2015 Monthly Doctor Walk Health Tips - Ascension Wisconsin

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2015 Walk with a Wheaton Doc Health Tips

During each walk in 2015, our physicians shared health and wellness tips on specific topics. To view the tips, select a month below and then a topic.

January | February | March | April | May | June | July | August | September | November | December

Want more information? Learn about the Walk with a Wheaton Doc program and join us for our next walk.

December 2015 Tips from Mushir Hassan, MD

Ovarian Cancer Screening Might Cut Cancer Deaths, U.K. Trial Suggests

By Amy Orciari Herman

Annual screening for ovarian cancer might lower cancer-related mortality, according to a large U.K. trial in the Lancet. The researchers caution that longer follow-up is needed "before firm conclusions can be reached."
Over 200,000 postmenopausal women aged 50–74 without prior ovarian cancer or increased family risk were randomized to annual multimodal screening, annual transvaginal ultrasound screening, or no screening. Multimodal screening involved serum CA125 testing, with rising levels interpreted using an ovarian cancer algorithm and ultrasound performed as indicated.

During a median 11 years' follow-up, the incidence of ovarian cancer mortality was not significantly lower in the multimodal and ultrasound groups (0.29% and 0.30%) than in the no-screening group (0.34%); however, the effect of multimodal screening became significant after 7 years. In addition, in a prespecified secondary analysis that excluded women with CA125 levels suggesting cancer at baseline, multimodal screening was associated with a 20% reduction in ovarian cancer mortality relative to no screening.

Dr. Andrew Kaunitz, editor-in-chief of NEJM Journal Watch Women's Health, weighed in: "This report represents the first time population screening has been shown to reduce mortality from ovarian cancer. However, translating these encouraging findings, which involved centers with extensive experience in gynecologic ultrasound, into clinical practice may be challenging."

SSRI Use During Pregnancy Associated with Autism Risk in Children

By Jenni Whalen

Using selective serotonin reuptake inhibitors (SSRIs) during the second or third trimester of pregnancy is associated with a heightened risk for autism spectrum disorder (ASD) in children, according to a JAMA Pediatrics study.

Researchers used data from a population-based cohort study of women from Quebec who delivered 145,000 full-term singleton infants. Children were followed until a mean age of 6.2 years.

Of these, 0.72% were diagnosed with an ASD. Use of any SSRIs during the second or third trimester was associated with increased risk for ASD, compared with no exposure (adjusted hazard ratio, 2.17; 1.4% vs. 0.72%). Use of multiple antidepressant classes in mid-to-late pregnancy was also tied to increased risk. The association between ASD and antidepressants persisted in a subanalysis of women with a history of depression.

NEJM Journal Watch Women's Health associate editor Allison Bryant comments: "While a small increase in ASD is noted, untreated depression has its own impressive maternal health risks. Research and policy efforts should focus on the provision of comprehensive mental health treatment of pregnant women."

Too Much TV in Young Adulthood, Worse Cognition Later?

By Christine Sadlowski

People who are both sedentary and watch a lot of television from young adulthood on have worse cognition in midlife, researchers report in JAMA Psychiatry.

More than 3000 U.S. adults described their activity levels and TV viewing habits starting at a mean age of 25 and periodically thereafter. At 25 years' follow-up, participants completed tests of cognitive speed, memory, and executive functioning.

In adjusted analyses, those who consistently had both high TV viewing (more than 3 hours a day) and low physical activity (the lowest quartile of sex-specific activity) were twice as likely to have poor cognition scores compared with participants with low TV viewing and high physical activity.

Each of the two behaviors was also independently associated with worse cognition. Processing speed and executive function, but not verbal memory, were affected by both behaviors.
The authors conclude that both behaviors may be modifiable risk factors for prevention of cognitive impairment.

For Kids with Uncomplicated Appendicitis, Let Families Choose the Treatment?

By Kelly Young

Giving families the choice to treat their child's uncomplicated appendicitis nonoperatively rather than with immediate appendectomy may be an effective strategy, suggests a JAMA Surgery study.

Researchers enrolled 102 children, aged 7 to 17, presenting with acute, uncomplicated appendicitis. Families chose whether the patient would undergo laparoscopic surgery immediately or begin antibiotic therapy (IV antibiotics for 24 hours, followed by oral antibiotics for 10 days); 37 chose antibiotics, and 65 chose surgery.

At 1 year, 76% of the antibiotic group did not need to have an appendectomy. The antibiotic group had significantly fewer disability days than did the surgery group (8 vs. 21), as well as lower appendix-related healthcare costs ($4219 vs. $5029).

Commentators write that they cannot yet "completely abdicate the responsibility for guiding our patient's decision making. Many patients still want us to be 'doctors,' not Google impersonators."

November 2015 Tips from Mushir Hassan, MD

Drinking Coffee Tied to Lower Relative Mortality Risk

By Kelly Young

Coffee consumption is associated with reduced mortality risk, suggests an observational study in Circulation.

The analysis included nearly 210,000 U.S. health professionals free of cancer and cardiovascular disease at baseline. Participants completed food-frequency questionnaires at baseline and every 4 years thereafter. Roughly 32,000 died during 4.7 million person-years of follow-up.

Participants who drank one to five cups of coffee (decaf or regular) daily had slightly lower risk for all-cause mortality than nondrinkers (hazard ratios, 0.91–0.95). For heavier coffee drinkers, there was no association. When the analysis was limited to people who never smoked, there was an inverse linear relationship between coffee consumption and all-cause mortality, with those drinking over five cups daily having the lowest risk (HR, 0.88). Among never smokers, coffee appeared protective against mortality related to cardiovascular and neurological diseases and suicide.

The authors conclude: "Results from this and previous studies indicate that coffee consumption can be incorporated into a healthy lifestyle."

Dr. Hassan’s Bottom Line: Coffee has some benefit for overall mortality. Recall previous studies that suggested 1-2 cups as optimal for the heart. I like to keep it at 1-2 cups per day.

Certain Antibiotics Could Affect Gut Microbiome for 1 Year

By Kelly Young

Gut microbial diversity may be diminished for up to a year following oral antibiotic use, suggests a small, industry-conducted study published in mBio.
Sixty-six healthy participants in the U.K. and Sweden were randomized to receive placebo or an antibiotic (clindamycin, amoxicillin, ciprofloxacin, or minocycline). They provided saliva and fecal samples before and after receiving antibiotics.

Over the long term, the salivary microbiome was largely undisturbed by antibiotic administration. Meanwhile, microbiome diversity in fecal samples was reduced for up to 4 months in patients receiving clindamycin and up to 12 months in those receiving ciprofloxacin. Specifically, bacteria that produce the short-chain fatty acid butyrate — which is linked to lower inflammation, carcinogenesis, and oxidative stress in the gut — were significantly reduced.

