The Attitude Doc

Aug. 27, 2009 - Early treatment of chronic obstructive pulmonary disease ( COPD) slows loss of lung function and likely extends survival, a large-scale clinical trial shows.

COPD is almost always caused by smoking. It includes two diseases: chronic bronchitis, in which the airways become inflamed; and emphysema, in which the air sacs in the lung are damaged.

Over time, COPD gets worse. Treatment does not reverse lung damage, but it can make patients feel better.

The enormous UPLIFT study enrolled nearly 6,000 COPD patients in 487 centers in 37 nations. UPLIFT tested the inhaled, long-acting bronchodilator Spiriva.

Last year, UPLIFT study investigators reported that Spiriva can safely help patients with severe COPD breathe more easily. But treatment did not slow the inexorable loss of lung function in COPD patients.

But what if Spiriva were begun earlier, in patients with more moderate, early disease? Few COPD studies have enrolled patients with early-stage disease.

Analysis of the subset of 2,739 UPLIFT patients with moderate COPD shows that Spiriva could actually slow COPD progression. Treatment also reduced COPD exacerbations and improved quality of life over the four-year study.

There was even a suggestion that Spiriva extended survival, although there were too few deaths among these patients for this finding to be statistically significant.

"Treatment of COPD should begin in symptomatic patients with moderate [COPD] disease," conclude UPLIFT investigators Marc Decramer, MD, PhD, and colleagues.

In an editorial accompanying the study, University of Liverpool researchers Lisa Davies and Peter Calverley note that the improvements seen with Spiriva treatment were greater in early-stage patients than in late-stage patients.

"Important gains in wellbeing can be produced and maintained in the earlier stages of COPD," they conclude.

The Decramer report, and the Davies/Calverley editorial, appear in the Aug. 28 online edition of The Lancet.

View Article Sources

SOURCES:

Decramer, M. The Lancet, published online Aug. 28, 2009.

Davies, L. and Calverley, P. The Lancet, published online Aug. 28, 2009.

Tashkin, D.P. The New England Journal of Medicine, Oct. 9, 2008; vol 359: pp 1543-1554.

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Aug. 27, 2009 -- People with peripheral artery disease (PAD) -- even without symptoms -- have a more than fourfold higher risk of bad outcomes after a transient ischemic attack (TIA) or stroke, a new study suggests.

But the same study finds that a simple test of blood pressure at the ankle can detect asymptomatic PAD, giving patients a chance to reduce their risk.

Heart disease risk goes way up in people who have suffered strokes or TIAs. That risk is even greater in people who also have PAD, a sign that plaque is clogging the arteries.

But some people with PAD don't have any symptoms. Are they, too, at higher risk after a TIA or stroke?

Yes, find Souvik Sen, MD, MPH, of the University of North Carolina, Chapel Hill, and colleagues.

Sen's team used a test called the ankle brachial index (ABI) to detect PAD in 102 patients who had just had a TIA or stroke but had no PAD symptoms (such as pain in the foot, leg, or buttocks after exercise, a symptom called intermittent claudication).

The ABI is a simple test that measures the blood pressure at the ankle and compares it to the blood pressure at the arm. If the ankle blood pressure is significantly lower, it indicates that plaque is clogging the outer arteries of the body. This is PAD.

About a fourth of the TIA/stroke patients in the Sen study did have PAD. Over the next two years, they were four times more likely to suffer a TIA, heart attack, or heart-related death. And they were five times more likely to suffer a stroke.

The ABI test isn't recommended to screen the general population for PAD. But it is advised for people at high risk of PAD.

Now Sen and colleagues suggest that ABI tests may be useful for recognizing risk -- and taking more aggressive steps to lower that risk -- in patients who've recently suffered a stroke or TIA.

The Sen study will appear in a November issue of the American Heart Association journal Stroke.

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SOURCE:

Sen, S. Stroke, manuscript received ahead of print.

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Aug. 26, 2009 -- Who's on the front line of this fall's flu fight? You are, say HHS and CDC officials.

Until Thanksgiving, at the earliest, it's going to be up to you to try not to catch the flu. And if you do catch the flu, it's going to be up to you to try not to infect anyone else.

Swine Flu Outbreak: Get the Facts

Get the latest swine flu facts and information from WebMD, the CDC and other public health agencies.

• Swine Flu Center
• Video: Swine Flu Precautions
• Swine Flu Symptoms
• Can a Mask Prevent Swine Flu?
• Swine Flu: 10 Things Not To Do
• CDC Swine Flu Updates
• World Health Organization

Swine Flu Slideshow

 Like people, pigs can get influenza (flu), but swine flu viruses aren't the same as human flu viruses. View the slideshow.

© 2009 WebMD, LLC. All rights reserved.

Why? The government is rushing to deliver H1N1 swine flu vaccine to states on or around Oct. 15. Vaccination likely will take two shots given three weeks apart. No protection is expected until two to four weeks after the second shot -- around Thanksgiving for those who start vaccination in mid-October.

