Clinically Significant Statin Drug Interactions

Perhaps the most serious consequence of statin interactions is rhabdomyolysis. The risk of myopathy is increased when statins are coadministered with medications that inhibit their metabolism. Atorvastatin (Lipitor), lovastatin (Mevacor), and simvastatin (Zocor) are CYP3A4 substrates and when coadministered with potent CYP3A4 inhibitors the incidence of myopathy is increased by about five fold.
The extent of interaction between atorvastatin and CYP3A4 inhibitors is less than that with lovastatin and simvastatin. Lovastatin and simvastatin are termed "sensitive substrates" because their levels may be increased five-fold or higher by CYP3A4 inhibitors.

Fluvastatin (Lescol) is primarily metabolized by CYP2C9 and to a lesser extent by CYP3A4 and CYP2D6. Pravastatin (Pravachol) is not significantly metabolized by the cytochrome P450 system and does not interact with other CYP substrates. Rosuvastatin (Crestor) is also not extensively metabolized by the cytochrome P450 system. Statins are substrates for P-glycoprotein; therefore, drugs that inhibit p-glycoprotein (e.g., cyclosporine, diltiazem, etc) may increase statin levels.
The increased risk of myopathy is well recognized when statins and fibric acid derivatives are coadministered since both classes of drugs have the potential for inducing myopathy. However, the risk is less with fenofibrate than gemfibrozil. This may be because gemfibrozil inhibits hepatic glucuronidation of statins, thereby interfering with statin elimination.

In managing statin interactions, choosing a non-interacting medication or switching to a non-interacting statin (i.e., for chronic therapy) may be the safest or easiest option. For certain statin interactions, reducing the statin dose may be an acceptable management technique.

Interactions between lovastatin or simvastatin and strong CYP3A4 inhibitors (e.g., clarithromycin, itraconazole) are managed by stopping the statin as soon as the interacting drug is started. Recommendations vary, but some experts suggest restarting the statin three days or so after the interacting drug has been discontinued. The cardiovascular risk of stopping a statin must be considered when managing drug interactions. Stopping a statin for up to six weeks in a stable patient appears safe. The cardiovascular risk of stopping a statin is higher in unstable patients. Morbidity and mortality is increased in acute myocardial infarction (MI) patients whose statins are discontinued.The results of statin discontinuation in high risk patients may be seen quickly. In one study there was increased risk of in-hospital death in patients with non-ST segment elevation MI whose statin was discontinued. In addition, stopping statin therapy in acute ischemic stroke patients resulted in early neurologic deterioration and poorer outcomes in an unpublished study. Therefore, statins should only be discontinued in acute MI or stroke when indicated (e.g., rhabdomyolysis).

Please remember, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

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THE ABCs Of Colon Cancer [CRC] Screening

Involved organizations promote a message for adults: get screened if you are 50 or older.

It is predicted that if all individuals aged 50 or older had regular colorectal screening tests resulting in the removal of all precancerous polyps, up to 90% of deaths from colorectal cancer could be prevented. The premise for the utility of cancer screening, in general, is that early diagnosis may reduce cancer mortality, result in less radical therapy, and decrease costs. Colorectal cancer screening, in particular, is capable of detecting precancerous polyps in the colon or rectum for removal and can detect early-stage cancer so that treatment may be initiated when it is more effective, often leading to a cure.

Screening for colorectal cancer begins soon after an individual turns 50 years of age, then continues at regular intervals. People at higher risk for colorectal cancer should be tested at a younger age and/or more frequently, including individuals who 1) have a personal or close family history of colorectal polyps or colorectal cancer; 2) have inflammatory bowel disease; 3) have genetic syndromes such as familial adenomatous polyposis (FAP) or hereditary nonpolyposis colorectal cancer. Patients should speak to their health care provider to ascertain when they should begin screening and how often they should be tested.

A consensus guideline for colorectal cancer screening was released in March 2008 by the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology (ACS/USMSTF/ACR), while the USPSTF updated its screening recommendations in October 2008. Ongoing studies drive the constantly evolving recommended screening schedules. For the latest in cancer screening point your medical professional to these articles. Ask your medical professional where you fit in.