In addition, genetic testing found more genes associated with antibiotic resistance in the fecal samples.

The authors conclude: "Clearly, even a single antibiotic treatment in healthy individuals contributes to the risk of resistance development and leads to long-lasting detrimental shifts in the gut microbiome."

Dr. Hassan’s Bottom Line: It’s cold season. Think twice about insisting on antibiotics for sniffles.

Sharing Patients' Genetic Risk for CHD Might Help Lower LDL Levels

By Kelly Young

Disclosing patients' genetic risk for coronary heart disease might be more effective in helping them lower their LDL cholesterol than disclosing their conventional risk score, according to a study presented at the American Heart Association's annual meeting.

Roughly 200 patients at intermediate CHD risk and not taking statins were randomized to have their 10-year probability of CHD shared with them using either conventional risk scores or conventional risk plus genetic risk scores, based on 28 genetic markers. Physicians and patients used this information to plan treatment.

At 6 months' follow-up, the mean LDL level was significantly lower in the genetic-score than conventional-score group (96.5 vs. 105.9 mg/dL). Patients at high genetic risk saw the greatest improvement (92.3 mg/dL).
The effect appeared to be driven largely by greater use of statins in the genetic-score group (39% vs. 22% of conventional-score patients), since there were no significant differences in fat consumption or physical activity.

The researchers note that this particular genetic test is not yet available for clinical use.

Dr. Hassan’s Bottom Line: Cholesterol levels, genetic testing (though not available yet here), and calcium scoring can help give risk assessments for patients on the fence about statin therapy.

Who Might Benefit from Long-Term DAPT? Risk Score May Help

By Kelly Young

Researchers have developed a risk score to determine which percutaneous coronary intervention (PCI) patients would benefit most from continuing dual antiplatelet therapy (DAPT) beyond 12 months, according to results presented at the American Heart Association's annual meeting.

In the DAPT study, nearly 12,000 patients who'd undergone PCI and finished 12 months of DAPT were randomized to continued thienopyridine plus aspirin or aspirin alone. For the risk score, points were added or subtracted based on numerous factors, including age, diabetes, prior PCI, and MI at initial presentation (total scores could range from -2 to 10).

Among patients with DAPT scores of 2 or more, those who continued thienopyridine had significantly lower rates of MI or stent thrombosis at 12–30 months after PCI compared with placebo recipients (2.7% vs. 5.7%); rates of moderate-to-severe bleeding did not differ between the groups.

Patients with lower DAPT scores who continued thienopyridine didn't see a significant benefit in ischemia prevention and did have an increased bleeding risk (3.0% vs. 1.4% for placebo).

For DAPT scores of 2 or more, 34 patients would need to be treated to prevent one ischemic event, and 272 treated to see one additional case of bleeding.

Dr. James de Lemos, who was not involved in the study, said that the risk score "offers a simple and practical solution to a daily clinical problem seen for practicing cardiologists and physicians. This completely revises my interpretation of the DAPT results. I had considered the trial essentially null based on the tradeoff of risk and benefit and the importance of the bleeding complications, but we see now a much more clearly favorable benefit-to-risk profile for a substantial subset of post-PCI patients."

Dr. Hassan’s Bottom Line: For those with a higher risk score, it may make sense to stay on plavix and aspirin together for 2-3 years post stent.

FDA Advisers Recommend Stronger Warnings on Fluoroquinolones

By Amy Orciari Herman

An FDA advisory panel voted late last week to recommend stronger label warnings on fluoroquinolones (e.g., ciprofloxacin) when used to treat sinus infections, urinary tract infections, and bronchitis that complicates preexisting chronic obstructive pulmonary disease, the Wall Street Journal reports.

Safety concerns include increasing reports of cardiac rhythm disturbances, peripheral neuropathy, and cognitive problems associated with the antibiotics. Some patients have reported permanent side effects.

The panel voted 21-0 to update the warnings for sinusitis treatment, 18-2 (1 abstention) for bronchitis, and 20-1 for urinary tract infections. The FDA usually follows its advisers' advice, although it is not required to do so.

Asked to comment, infectious disease expert Dr. Paul Sax said: "While fluoroquinolones are usually safe, there is an increasing appreciation that rarely they may cause severe and sometimes permanent side effects. The additional warnings will be a reminder that no antibiotic should be used unless clearly indicated."

Dr. Hassan’s Bottom Line: This class of drugs should be used second line for UTIs and bronchitis and sinusitis. I have gone back to using more sulfa for UTIs.

September 2015 Tips from Mushir Hassan, MD

Link Between Smoking and Diabetes Risk Detailed

By Amy Orciari Herman

Smoking — whether current, former, or passive — is associated with increased risk for type 2 diabetes, according to a meta-analysis in the Lancet Diabetes & Endocrinology. Researchers examined data from nearly 90 studies reporting on smoking behaviors and incident type 2 diabetes; almost 6 million participants and 300,000 diabetes cases were included. Among the significant findings:

  • Current smokers had a 37% increased risk for diabetes, relative to nonsmokers.
  • Former smokers had a 14% increased risk, compared with those who'd never smoked.
  • Among individuals who'd never smoked, those exposed to secondhand smoke had a 22% increased diabetes risk relative to unexposed participants.
  • People who quit smoking had a 54% increased diabetes risk in the first 5 years after quitting, compared with those who'd never smoked; this risk increase declined to 11% by 10 years.

The researchers conclude that if the association between smoking and diabetes is causal, then an estimated 11.7% of type 2 diabetes cases among men and 2.4% among women can be attributed to active smoking

Dr. Hassan’s Bottom Line: Do Not Smoke. Do Not Start Smoking. Stop Smoking. The additional risks conferred by smoking should be emphasized most especially to young people who are starting to smoke.

Diet + Exercise Still Best for Diabetes Prevention

By Amy Orciari Herman

Diet and exercise interventions continue to be the best way to prevent type 2 diabetes, according to long-term follow-up of Diabetes Prevention Program (DPP) participants, published in the Lancet Diabetes and Endocrinology.
Nearly 2800 adults who participated in the DPP randomized trial agreed to longer follow-up in the outcomes study. In the randomized trial, participants were assigned to a behavioral lifestyle intervention (diet and exercise), metformin, or placebo; the interventions lasted for about 3 years. Then, in the outcomes study, all participants were offered maintenance lifestyle sessions; those originally assigned to metformin received the drug unmasked, and those assigned to the lifestyle intervention were offered supplemental group sessions.

During a total 15 years' follow-up, diabetes incidence was reduced by 27% in the lifestyle group and 18% in the metformin group, relative to the placebo group. The differences among the groups, however, declined throughout follow-up. In women only, the lifestyle intervention reduced risk for microvascular complications — by about 20% relative to metformin or placebo.