"We are not going to have vaccine before H1N1 disease gets here because the disease never went away this summer," Anne Schuchat, MD, director of the CDC's Center for Immunization and Respiratory Diseases, said this week at a pandemic flu symposium. "Schools are now opening and cases are appearing. I would expect to see clusters popping up soon."

"I think we're going to have an interesting fall," Steven C. Redd, MD, director of the CDC's Influenza Coordination Unit, said at the symposium.

All relevant branches of the U.S. government are making full-speed-ahead efforts to prepare for a bad flu season, as the new H1N1 swine flu collides with the seasonal flu. But in the end, the government can do only so much.

The rest is up to citizens, says Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services (HHS).

"It is essential people make plans, because we will not have a vaccine available for a few months," Sebelius said at the CDC symposium.

What plans?

The first part of the plan is to avoid infection:

• Wash your hands frequently and thoroughly. Use soap and warm water when available; use hand sanitizer between hand washings.
• Avoid close contact with sick people. Close contact means getting within 6 feet of a sick person. If you must care for someone who is ill, minimize close contact.
• It's not known whether face masks protect against infection. If you use one, don't slack off on hand washing or avoiding close contact with sick people. Use the face mask properly and throw it away after use.
• Get your seasonal flu vaccine as soon as possible. It's safe, and it protects against the three seasonal flu bugs expected to circulate this fall and winter -- even though it won't protect against H1N1 swine flu.

The second part of the plan is to keep from spreading the swine flu virus:

• Stay home if you are sick.
• Observe flu etiquette. Don't cough or sneeze into your hands. Cough/sneeze into a tissue -- or, failing that, your elbow.
• If you can do so comfortably, wear a face mask if you come into contact with others.
• If you are an employer, do not penalize workers for staying home if sick or for caring for sick children.
• Make plans -- now -- for what you'd do if you or your children get sick this fall.

continued...

Does this stuff really work? From the standpoint of an individual, nothing may seem to be happening.

"All these efforts are leaky," acknowledged Martin Cetron, MD, director of the CDC's division of global migration and quarantine.

Swine Flu Outbreak: Get the Facts

Get the latest swine flu facts and information from WebMD, the CDC and other public health agencies.

• Swine Flu Center
• Video: Swine Flu Precautions
• Swine Flu Symptoms
• Can a Mask Prevent Swine Flu?
• Swine Flu: 10 Things Not To Do
• CDC Swine Flu Updates
• World Health Organization

Swine Flu Slideshow

 Like people, pigs can get influenza (flu), but swine flu viruses aren't the same as human flu viruses. View the slideshow.

© 2009 WebMD, LLC. All rights reserved.

But if enough people do these things often enough, it will slow the speed at which flu spreads through a community. This actually slows down the pandemic -- and buys precious time for vaccination to do its work.

"By altering patterns of transmission, we reduce the peak of an epidemic wave, we buy time, and we reduce the total number of cases," Cetron said at the CDC symposium. 

View Article Sources

SOURCES:

Influenza Workshop for Journalists, Aug. 24-25, 2009, with:

• Kathleen Sebelius, secretary, Department of Health and Human Services
• Anne Schuchat, MD, director, National Center for Immunization and Respiratory Diseases, CDC
• Stephen C. Redd, MD, 2009 CDC H1N1 incident manager and director, Influenza Coordination Unit, CDC
• Martin Cetron, MD, director, division of Global Migration and Quarantine, CDC

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Aug. 26, 2009 -- As many as 4 million adults in the U.S. under the age of 65 are being exposed to high, potentially cancer-causing levels of radiation from medical imaging tests of unproven value, according to a new government-funded study.

Analysis of insurance claims for close to 1 million non-elderly adults found that roughly two-thirds had at least one medical imaging test resulting in radiation exposure and one-fifth were exposed to moderate-to-high doses of radiation during the study period.

Nuclear imaging (often done to check for heart disease) and computed tomography (CT) scans delivered the most radiation.

An earlier study in 2007 estimated that as many as 2% of cancers in the U.S. are caused by radiation exposure from CT-related imaging alone.

The new study appears in this week's New England Journal of Medicine.

"We don't want to scare people and have them refuse necessary procedures, but physicians and patients need to be aware that radiation is not benign," study researcher Reza Fazel, MD, of Atlanta's Emory University School of Medicine, tells WebMD. "Our study shows that a lot of people are getting high doses of radiation."

Government estimates suggest that per capita radiation doses in the U.S. have risen sixfold since the early 1980s as a result of greater utilization of medical imaging tests performed to diagnose and monitor a wide range of diseases.

The study shows that:

• CT scans and nuclear imaging accounted for three-fourths of radiation exposure, with nuclear stress tests, also known as myocardial perfusion imaging, identified as the procedure accounting for the largest single radiation exposure. 
• The highest radiation exposures occurred among women and older adults. 
• Imaging-associated exposures among young adults were not insignificant. Thirty percent of men and 40% of women with high exposure per year in the study were under the age of 50. 
• 80% of radiation exposures occurred among non-hospitalized patients.

Radiation exposure is commonly measured in millisieverts (mSv). The average person in the U.S. can expect to receive no more than 3 mSv of exposure per year from naturally occurring background radiation. An exposure of greater than 20 mSv is considered high, while greater than 3 mSv to 20 mSv is considered moderate.