Levin B, Lieberman D, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008;58:130-160. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149:627-637.

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

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Thin Thighs Associated with Increased Risk for Death, Cardiovascular Disease

Thin Thighs Associated with Increased Risk for Death, Cardiovascular Disease
Adults with very thin thighs may be at increased risk for cardiovascular disease and death, BMJ reports. Published 3 September 2009, doi:10.1136/bmj.b3292
Cite this as: BMJ 2009;339:b3292

Researchers measured thigh circumference in some 2800 men and women, aged 35 to 65, and then followed them for about 10 years to assess incident cardiovascular disease, coronary heart disease (CHD), and mortality.

In adjusted analyses, a thigh circumference below roughly 24 inches (60 cm) was associated with significantly elevated risk for death and cardiovascular disease (but not CHD), with risk increasing as circumference decreased. While a circumference above 24 inches appeared to be protective, the benefit did not continue to increase with increasing circumference. As a potential underlying mechanism, the authors cite research suggesting that low subcutaneous thigh fat results in poor glucose and lipid metabolism. They and an editorialist call for further research to confirm these findings.

Participants 1436 men and 1380 women participating in the Danish MONICA project, examined in 1987-8 for height, weight, and thigh, hip, and waist circumference, and body composition by impedance.

Main outcome measures 10 year incidence of cardiovascular and coronary heart disease and 12.5 years of follow-up for total death.
Results A small thigh circumference was associated with an increased risk of cardiovascular and coronary heart diseases and total mortality in both men and women. A threshold effect for thigh circumference was evident, with greatly increased risk of premature death below around 60 cm. Above the threshold there seemed to be no additional benefit of having larger thighs in either sex. These findings were independent of abdominal and general obesity, lifestyle, and cardiovascular risk factors such as blood pressure and lipid concentration.

Conclusion A low thigh circumference seems to be associated with an increased risk of developing heart disease or premature death. The adverse effects of small thighs might be related to too little muscle mass in the region. The measure of thigh circumference might be a relevant anthropometric measure to help general practitioners in early identification of individuals at an increased risk of premature morbidity and mortality. Several studies have shown a U-shaped association between body mass index (BMI) and mortality, suggesting both a high and a low BMI are associated with premature death. More recent data suggest that while the increased risk seen with a high BMI is mirrored by the risk associated with a high body fat mass, the risk observed at low BMI seems more closely linked to the risk associated with low fat free mass than low fat mass. A larger hip circumference relative to BMI and waist circumference seems a strong inverse predictor of both morbidity and mortality. In this context, a recent study suggested that lower body muscle mass is particularly related to the development of type 2 diabetes. Indeed, studies have reported that insulin resistance could be provoked in lower body muscle, such as leg muscle, but not in arm muscle,8 9 suggesting that the size of the lower body muscle might have great relevance for developing type 2 diabetes. These findings are in line with results from a study among patients with chronic obstructive pulmonary disease, a condition characterized by wasting of muscle, particularly of the lower extremities, which found that the cross sectional area of mid-thigh muscle was a far better predictor of mortality than BMI. Lower body fat, however, might also offer cardioprotection through endocrine secretion of various adipokines, such as adiponectine, a peptide with apparent anti-inflammatory properties.

DISCUSSION
The asuthors found independent inverse associations between thigh circumference and total death and morbidity from cardiovascular disease in both men and women that were particularly evident when thigh circumference was below a threshold of around 60 cm. Above this threshold there did not seem to be any further benefit of having larger thighs. The increased risk associated with smaller thigh circumferences was seen independently of percentage body fat mass and height or of waist circumference and BMI for all end points, suggesting that for any given degree of general and abdominal obesity, smaller thighs are a disadvantage to health and survival for both sexes. Further analyses with adjustment for systolic blood pressure, total cholesterol and triglyceride concentrations, and alcohol weakened the associations only slightly, and suggested that associations between thigh size and the end points were not mediated by differences in these variables. Some power was lost, however, by the inclusion of more covariates and the associations between thigh circumference and particularly coronary heart disease did not remain significant. Their analyses indicated that associations were independent of heavy smoking as measured by pack years, and associations seemed to be stronger for smokers than for never smokers, but this difference was not significant, probably because of too few end points in the two groups of the stratified analysis.