Dr. Hassan’s Bottom Line: Best way to stop diabetes is still eat smart and move.

Guidelines for Preventing Fractures in Long-Term Care Residents Published

By Jenni Whalen

New guidelines in the Canadian Medical Association Journal recommend ways to reduce fracture risk in patients living in long-term care facilities. The project was supported, in part, by grants from pharmaceutical companies.

The guidelines apply to both high-risk individuals (e.g., with prior fractures of the hip or spine or more than one previous fracture) and low-risk residents. The recommended interventions include:

  • Dietary calcium supplements (up to 500 mg) — recommended for high-risk patients, suggested for low-risk
  • Vitamin D3 supplements (800–2000 IU) — recommended for high-risk, suggested for low-risk
  • Weekly alendronate or weekly or monthly risedronate — recommended for high-risk
  • Zoledronic acid or denosumab — recommended for high-risk residents who have trouble taking oral medication
  • Hip protectors for mobile residents — recommended for high-risk adults, suggested for low-risk
  • Balance, strength, and functional training exercises — suggested for all residents

Overall, the authors conclude that interventions "should be tailored to each resident's level of fracture risk, mobility, life expectancy, renal function and ability to swallow."

Dr. Hassan’s Bottom Line: some simple measures to stop fracture in later life. All the more reason to work on gait stability at all stages of life.

Mediterranean Diet + Extra EVOO Linked to Reduced Breast Cancer Risk

By Amy Orciari Herman

A Mediterranean diet — particularly one high in extra-virgin olive oil (EVOO) — is associated with reduced risk for invasive breast cancer, according to a secondary analysis from the PREDIMED study published in JAMA Internal Medicine.

Over 4100 older Spanish women at high cardiovascular risk and without a history of breast cancer were randomized to a Mediterranean diet supplemented with either EVOO (1 L/week for the women and their families) or nuts (30 g/day) or to a control diet (dietary advice).

During a median 4.8 years' follow-up, 35 incident breast cancers occurred.

After multivariable adjustment, women assigned to a Mediterranean diet plus EVOO showed a significant, 68% lower risk for breast cancer relative to controls. Those assigned to the diet plus nuts showed a 41% risk reduction relative to controls, but this was not statistically significant.

Dr. Andrew Kaunitz, editor-in-chief of NEJM Journal Watch Women's Health, offered his take: "That all participants were white and at elevated baseline risk for cardiovascular disease, and that breast cancer was not the primary outcome, represent study limitations. However, given the recognized cardiovascular benefits of a Mediterranean diet, it would now appear reasonable to also recommend this strategy for the possible prevention of breast cancer while awaiting future studies that focus on this outcome."

Dr. Hassan’s Bottom Line: More reason to push olive oil, extra virgin and the Mediterranean diet. Not definitive evidence, but given the proven heart benefits, the cancer benefit is an added plus.

August 2015 Tips from Mushir Hassan, MD

Risks from Trans Fat Confirmed in Meta-Analysis — Saturated Fat Seems Innocent

By Joe Elia

Saturated fat intake doesn't translate readily into higher cardiovascular risk, but increased trans fat intake does, a BMJ meta-analysis confirms. In an attempt to better quantify risks associated with dietary fats, researchers pooled results of several observational studies. They focused on results comparing the highest versus lowest levels of fat intake (measured, for the most part, with dietary recall).

Saturated fat wasn't associated with all-cause mortality, total coronary heart disease (CHD), stroke, or diabetes. Trans fat, on the other hand, was associated with increased risks for all-cause mortality — but not stroke or diabetes.

Asked to comment, Harlan Krumholz, editor-in-chief of NEJM JournalWatch Cardiology, writes: "Caveats abound in observational studies of nutrition, but this comprehensive review not only supports policies to reduce trans fat and undermines dogma about the evil of saturated fat, but also propels the growing concerns about replacing saturated fats with carbohydrates. What this study says most clearly is that we need better and stronger evidence about what diets are best for health at the individual level."

Dr. Hassan’s Bottom Line: Trans fats are bad. Saturated fats not so bad, in fact, might be useful calories to replace carbohydrates. Go for the Mediterranean Diet. Eat mostly plants and not too much.

AHA and ADA Summarize Evidence on CVD Prevention in Patients with Diabetes

By Kelly Young

The American Heart Association and American Diabetes Association have summarized the latest evidence, guidelines, and clinical targets for cardiovascular disease prevention in adults with type 2 diabetes. The report appears in Diabetes Care and Circulation.

Among the recommendations:

  • Clinicians should inform overweight or obese patients with diabetes that lifestyle change can lead to a 3%–5% weight loss that can be sustained and confer clinical benefits.
  • Bariatric surgery may improve health in patients with a BMI of at least 35 who have an obesity-related condition.
  • Most patients should aim for an A1c level at or below 7.0%. Certain patients (e.g., those with a longer life expectancy) could aim for a lower target, while others (e.g., those with a limited life expectancy) could have a more lenient target.
  • For most patients, a blood pressure goal of under 140/90 mm Hg is reasonable.
  • Adults aged 40–75 with LDL cholesterol of 70–189 mg/dL should initiate a moderate-intensity statin. Those with at least a 7.5% estimated 10-year risk for atherosclerotic cardiovascular disease should take a high-dose statin.

The groups also highlight the use of aspirin for CVD prevention, useful screening tests for asymptomatic coronary artery disease, and strengths and limitations of using A1c to diagnose diabetes.

Dr. Hassan’s Bottom Line: A BMI over 35 may be a good reason to see a surgeon.

More Chili Peppers, Please: Spicy Food Consumption Linked to Lower Mortality

By Amy Orciari Herman

The more often you eat spicy foods, the longer you might live, according to an observational study in the BMJ.

Nearly 500,000 adults in China reported how frequently they consumed spicy foods. Those with cancer, stroke, or heart disease at baseline were excluded.

During 7 years' follow-up, 20,000 participants died. After multivariable adjustment, the risk for all-cause mortality was 10% lower among those who ate spicy foods 1–2 days/week — and 14% lower among those who ate spicy foods 3–7 days/week — relative to those who ate them less than once/week. Significant reductions were seen in deaths attributable to cancer, ischemic heart disease, and respiratory diseases.

Chili pepper was the most commonly used spice. The authors note that capsaicin, the main active component of chilis, has long-reported anti-obesity, antioxidant, anti-inflammatory, anticancer, and antihypertensive benefits.

Dr. Paul Mueller of NEJM Journal Watch General Medicine commented, "As noted by the authors, causality cannot be established because of the study's design. Nonetheless, these results should be gratifying for people who enjoy spicy foods."

