors such as heredity, diet and lifestyle issues may be factors as well. They recommended further study to determine the exact relationship between exercise and prostate health or disease.

Both these studies strongly support the concept that regular exercise of a moderate level probably has strongly favorable influences in multiple areas of health. I will continue to urge my patients to get some form of regular exercise that they enjoy on a daily basis while the researchers confirm the long term benefit of regular exercise and fitness.

Narcotic Painkiller Use Increased in the Elderly

An investigative newspaper article published in the May 30, 2012 issue of the Milwaukee Journal Sentinel, in cooperation with online periodical MedPage Today, chronicles the increased use of narcotics for chronic pain relief in the elderly. The article highlights how in 2009 the American Geriatrics Society put together a panel of geriatric pain specialists who published geriatric narcotic pain relief guidelines that have led to the dramatic increase in use of narcotics in the elderly. There is apparently no outstanding or solid evidence that Opioids or narcotics actually work better than non-narcotic pain medications in relieving the chronic pain of senior citizens.  It is the Milwaukee Journal’s opinion that the members of the blue ribbon panel who made this decision received financial benefits from the pharmaceutical manufacturers who produce narcotic pain pills and were biased in their recommendations.  Individual members of the panel received financial rewards from the companies making the narcotic pain pills and the sponsoring organization, the American Geriatric Society, reportedly received $344,000 from Opioid manufacturers.

A study in the 2010 Annals of Internal Medicine looked at over 10,000 people who had received 3 or more Opioid prescriptions over a 90 day period. The researchers found that 51 had suffered an overdose including six deaths.  Of the 40 most serious overdoses, 15 occurred in those aged 65 or older.  A 2010 research paper in the Archives of Internal Medicine looked at 12,840 Medicare patients with an average age of 80 who had used Opioids, traditional anti-inflammatory drugs, or a class of non narcotic   prescription painkillers like Celebrex. Their findings included:

  • Opioid users were more than four times more likely to suffer a fall with a fracture than non-Opioid users
  • Deaths from any cause were 87% more likely in Opioid users.
  • Cardiovascular complications including heart attacks, strokes, and cardiac death were 77% higher in Opioid users than in users of NSAIDS.

In part, as a result of the American Geriatrics Society guidelines, Opioid use for pain relief has increased by over 32% since 2007.   Locally, we have seen the proliferation of pain clinics. These clinics, often owned by non-physicians, bear some responsibility for the proliferation of narcotic pain pills on the streets of America being used illegally.   Poorly conceived state legislation and the lack of surveillance and monitoring led out-of-state drug pushers to drive into Florida, hire individuals to doctor shop from pain clinic to pain clinic where they accumulate thousands of pills that are sold out of state on the streets illegally.  Ultimately this led to a law enforcement and statewide crackdown which drove illegal and legitimate pain specialists out of the state of Florida. It is almost impossible to find a certified pain physician in Palm Beach or Broward County who will take on a new patient under the age of 65 years old due to the legal hurdles recently imposed on them to crack down on the illegal dispensing of drugs.

George Lundberg, MD and Maria Sullivan, MD of Columbia University presented a sane and reasonable approach to pain pill management in MedPage Today in the June 11th issue.  They suggested that non narcotic pain products be tried initially. They encouraged doctors and nurses to discuss the side effects of narcotics with patients including constipation, sedation, addiction, and overdose and with long term use the risk of hyperalgesia and sexual dysfunction.

They noted the high abuse potential of short acting Opioids such as Dilaudid (hydromorphone) and Vicodin (Hydrocodone/acetaminophen) and pointed out that these drugs may be good for short term initial pain relief but not chronic use.  They reviewed the pharmacology of methadone and pointed out that it is responsible for far too many overdoses due to its basic metabolism and mechanism of action. They suggested never using it in patients who have not taken Opioid narcotics regularly.

They discussed the need for patients to keep controlled substances in a secure and locked place to prevent theft of the medication.

For those practitioners who prescribe Opioids for chronic pain they suggested having a chronic pain narcotic protocol including a medication contract with the patient that outlines its correct use. Psychological evaluation for abuse potential should be considered in all chronic pain patients prescribed narcotics. Urine toxicology screening periodically should be performed to look for abuse.  There are clinical interview screening materials such as the SOAPP (Screening and Opioid Assessment for Patients with Pain) form which helps identify individuals with a high risk of abuse.  Stratifying your pain patients into low, medium, and high risk individuals may help distinguish the level of surveillance necessary to safely treat the patients.

It would make great sense for the state of Florida and the Florida Medical Association to develop a common sense pain management course for practicing providers to take prior to renewing their state medical licenses.  The course would cover the newer pain protocols and medicines and review the safe and monitored use of Opioid narcotics.  We must treat and eliminate or reduce pain. We just need to do this in a safer manner.

Statistics For Dummies: Primary Care Doctors’ Inability to Understand Statistical Concepts …

An article and editorial have appeared in the Annals of Internal Medicine demonstrating that primary care physicians do not understand simple statistical data presented to them regarding screening tests for cancer. The consequences, as outlined in an editorial written by a former chairperson of the much maligned Institute of Medicine, is that primary care doctors are over-using cancer screening tests because they do not understand the statistical ramifications and conclusions presented in the study. The editorialist recommends improving statistical courses at the medical school level and improving the editorial comments in journals when these studies appear.

As a primary care physician, out of medical school for 36 years, let me make a suggestion.  Keep It Simple Stupid.   Medical school was a four year program.  The statistics course was a brief three week interlude in the midst of a tsunami of new educational material presented in a new language (the language of “medicalese”) presented en masse in between students being used as cheap labor at all hours of the day to fill in drawing bloods, starting intravenous lines and running errands for the equally overworked interns and residents who were actually being paid to perform these tasks.

While internship and residency included a regular journal club, there was little attention paid to analyzing a paper critically from a statistical mathematical viewpoint.  I suggest applying the KISS principle to analyzing medical research papers. Make the language and definitions clear cut and understandable for the non math majors and non researchers.  We have eliminated the use of Latin, medical abbreviations and other time honored traditions of the profession in the name of clarity and safety.  It’s time to do the same with statistical analysis of research papers. Let authors and reviewers say what they mean at an understandable level. Practicing clinicians do not use this vocabulary regularly enough to master it.

It’s time for creating a “Khan Kollege” You-Tube video on statistical analysis and medical paper review that clinicians can refer to routinely to buff up their understanding of medical research papers.  If the American College of Physicians or American Academy of Family Practitioners already have such programs on their websites I apologize for not knowing where to find it.

Each year the economic advisors who freely give advice to us PCP providers have asked me to add three patients per day per year to my schedule to economically be able to stay in the same place.  Amidst that high volume and need to stay current and need to have some balance in my life I admit my statistical analysis skills have grown rusty.  I believe many of my colleagues have suffered the same fate. When the Medical Knowledge Self Assessment syllabus arrives every other year, the statistics booklet is probably one of the last we look at because not only does it involve re-learning material but you must first re–learn a vocabulary you do not use day to day or week to week.

I will make my effort to re-learn statistics to better understand the literature. It is my professional responsibility to do so. I ask my colleagues in academia to do a better job, however, of explaining and teaching the concepts so the data and the logical conclusions are understandable.