SUMMARY
Low BMI and low fat free mass are associated with early mortality
High BMI, waist circumference, waist to hip ratio, and low hip circumference are also associated with early mortality
Among both men and women, smaller thighs were associated with increased risk of cardiovascular disease and total mortality
A threshold effect for smaller thigh circumference was seen at around 60 cm; above this threshold the protective effect of having larger thighs carried no further survival advantage
A focus on thigh circumference might help medical providers identify individuals who are at increased risk of early morbidity and mortality


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

*Tune in later for THE SIX QUESTIONS: A GUIDE TO JUDGING FAVORABLY.

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WHAT IS GERD?

WHAT IS GERD?
Acid reflux [GASTRO-ESOPHAGEAL REFLUX DISORDER]occurs when the lower esophageal sphincter (LES) muscle allows the stomach's contents to splash back into the esophagus, resulting in painful heartburn, chest pain, coughing or choking while lying down, or increased asthma symptoms while sleeping. Eating too much at one time, too much acid in the stomach, or food remaining in the stomach for too long a time can all prevent this muscle from doing what it is supposed to. Ideally, food should move smoothly and relatively quickly through the stomach and on to the lower digestive tract.

WHAT FOODS TO AVOID?
Foods that can increase acid production include coffee (caffeinated and decaffeinated), chocolate, soft drinks and cocoa. Acidic foods that should be avoided include citrus fruits and juices (orange, lemon, grapefruit), cranberry juice, lemonade, pineapple, tomatoes and tomato products (spaghetti sauce, salsa, soup).
Other foods that can cause heartburn are those high in fat, such as french fries, ground beef (chuck), marbled steak, chicken nuggets, buffalo wings, sour cream, milkshakes, ice cream, regular cottage cheese, macaroni and cheese, doughnuts, corn chips, regular potato chips, brownies, butter cookies, mayonnaise, butter, margarine, creamy sauces, salad dressing and whole-milk dairy products.
Raw onions and spicy foods can cause heartburn and alcohol relaxes the LES muscle causing it to allow acid reflux.
Avoid when possible processed foods, white sugar, white flour and wheat, which can produce an acidic reaction. Healthcentral.com suggests that wheat, a known allergen, may be the sole cause of some acid reflux and that eliminating gluten from your diet might be all that is necessary to stop acid reflux.

LOW-RISK FOODS
Foods that carry little risk of causing heartburn include apples (juice, dried and fresh), bananas, baked potato, broccoli, cabbage, carrots, green beans, peas, extra lean ground beef, London broil, skinless chicken breast, egg whites, egg substitute, fish prepared with no additional fat, feta or goat cheese, fat-free cream cheese and sour cream, low-fat soy cheese, multi-grain or white bread, bran cereal or oatmeal, corn bread, graham crackers, pretzels, brown or white rice, rice cakes, mineral water, low-fat salad dressing, fat-free cookies, jelly beans, red licorice, angel food cake, baked potato chips.

WORTH TRYING
These foods may require some experimentation, but may be tolerated in moderate amounts by some GERD patients: low-acid orange juice, peaches, blueberries, raspberries, strawberries, grapes and dried cranberries, garlic, cooked onion, leeks, chicken salad, eggs scrambled in butter, fried eggs, tuna salad, beef or pork hot dogs, ham, yogurt, 2-percent or skim milk, frozen yogurt, cheddar or mozzarella cheese, garlic bread, granola, non-alcoholic wine or beer, root beer, small amounts of ketchup.
Complex carbohydrates, whole grains and starchy vegetables, including sweet potatoes and plantains, are not only gentle on the stomach, but also help control excess stomach acid. Among the best whole grains for long-term acid reflux reduction are millet, couscous and amaranth, all of which are considered alkaline.