Dr. Hassan’s Bottom Line: Spicy food may be good for you.

FDA Warns that Hospira's Infusion System Vulnerable to Hacks

By the Editors

The FDA is warning that Hospira's Symbiq Infusion System is vulnerable to cyber-attacks and that hospitals should stop using these pumps and switch to different systems as soon as possible.

The manufacturer and an independent researcher have found that the computerized infusion system, designed for continuous delivery, could be accessed through a hospital network, potentially allowing someone to control the device remotely and alter a patient's dose. There have been no reports of unauthorized access or adverse events.

Dr. Hassan’s Bottom Line: Skyfall comes to the hospital. Yikes!

MOC to Cost Physicians Roughly $24,000 Over 10 Years

By Kelly Young

The 2015 American Board of Internal Medicine's Maintenance of Certification program could cost physicians an average of $23,600 over 10 years, according to an analysis in the Annals of Internal Medicine.

That figure includes fees to the ABIM, but the majority is made up of the cost of physicians' time to fill MOC requirements (average, $21,000). The costs were higher for specialists. The authors call MOC changes announced in February "a step in the right direction." These included eliminating several modules and offering MOC points for common continuing medical education (CME) activities.

They conclude: "Reform of MOC should focus on decreasing the time required to fulfill MOC requirements and increasing integration with existing continuing education activities."

Dr. Hassan’s Bottom Line: This is a step in the right direction. Reward doctors for the CME they are already doing.

July 2015 Tips from Mushir Hassan, MD

Endovascular and Open Repairs of Abdominal Aortic Aneurysms Have Similar Long-Term Mortality Rates

By Christine Sadlowski

After endovascular repair of abdominal aortic aneurysms, mortality rises over time but doesn't surpass that associated with open repair, a New England Journal of Medicine study suggests.

From more than 125,000 Medicare beneficiaries who underwent either procedure, about 40,000 in each procedure group were matched according to propensity to undergo endovascular repair. Periprocedural mortality was 1.6% with endovascular repair and 5.2% with open repair. Survival remained significantly better after endovascular repair for 3 years, after which it was essentially the same in both groups. Cumulative mortality in the study population was 50% at 8 years. Late rupture occurred in 5.4% after endovascular repair and 1.4% after open repair.

NEJM Journal Watch General Medicine Editor-in-Chief Allan Brett concludes that "the U.S. trend favoring endovascular repair appears justified for patients who are reasonable candidates for either procedure."

Dr. Hassan’s Bottom Line: Less invasive looks to be just as safe when it comes to AAA repair.

ADHD Meds Associated with Reductions in Childhood Injuries

By Amy Orciari Herman

Use of medications for attention-deficit/hyperactivity disorder may help lower injury rates in affected children, according to an observational study in the Lancet Psychiatry. Using Danish registries, researchers followed over 700,000 children born between 1990 and 1999. Some 4500 were diagnosed with ADHD between ages 5 and 10 years; of these, about one third received ADHD medications, usually methylphenidate.

After multivariable adjustment, children with ADHD were about 30% more likely to sustain injuries than those without ADHD. Among those with ADHD who received medical therapy, the prevalence of injuries dropped from 19% at age 5 years to 14% at 10 years, roughly equivalent to the level of children without ADHD. Among those who went untreated, the prevalence held steady at roughly 17%. ADHD treatment was also associated with significant reductions in emergency department visits.

Dr. Hassan’s Bottom Line: ADHD diagnosed by a specialist and treated with common therapy may reduce injury. Our reluctance to use medicines as parents may affect more than just school work.

Efforts to Increase Bystander CPR and Defibrillation Pay Off

By Daniel J. Pallin, MD, MPH

Recent efforts to improve bystander resuscitation for out-of-hospital cardiac arrest (OHCA) were associated with increased rates of neurologically intact survival, according to two registry studies in JAMA.

In a study from Japan, where access to automated external defibrillators (AEDs) was expanded in 2004, researchers reviewed nearly 168,000 OHCA cases from 2005 to 2012. During that period, bystander-performed chest compression and defibrillation increased, as did neurologically intact survival (from 3% to 8%). Odds of neurologically intact survival were 1.5 times higher with bystander chest compression than without it, and were 2.2 times higher when defibrillation was performed only by bystanders versus only by emergency medical service providers.

In a separate study, researchers reviewed roughly 5000 OHCA cases in North Carolina in the 4 years after the state initiated efforts to improve bystander and first-responder use of CPR and AEDs. Among patients who received bystander-initiated CPR and defibrillation, 34% survived with favorable neurological outcome. Odds of survival with favorable neurological outcome were 3.4 times higher when CPR and defibrillation were initiated by bystanders versus EMS providers.

Decades of effort by local communities, the American Heart Association, first responders, and others seem to be paying off. Everyone should know to shout "call 911" when someone collapses and then push hard and fast. The cost-effectiveness of AEDs in public places is debatable, but these studies show evidence of their benefit.

Dr. Hassan’s Bottom Line: Get those Vitality Points!! CPR is a skill most every adult should know and be encouraged to know. I personally also feel more AEDs would be better.

USPSTF: Not Enough Evidence to Recommend for or Against Vision Screening for Seniors

By Kristin J. Kelley

The U.S. Preventive Services Task Force says there is insufficient evidence to recommend for or against screening adults aged 65 years and older for impaired visual acuity in a primary care setting. This recommendation pertains to age-related macular degeneration, cataracts, and refractive error, but it excludes glaucoma screening.

The grade I (insufficient evidence) draft statement reaffirms the USPSTF's 2009 stance. Other groups (e.g., American Optometric Association) recommend a routine eye examination every 1–2 years for asymptomatic older adults. A 2007 study cited by the USPSTF found that nearly half of adults aged 65 and older in the U.S. reported having an eye examination within the last year.

Dr. Hassan’s Bottom Line: Yearly eye exam for diabetics is not up for debate. Healthy, with no other risks may not need a yearly exam. I still push every 2 years to make sure glaucoma is not an issue.

Fetal Ultrasounds on the Rise — Often Without Medical Indication

By Amy Orciari Herman

U.S. women underwent an average of 5 fetal ultrasounds per delivery in 2014 — up 92% since 2004 — according to a Wall Street Journal report. Medical groups recommend just one to two ultrasounds in low-risk pregnancies.

Among the reasons cited for the increase: clinicians' fear that they will miss something, patients' desire to see and bond with their growing baby, and possible financial motives.

While many clinicians believe that ultrasounds are safe because there's no cancer-causing radiation, most safety studies were performed on equipment made before 1992. Today's equipment emits much stronger acoustic waves than older versions. In addition, animal studies have suggested ill effects from ultrasound exposure, such as neurologic abnormalities and hyperactive behavior. And there's always the concern that too many ultrasounds can lead to false-positives.