Myocardial perfusion imaging for heart disease delivers about 15 mSv per test.

Value of Some Medical Imaging Unclear

In a perspective published with the study, cardiologist Michael S. Lauer, MD, of the National Heart Lung and Blood Institute (NHLBI) presented the hypothetical case of a 58-year-old man named Jim with risk factors for heart disease who has an inconclusive nuclear stress test followed by another commonly used imaging test known as CT angiography, which also fails to confirm his diagnosis.

The two tests would result in more than 20 mSv of radiation exposure.

Value of Some Medical Imaging Unclear continued...

"Jim's story reflects outpatient practice that has become increasingly common in the United States, which has the world's highest per capita imaging rate," Lauer writes.

"Most physicians who order imaging tests experience no consequences for incurring costs for procedures of unproven value. On the contrary, they or their colleagues are paid for their services, and their patients don't complain because the costs are covered."

While health care reform has the potential to slow the growth of medical imaging, Lauer says the real challenge is to identify which tests add value for the diagnosis and management of disease and which do not.

He tells WebMD that for some tests, like mammography, the benefits are clear. But for others, like nuclear stress testing to identify heart disease, the risks may very well outweigh the benefits.

"Medical practice should be based on the most rigorous science, and we don't have that for many of these tests," he says. "We need large, well-designed trials to figure this out."

View Article Sources

SOURCES:

Fazel, R. New England Journal of Medicine, Aug. 27, 2009; vol 361: pp 849-857.

News release, National Heart Lung and Blood Institute.

Reza Fazel, MD, MSc, division of cardiology, department of medicine, Emory University School of Medicine.

Michael S. Lauer, MD, National Heart Lung and Blood Institute.

Brenner, D.J. New England Journal of Medicine, Nov. 29, 2007; vol 357: pp 2277-2284.

NCRPM: "Ionizing Radiation Exposure of the Population of the United States," March 2009.

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Aug. 26, 2009 -- Teens who witness their parents tie one on are more likely to get drunk than teens who never see their parents imbibe, according to survey results released Wednesday at a news conference in Washington, D.C.

Researchers from the National Center on Addiction and Substance Abuse (CASA) of Columbia University in New York City polled 1,000 teens aged 12 to 17 and 452 of their parents about their attitudes on alcohol and drug use.

Of children who have one or more drink a month, 2/3 will get drunk at least once a month. “For most kids, just drinking also means getting drunk regularly; and we care about that for a lot of reasons, including driving accidents, risky sexual behavior, and assaults,” says Elizabeth Planet, vice president and director of special projects at CASA.

And it doesn’t stop at getting drunk either. “There is a connection between that drink, drunkenness, and regular substance use,” she says. Teens who get drunk at least once a month are 18 times more likely to smoke marijuana. Between 2007 and 2009, there was a 37% increase in the percentage of teens that said marijuana is easier to buy than cigarettes and beer, the survey found.

“Drinking is a sign,” she says. “If your kid is drinking regularly, don’t discard it as not serious.”

Compared to teens who have never tried alcohol, teens who get drunk monthly are:

• Four times more likely to be able to get marijuana in an hour
• Four times more likely to know someone who abuses prescription drugs
• Twice as likely to know a girl who was forced to perform a sexual act, and
• Four times more likely to know a guy who uses drugs or alcohol to hook up

The survey also asked teens how fast they could get their hands on prescription drugs. Nearly one in five said they can get these prescription drugs in an hour, and more than one-third can get them in a day, the survey showed. Growing numbers of teens are abusing a host of prescription drugs, including painkillers, sleeping pills, anti-anxiety drugs, and stimulants.

Father Knows Best

For the first time, the new survey asked specific questions about fathers’ attitudes toward drinking and drugs. Teens who think their father is OK with them drinking are two and a half times more likely to get drunk in a given month.

“If dads don't want their kids to be drinking or getting drunk, they should tell them that and make sure there is no confusion,” Planet says.

Do as I Say and as I Do

“What parents say is important and what they do is important,” she says. “The expectations that you set will also drive your kids’ behavior,” she says. “Set high expectations, be clear about these expectations, communicate these expectations, and model healthy behavior,” she says.

“There is no question that actions speak louder than words,” says Joseph A. Califano Jr., the founder and chairman of CASA and the author of How to Raise a Drug-Free Kid. But it’s not just ‘don’t get drunk in front of your kids,’ you also have to communicate with your children all along, have family dinners frequently, go to their games and events, and attend religious services as a family. Then when you do talk to them, you will really have some power to influence their conduct and get them to choose not to use.”

View Article Sources

SOURCES:

National Center on Addiction and Substance Abuse: "National Survey of American Attitudes on Substance Abuse XIV: Teens and Parents."

Elizabeth Planet, vice president and director of special projects, National Center on Addiction and Substance Abuse (CASA), Columbia University, New York.

Joseph A. Califano Jr., founder and chairman, National Center on Addiction and Substance Abuse; author, How to Raise a Drug-Free Kid.

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