MORE TIPS
Eating five or six small meals per day instead of three large ones prevents the stomach from becoming too full.
Putting your fork down between bites will prevent you from eating too much too fast.
After dinner, chewing gum stimulates saliva production which can help neutralize stomach acid and increase peristalsis, the contractions and relaxation of muscles along the digestive tract that helps move stomach contents along the digestive system.
Drinking a glass of lukewarm water or herbal tea after a meal can dilute and flush out stomach acid.
An after-dinner cigarette, cigar or pipe can cause problems by weakening the LES muscle.

WEB SITES
www.heartburn.about.com/library/bl_samplemenu_charts.html.
http://www.drgourmet.com/gerd

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

*Tune in later for Thin Thighs Associated with Increased Risk for Death.

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REVIEW SUGGESTS H1N1 FLU DRUGS SHOULD NOT BE USED FOR CHILDREN UNDER 12.

A review of research published in the British Medical Journal found that children "under the age of 12 shouldn't be given the common antivirals Tamiflu [oseltamivir] or Relenza [zanamivir] to treat suspected A/H1N1 swine flu." Dr. Matthew Thomson, one of the report's authors, "said giving Tamiflu or Relenza to children under 12 reduces the length of the illness by an average of one day, which he described as a 'short effect for an illness that lasts about a week.'" Dr. Thomson also said that antivirals "could do more harm than good."

The Oxford University researchers "also concluded that giving the drugs to children after they have been exposed to the flu virus -- post-exposure prophylaxis -- reduces transmission by only eight percent. The researchers "studied four separate randomized trials (two with Tamiflu and two with Relenza) that treated 1,766 children with the flu and three trials of post-exposure prophylaxis involving 863 children." They "concluded that, despite shortening the duration of infection, the drugs did not reduce the normal complications of flu, including asthma flareups, ear infections, sinusitis, bronchitis, and convulsions from fever."


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

*Tune in later for CHILDHOOD POISONINGS RESULT IN 71,224 EMERGENCY DEPARTMENT VISITS NATIONWIDE EVERY YEAR.

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DR. SIEGAL’S SECRET RECIPE REVEALED

I discovered Dr. Siegal's COOKIE DIET(R) three years ago in a mall in Boca Raton, Florida, when my friend tried Dr. Siegal's cookies. She lost weight. I assumed there were illegal weight reducing compounds in the cookies, but when I tried to look up the ingredients I could not find them.

Dr. Sanford Siegal, known to generations as the Cookie Doctor(R) is the man behind the Dr. Siegal's COOKIE DIET(R) weight-loss system. He has author of books including Dr. Siegal's Cookie Diet Book: How a Doctor and His Cookie Helped 500,000 People Lose Weight Fast.

Dr. Siegal introduced his diet in his South Florida medical practice in 1975 and it was an immediate success.
Eating to decrease appetite was not a new idea. Ayds (pronounced as "aids") was an appetite-suppressant candy which enjoyed strong sales in the 1970s and early 1980s. It was available in chocolate, chocolate mint, butterscotch or caramel flavors, and later a peanut butter flavor was introduced. The original packaging used the phrase "Ayds Reducing Plan vitamin and mineral Candy"; a later version used the phrase "appetite suppressant candy".

In 1944 the US Federal Trade Commission objected to the claim that the product could cause the user to “lose up to 10 pounds in 5 days, without dieting or exercising.” However, public awareness of the disease AIDS beginning around mid-1981 caused problems for the brand due to the phonetic similarity of names. By 1988 the product's name was changed to Diet Ayds (Aydslim in Britain), but eventually it was withdrawn from the market. It was about this time that Dr. Siegal came up with his cookie idea.

Eating six cookies a day he maintained enabled most of his patients to stick to the diet without significant hunger, and the fast weight loss they experienced kept them motivated until they reached their goal. At age 80, Dr. Siegal still personally mixes every batch of his proprietary protein formula in his private bakery near his Miami medical clinic. The cookie ingredients are, or at least have been a secret for 30 years. Siegal, however, still maintains his dark-of-night mixing routine and hints that there are subtleties in the recipe not apparent from the ingredient list.