One ultrasound scientist told the Journal: "The public needs to be made aware that if you're pregnant ... you don't need to have an ultrasound at every doctor's visit."

Dr. Hassan’s Bottom Line: Too much technology is not necessarily a good thing. There is likely a component of defensive medicine at play here too.

June 2015 Tips from Guest Physician, Bobby Wu, MD

Breakfast Is Key to Weight Loss

By Heidi Tyline King

A healthy breakfast makes it easier to lose weight. And there are other benefits, like better concentration, more strength, and greater endurance.

According to researchers at the University of Florida, children who ate breakfast consistently generally consumed more calories each day but were less likely to be overweight. The same study also indicated that eating breakfast may improve memory, test scores, and school attendance.

Adequately fueling your body has indirect benefits. People who skip breakfast often feel more tired, irritable, and restless in the morning. People who eat breakfast have a better attitude toward work, more strength and endurance, and better concentration — all of which are crucial to sticking with a diet and an exercise program.

Dr. Wu’s Bottom Line: Even though it seems counter intuitive, eat a good, healthy breakfast every day to help you maintain or lose weight.

Why Is Cholesterol Important?

High blood cholesterol is one of the major risk factors for heart disease. A risk factor is a condition that increases your chance of getting heart disease.

When there is too much cholesterol (a fat-like substance) in your blood, it builds up in the walls of your arteries. Over time, this buildup causes "hardening of the arteries" so that arteries become narrowed and blood flow to the heart is slowed down or blocked.

High blood cholesterol itself does not cause symptoms, so many people are unaware that their cholesterol level is too high.

Everyone age 20 and older should have their cholesterol measured at least once every 5 years. It is best to have a blood test called a "lipoprotein profile" to find out your cholesterol numbers. This blood test is done after a 9- to 12-hour fast and gives information about your:

  • Total cholesterol
  • LDL (bad) cholesterol--the main source of cholesterol buildup and blockage in the arteries
  • HDL (good) cholesterol--helps keep cholesterol from building up in the arteries
  • Triglycerides--another form of fat in your blood

Dr. Wu’s Bottom Line: It is important to find out what your cholesterol numbers are because lowering cholesterol levels that are too high lessens the risk for developing heart disease and reduces the chance of a heart attack or dying of heart disease, even if you already have it.

May 2015 Tips from Mushir Hassan, MD

Increased Mortality Risk Found with Digoxin

By Larry Husten

Digoxin is associated with an elevated mortality risk, according to a meta-analysis in the European Heart Journal.

Researchers examined 19 studies of digoxin, including more than 235,000 patients with atrial fibrillation (AF) and 91,000 with congestive heart failure (CHF). With the exception of one randomized, controlled trial, all the studies were observational.

Overall, there was a 21% increase in the relative risk for death in people taking digoxin. Separately, the increased risk was 29% in the AF population and 14% in the CHF population. In three trials that included both AF and CHF patients, there was a 28% increase in mortality in the AF group but no significant effect in the CHF group.

The authors write that their finding "calls for randomized trials of dose-adjusted digoxin therapy at least in CHF patients. Until such proper randomized controlled trials are being completed, digoxin should be used with great caution (including monitoring plasma levels), particularly when administered for rate control in AF."

Dr. Hassan’s Bottom Line: Digoxin is old school and not necessarily the “go to” drug it used to be. Better options exist.

Effectiveness of Tdap Vaccine in Adolescents Wanes with Time

By Kelly Young

For adolescents, protection against pertussis wanes within 2 to 4 years of receiving the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine, according to a case-control study in Pediatrics.

Researchers examined data from the pertussis epidemic in Washington State in 2012 and matched nearly 900 adolescents with pertussis to 2600 controls without pertussis.

For adolescents who received only acellular vaccines in the primary series, Tdap effectiveness was 64%. The vaccine's protection faded with time, from 73% within 1 year of vaccination to 34% 2 to 4 years after vaccination. The Boostrix vaccine may have been slightly more effective than the Adacel vaccine, but the difference was not statistically significant.

A commentator concludes: "It is my opinion that we should continue with our present Tdap schedules. Of most importance is to see that all pregnant women receive Tdap with each pregnancy. This alone can prevent virtually all pertussis deaths in young infants."

Dr. Hassan’s Bottom Line: It’s important to get Tdap with each pregnancy as an expectant mom.

Hispanics in the U.S. Have a Mortality Advantage Over Whites

By Amy Orciari Herman

All-cause mortality is 24% lower for Hispanics than non-Hispanic whites living in the U.S. — even though Hispanics have less access to healthcare — according to a new "Vital Signs" report in MMWR.

CDC researchers examined national mortality data for 2013 and national health survey data for 2009 through 2013 to compare causes of death, risk factors, and healthcare utilization between Hispanics and whites. Among the findings:

  • Hispanics had lower death rates than whites for nine of the 15 leading causes of death, including heart disease and cancer (the two leading causes in both groups).
  • Deaths due to diabetes and chronic liver disease were about 50% higher — and those due to homicide were nearly 100% higher — among Hispanics than whites.
  • Over 40% of Hispanics did not have health insurance, versus 15% of whites.

The authors note that less smoking and more family support among Hispanics might help explain their mortality advantage.

Dr. Hassan’s Bottom Line: Some interesting findings in terms of income, family support, and mortality.

AAP Issues Updated Guidance on Managing Head Lice

By Amy Orciari Herman

The American Academy of Pediatrics has issued an updated clinical report on the management of head lice.

Dr. Hassan’s Bottom Line: Classroom transmission is low, and most OTC stuff works.

April 2015 Tips from Mushir Hassan, MD

Obesity Associated with Higher Risk for Prostate Cancer in Black Men

By Amy Orciari Herman Edited by William E. Chavey, MD, MS

Researchers examined data on 3400 black men and 23,000 non-Hispanic white men participating in a trial of dietary supplements for prostate cancer prevention. During a 5.6 years' follow-up, prostate cancer developed in some 1700 men, with both low- and high-grade cancers significantly more common among black than white men.

Obesity was associated with risk for total prostate cancer among black, but not white, men. Black men with a BMI of 35 or more had about a 50% increased risk for prostate cancer relative to those with normal BMIs, and the higher the BMI, the greater the risk.

The authors note that "inflammation plays a role in prostate carcinogenesis, and the effect of obesity on systemic inflammation could be stronger" in black than in white men.

Dr. Hassan’s Bottom Line: Be careful about the fatty food in your diet. It is not just your heart risk but also cancer risk, especially for African American males.

Zoledronic Acid Improves Bone Density in Frail Elders with Osteoporosis

By Jenni Whalen Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD

Frail older women with osteoporosis may benefit from one dose of zoledronic acid (Reclast) during a 2-year period, according to a study in JAMA Internal Medicine.

Some 180 osteoporotic women aged 65 or older living in nursing homes or assisted living facilities were randomized to receive either one 5-mg dose of intravenous zoledronic acid or placebo, in addition to daily calcium and vitamin D supplements.

Mean total hip and spine bone density each improved more with zoledronic acid than with placebo at 12 and 24 months (up to a 3.9-percentage-point difference between the groups at 24 months). In exploratory analyses, there was no significant effect on fracture rates.

A commentator writes: "It would be premature to use this study to immediately modify our clinical use of potent bone-active agents in the nursing home population with documented osteoporosis.... Fall prevention programs have been well described and are clearly also important."

Dr. Hassan’s Bottom Line: For those who cannot take the weekly pill for their bones, we have once a year infusion, that works into older age.

Mental, Social Activities in Middle and Late Life Tied to Lower Risk for Cognitive Impairment

By Christine Sadlowski

Certain social and personal activities in mid- or late life might help protect against dementia, suggests an observational study in Neurology.

At a median age of 87, about 250 cognitively normal adults reported their current and former activities, demographics, and other risk factors. Roughly 4 years later, nearly half had developed mild cognitive impairment. Cognitive impairment was about 75% less likely in those who had reported both midlife and late-life engagement in artistic activities, and about half as likely in those reporting engagement in social activities or crafts. Late-life computer use was also associated with a 50% lower risk.

A commentator notes that self-report may have caused bias but that the findings are consistent with other research.

Dr. Hassan’s Bottom Line: Arts and crafts are important as are social groups. Hobbies and social clubs are a good thing.

Amphetamine Isomer Detected in Nutritional Supplements

By Kelly Young Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM

Beta-methylphenylethylamine (BMPEA), an amphetamine isomer, was still detected in Acacia rigidula supplements a year after the FDA first discovered the chemical's presence in supplements, according to a study in Drug Testing and Analysis.

Researchers purchased 21 brands of Acacia rigidula supplements online from January through April 2014. Through mass spectrometry, BMPEA was detected in 52% of the supplements, which are marketed for weight loss, athletic performance, and cognitive function.

BMPEA has never been proven safe in humans, and animal studies have found that it increases heart rate and blood pressure. The authors suggest that the compound is produced synthetically and added to the supplements, and consumers could be exposed to "pharmacological dosages of an amphetamine isomer."

They conclude: "We recommend that supplement manufacturers immediately recall all supplements containing BMPEA, and that the FDA use all its enforcement powers to eliminate BMPEA as an ingredient in dietary supplements. Consumers should be advised to avoid all supplements labeled as containing Acacia rigidula. Physicians should remain alert to the possibility that patients may be inadvertently exposed to synthetic stimulants when consuming weight loss and sports supplements."

Dr. Hassan’s Bottom Line: First it was ephedra (Metabolife), now it is Acacia. The cardiovascular stimulation from these types of supplements is unstudied in terms of risk. I advise against taking them.

See also: Study Warns of Diet Supplement Dangers Kept Quiet by F.D.A. from the New York Times

March 2015 Tips from Mushir Hassan, MD

Has CT Angiography Lived Up to Its Early Promise?

In patients with suspected coronary artery disease, an initial strategy of computed tomographic angiography (CTA) does not appear to improve long-term outcomes compared with initial stress testing. Findings from the PROMISE study were presented at the American College of Cardiology and published in the New England Journal of Medicine.

Over 10,000 patients with chest pain were randomized to CTA or functional testing, consisting of exercise ECG, nuclear stress testing, or stress echocardiography. After two years, the primary endpoint - a composite of death, MI, hospitalization for unstable angina, or major procedural complications - did not differ between the groups.

Within the first 3 months, more CTA patients than functional-testing patients underwent invasive catheterization, but among these, fewer CTA patients were found to have no obstructive disease.

"Although PROMISE didn't provide a definitive answer to the role of CTA in clinical practice, it also didn't give a broad endorsement to CTA," said cardiologist John Ryan.

A PROMISE investigator who presented the trial's economic substudy said that CTA "may not be the 'holy grail' of diagnostic testing once hoped for" but that more liberal use "will improve some aspects of care without causing a major new economic burden on the health care system." He said that after more than two years' follow-up, CTA use resulted in only a small, non-significant increase in cost (under $500) and resulted in fewer patients going on to have an invasive cardiac catheterization with normal findings.

The American College of Physicians (ACP) has recommended that clinicians should not screen low-risk, asymptomatic adults for heart disease.

In guidelines published in the Annals of Internal Medicine, the ACP says that adults with a 10-year risk for coronary heart disease events under 10% should not undergo screening with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging. There is no evidence that these tests improve patient outcomes, but they can lead to increased costs and possible harms, such as radiation exposure and unnecessary follow-up tests.

Instead, clinicians should focus on strategies to modify risk factors such as smoking, diabetes, hypertension, and hyperlipidemia, and encourage physical activity.

Dr. Hassan’s Bottom Line: Just because we have cardiac tests and gizmos, does not mean that we have to use them, nor do they necessarily help you live any longer.

Vegetarianism Associated with Reduced Risk for Colorectal Cancer

Vegetarian diets are associated with a lower incidence of colorectal cancer, according to a study in JAMA Internal Medicine.

Nearly 80,000 adults from the Adventist Health Study 2 completed food-frequency questionnaires at baseline and then were divided into five dietary groups: vegan (8% of the population), lacto-ovo vegetarian (29%), pesco-vegetarian (10%), semi-vegetarian (6%), and non-vegetarian (48%).

During 7 years' follow-up, researchers documented 490 cases of colorectal cancer. Compared with non-vegetarians, all vegetarians combined had a significantly reduced risk for colorectal cancer. When examined by type of vegetarian diet, only pesco-vegetarians had a significant reduction in risk.

"The evidence that vegetarian diets ... may be associated with a reduced risk of colorectal cancer, along with prior evidence of the potential reduced risk of obesity, hypertension, diabetes, and mortality, should be considered carefully in making dietary choices and in giving dietary guidance," the authors conclude.

Learn more about the Adventist Health Studies.

Dr. Hassan’s Bottom Line: Vegetarian diets with some fish can have tremendous colon health benefits, not to mention other benefits as well for heart and diabetes.

Dutch Study Shows Efficacy of 13-Valent Vaccine Against Pneumonia in Elders

A 13-valent pneumococcal vaccine shows efficacy against pneumonia in older adults, according to an industry-funded study in the New England Journal of Medicine.

In a study conducted in the Netherlands, some 85,000 people aged 65 and older were randomized to either vaccine or placebo. The study sought to determine the vaccine's effectiveness in preventing first episodes of vaccine-type community-acquired pneumonia (CAP). Cases were confirmed mainly through the presence of serotype-specific urinary antigens.

During a 4-year follow-up, there were 49 cases of vaccine-type CAP among vaccine recipients and 90 in the placebo group, for a 45% efficacy. A similar level of protection was also found against nonbacteremic and noninvasive vaccine-type CAP.

In August 2014, the CDC's Advisory Committee on Immunization Practices recommended the 13-valent vaccine be given to older adults, along with Pneumovax 23.

Dr. Hassan’s Bottom Line: There is a new pneumonia shot that is indicated for elders over 65 even if you have had the old pneumonia shot. Each shot is important and helps in subtly different ways.

Transcatheter Aortic Valve Replacement (TAVR) in the U.S.

Researchers linked records from over 12,000 patients who were enrolled in a national transcatheter valve therapies registry with outcomes data from the Centers for Medicare & Medicaid Services. The mortality rate was 7% at 30 days and 24% at 1 year; the stroke rate was 2.5% and 4.1%, respectively. More than half the patients were readmitted at least once in the year following their procedure.

The report makes clear that this was a very sick group of patients who were offered TAVR because they were considered to be at high surgical risk. Most of the patients had advanced heart failure and other comorbidities. The risk for death at 1 year was linked to older age, males, end-stage renal disease, and severe chronic obstructive pulmonary disease. Women had a higher risk for stroke than men.

An interventional cardiologist says, "I agree that this emphasizes the need for tools to predict more accurately which patients are chronically ill with aortic stenosis versus those who are ill because of aortic stenosis. The latter would appear to be the best candidates for TAVR, while the former would likely not be."

Dr. Hassan’s Bottom Line: This is an exciting new procedure that is being done here in Milwaukee and nationally that offers an option for some of our sickest aortic stenosis patients.

February 2015 Tips from Mushir Hassan, MD

FDA Warns People with Peanut Allergies to Consider Avoiding Ground Cumin

People with severe allergies to peanuts should be extra cautious not to consume food with cumin powder or ground cumin (e.g., as a spice or as an ingredient in seasoning mixes), the FDA warned on Thursday. Some products containing cumin have tested positive for undeclared peanut protein.

The FDA recommends that consumers with peanut allergies and their caregivers read ingredient panels when shopping, and call manufacturers to see if products that contain unnamed "spices" have any cumin powder in them.

Dr. Hassan’s Bottom Line: There is some crossover here for peanuts and cumin. Remember that cumin is very popular in ethnic cuisines, especially Indian food.

Study Tests Very Simple High-Fiber Diet

A new study in the Annals of Internal Medicine indicates that a radically simple diet containing only one positive rule — eat more fiber — might be nearly as beneficial as a more traditional, complex diet.

Researchers randomized 240 adults with metabolic syndrome to the multicomponent American Heart Association (AHA) diet or a very simple diet that focused solely on increasing fiber intake to at least 30 grams/day. After 1 year, mean weight loss was similar, albeit modest, in the fiber and AHA groups (2.1 kg and 2.7 kg, respectively). Both groups experienced additional modest improvements in blood pressure, dietary quality, and insulin resistance.

Over the course of the year, 10% of the fiber group and 13% of the AHA group dropped out of the study. Seven people in the fiber group and one in the AHA group developed diabetes. Neither of these differences was statistically significant.
The authors note that Americans now average only 16 g/day of fiber, and just 7% of adults between ages 40 and 59 consume 30 g/day or more.

Dr. Hassan’s Bottom Line: This adds to other studies that show high fiber benefits the colon and heart and really beckons the question, why eat white flour?

New U.S. Guidelines Will Lift Limits on Dietary Cholesterol

The Dietary Guidelines Advisory Committee, appointed by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture, has recommended that limitations on dietary cholesterol be removed from the upcoming 2015 edition of Dietary Guidelines for Americans.

Recommendations to reduce dietary cholesterol have been a mainstay of U.S. guidelines for years, starting with guidance from the American Heart Association in the 1960s.

The proposed change reflects a major shift in the scientific view of cholesterol in recent years. Although serum cholesterol is still considered an important risk factor, cholesterol consumed in food is now thought to play a relatively insignificant role in determining blood levels of cholesterol. The committee's new report states, "Cholesterol is not considered a nutrient of concern for overconsumption."

"It's the right decision," cardiologist Steve Nissen told USA Today on Tuesday. "We got the dietary guidelines wrong. They've been wrong for decades."

Dr. Hassan’s Bottom Line: Eggs are not taboo anymore. Sensible protein intake that has cholesterol rich foods can be entertained. I still push chicken, fish, and turkey first. 2 legs or no legs is better than 4 legs.

How Sweet It Is to Be Funded by Big Sugar

Worried about government regulation, global food-and-drink companies are increasingly funding research, especially on sugar, according to a four-part feature in the BMJ.

One government-funded organization looking to address obesity in the U.K. — the Scientific Advisory Committee on Nutrition — has had 40 scientists as members over a 12-year span. Only 13 of the 40 have not had to declare potential conflicts of interest over industry ties.

Both Coca-Cola and PepsiCo have declared, in filings with the U.S. Securities & Exchange Commission, that research on the adverse health effects of their products is worrisome. Such fears, according to a Union of Concerned Scientists report, have led to a funding strategy that "could produce systematic biases in nutrition research."
The feature notes that industry-funded research has been found five times likelier to observe no relation between sugar-sweetened beverages and obesity or weight gain than industry-independent work.

Dr. Hassan’s Bottom Line: Be wary of studies that sugar and obesity are not linked. This reminds me of the NFL flooding neurosurgery journals with papers saying concussions were not linked to CTE. Most troubling is that the influence was being peddled to health care policy making physicians.

Lower Hospital Volume Associated with Reduced Readmission Rate

Lower-volume hospitals generally have lower readmission rates than higher-volume hospitals, according to a BMJ study. (Previous studies have found that high-volume hospitals typically have lower mortality and complication rates.)

Using Medicare claims data, U.S. researchers assessed 30-day readmission rates following 7 million discharges from 4600 hospitals.
The hospital quintile with the smallest volume had a slightly, albeit significantly, lower standardized readmission rate than the quintile with the highest volume (15% vs. 16%). A similar pattern was observed in medicine, cardiorespiratory, and neurology specialties, but the opposite was seen in cardiovascular patients.

The authors note: "Readmissions are often precipitated by acute exacerbations of chronic disease, persistence of the initial problem, or increased frailty. It is possible that the risk of these events may be reduced by more time and effort spent in educating patients, conducting high quality medication reconciliation, following up after discharge, and other activities that do not necessarily improve with greater patient volume."

Dr. Hassan’s Bottom Line: Bigger is not necessarily better. Elmbrook Memorial is well positioned to serve these educational needs for patients.

January 2015 Tips from Mushir Hassan, MD

Fecal DNA Testing: Finally Ready for Prime Time?

People who decline invasive options for colorectal cancer screenings (colonoscopies) should be more comfortable with this new test.

Many large studies have confirmed the value and cost-effectiveness of screening for colorectal cancer. The U.S. Preventive Services Task Force recommends fecal occult blood testing and two invasive options, flexible sigmoidoscopy and colonoscopy, to accomplish this. Yet at least 1/3 of eligible U.S. residents don't get screened: Flexible sigmoidoscopy is rarely offered, and many patients decline colonoscopy because they perceive it as too invasive or unpleasant. Fecal occult blood testing, however, is not very sensitive and misses both precancerous lesions and cancers. What we need is a more sensitive noninvasive test.

In 2014, a major study showed that a particular DNA test that evaluated multiple different genetic changes linked to colon cancer was significantly more sensitive than fecal occult blood testing. Stool was collected from nearly 10,000 patients who were scheduled to undergo colonoscopy. The stool was evaluated both by the new DNA tests and by a currently marketed fecal immunochemical test (FIT). Using the gold standard of colonoscopy, colorectal cancer was detected in 0.7% of participants, and advanced precancerous lesions were found in 7.6%. The sensitivity of the fecal DNA assay was 92% for cancer overall and 93% for early cancers (stages I–III), compared with 74% and 73%, respectively, for FIT.

Colonoscopy is more sensitive and specific than a fecal DNA assay, and precancerous lesions can be removed during colonoscopy. For those reasons, colonoscopy remains the best option. However, if availability of a sensitive noninvasive screening test increases the number of people who consent to screening by attracting those who prefer not to undergo invasive testing, it will be an important advance. The manufacturer of this test, which has been FDA approved, lists the “maximum out-of-pocket cost” at US$599; however, the cost-effectiveness of the test remains to be determined.

Dr. Hassan’s Bottom Line: Colonoscopy is still the gold standard and best test. But, for those who want an option that is not as invasive initially and not as costly as a screen, fecal DNA testing does make sense for those with no family history of colon cancer.

Has Risk for Contrast-Induced Nephropathy Been Exaggerated?

In a well-controlled observational study, contrast-enhanced computed tomography wasn't associated with kidney injury.

Conventional wisdom holds that patients with even modestly abnormal renal function are vulnerable to contrast-induced nephropathy. Presumed causes include direct renal toxicity and intrarenal hemodynamic effects of contrast media. In 2014, Mayo Clinic researchers published two studies that challenged the importance of contrast-induced nephropathy after CT scanning. The researchers drew from a database of patients who underwent chest, abdominal, or pelvic CT scanning. One group had undergone intravenous contrast-enhanced CT, and the other had undergone unenhanced CT, but the two groups otherwise were remarkably well-matched in important demographic and clinical variables. The overall incidence of a rise in serum creatinine following CT scanning was 5% in both groups. Even among patients with prescan incidences of postscan declines in renal function were similar in the contrast-enhanced and unenhanced groups.

The researchers also examined two important clinical outcomes, death and need for dialysis, in a separate analysis. They found that the 30-day incidence of these outcomes was not higher in the contrast-enhanced group than in the unenhanced group.

The most likely explanation is that the random fluctuations in serum creatinine levels commonly seen in hospitalized patients are misinterpreted as contrast-related when, in fact, they reflect unrelated effects of fluctuating hydration, fluctuating blood pressure, other nephrotoxic drugs, or comorbid diseases.

The authors believe that intravenous contrast should not be withheld when it is deemed to be essential for accurate CT diagnosis.

Dr. Hassan’s Bottom Line: We as physicians are likely too cautious in withholding contrast for tests of inpatients. Study seems to say we can use contrast more often to get answers for our patients.

JNC 8: Raising the Blood Pressure (and Ire) of Many

The Joint National Committee (JNC) recommends that patients older than 60 be treated for hypertension only when systolic blood pressure exceeds 150 mm Hg.

The JNC 8 guideline addresses blood pressure (BP) thresholds at which drug therapy should be initiated, BP targets during hypertensive treatment, and choice of antihypertensive agents.

For patients younger than 60, JNC 8 specifies that drug therapy should be considered when diastolic BP is >90 mm Hg or systolic BP is >140 mm Hg. For older patients (age, ≥60), the diastolic BP threshold remains >90 mm Hg, but the systolic BP threshold is >150 mm Hg. Among people with diabetes or chronic renal disease, the threshold to initiate drug therapy is 140/90 mm Hg, and the goal for treatment is <140/90.

The JNC 8 writing committee drew its conclusions more strictly from randomized-trial evidence and limited the scope of the guideline to drug therapy for hypertension. The most controversial and contested recommendation is the higher threshold (systolic BP, >150 mm Hg) for people older than 60. Some experts, and the American Society of Hypertension, recommend a target this high only for patients older than 80.

Dr. Hassan’s Bottom Line: I tend to be more liberal with patients over 75 and allow them to run a little higher for BPs. 130/80 is good for most, but I could tolerate150/80 for an elder who feels well and is not dizzy.

What Is an Ounce of Cardiovascular Prevention Worth?

Low-dose aspirin and imaging-guided therapy both were largely ineffective for preventing cardiovascular disease in elders with risk factors.

Cardiovascular disease (CVD) remains the leading cause of death in U.S. adults. However, two studies in 2014 cast doubt on the efficacy of two CVD prevention strategies — one old and one new.

In a Japanese study, 15,000 older adults (age range, 60–85) with cardiovascular risk factors but without known CVD were randomized to daily low-dose aspirin (100 mg) or no aspirin. After a median follow-up of approximately 5 years, no difference was found in the prespecified endpoint of myocardial infarction (MI), stroke, or incident CVD. Nonfatal MI and transient ischemia attack were less common in the aspirin group, but that benefit was offset by a higher risk for bleeding.

The Japanese study adds to the controversy about aspirin for primary prevention. Although the study is limited by a low overall CVD event rate, reserving aspirin for higher-risk patients in whom vascular benefits clearly outweigh bleeding risks seems prudent. Editorialists point out that risk for hemorrhagic stroke is higher in this largely Asian population than in Western populations. Three large ongoing trials of aspirin for primary prevention in higher-risk populations will provide more answers in coming years.

Dr. Hassan’s Bottom Line: Taking a baby aspirin a day may not be necessary for those who have no risk factors. The old adage of taking an aspirin a day to keep the doctor away may not be true as the GI doctor may need to see you for a bleeding stomach. Best to use aspirin in those who have known disease or multiple vascular risk factors.

Special thanks again to our friends at NEJM Journal Watch.