Once a week Sanford Siegal makes a late-night visit to a bakery in Miami. There, he mixes cookie batter. When he's finished, 22 bakery workers pick up where he leaves off, stirring, baking and packaging 10 million cookies a year that Siegal, who keeps his exact recipe under wraps, sells for up to $1.50 each Siegal,

He maintains that there’s good reason for keeping his recipe a secret. He’s afraid of imitators. For most of the time, therefore, the osteopathic physician sold the cookies, without listing their ingredients.

Last year Siegal's son Matthew, 45, decided to help with his operation. Matthew launched a Web site called www.cookiedietonline. It now has 60,000 registered users and brings in slightly less than half of Siegal's cookie sales, which totaled $7.2 million for the year ended in May. Pretax profit, according to the Siegals: $2 million. Siegal senior owns 60% of the Web-based company. His son owns the rest. Matthew has overseen a massive public relations offensive for his dad, getting him on 15 TV and radio shows this year. When Madonna mentioned on a radio show in April that an unnamed cookie diet had depressed her husband's libido, instead of denying ownership- of the cookies the Siegals quickly claimed she was talking about Dr. Siegal's--and debunked her suggestion. So it doesn’t matter what they say about you—as long as your name is in the headlines.

Expanding the operation beyond his own medical practice, however, put Siegal within the realm of federal food guidelines. That took some of the mystery out of the magical diet food: He had to list ingredients.

The ingredients are
• wheat bran,
• egg white solids and
• to top it all of the real secret ingredient--microcrystalline cellulose.

This is a filler that isn't completely digestible except by termites. You might as well be eating sawdust or wood chips. It goes in whole in one end and goes out the other unchanged. But on the way hold on to a lot of water, which is the stomach acts to keep you full.


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

*Tune in tomorrow for WHAT IS CELL PHONE ELBOW?

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WHY IS THE MEDITERRANEAN DIET AN ADVANTAGE IN LONGEVITY?

What is the Mediterranean diet?

The Mediterranean diet is the traditional cooking style of countries bordering the Mediterranean Sea. It is characterized by high amounts of omega-3 fatty acids, high fiber foods, low intakes of saturated fats and a high intake of mono-saturated fats, such as olive oil and nuts. Fish is favored more often than meat because of its high source of omega-3s.

High protein options like lentils, beans and other legumes are also an important part of this diet. The Mediterranean diet incorporates the basics of healthy eating -- plus a splash of flavorful olive oil and perhaps a glass of red wine -- among other components.

Most healthy diets include fruits, vegetables, fish and whole grains and limit unhealthy fats. While these parts of a healthy diet remain tried-and-true, subtle variations or differences in proportions of certain foods may make a difference in your risk of heart disease. Always consult your health physician before embarking on any new venture, as medicines can interact with certain food groups.

Key components of the Mediterranean diet include:
• Eating generous amount of fruits and vegetables daily
• Consuming healthy fats such as olive oil and canola oil avocadoes in moderation
• Eating small portions of nuts
• Drinking red wine, in moderation
• Consuming very little red meat if at all
• Eating fish on a regular basis
• Goat cheese is preferred choice over other cheeses
• Whole grain bread is eaten without butter or margarines, which contain saturated or Trans fats, because these contribute to heart disease.



This pyramid suggests amounts of serving of various food groups. Notice that the first component of this pyramid is exercise. All the doctors concurred that we should not underestimate the importance of daily activity, as it is a tremendous deterrent for any of above mentioned conditions.

Vegetables, nuts, olives, fruit and fish — and a pleasant, sunny climate! Mediterranean’s live long and eat well, there's no question. Their diet has scored praise from nutrition experts and culinary enthusiasts. But what is it about the diet exactly that makes it so healthy?

A new study by the Harvard School of Public Health in Boston and the University of Athens Medical School in Greece breaks down the diet staples of the Mediterranean diet. Results were released in the online edition of the British Medical Journal.

Researchers looked at more than 23,000 Greek men and women participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) over eight and a half years. They found that certain foods in the diet may offer the bulk of the nutritional benefits.

As a surprise to us all the high consumption of fish and cereals that most of us associate with the diet, and the avoidance of dairy, did not impact the benefits of the overall diet. But the omission of prepackaged and processed foods with sugars and additives — commonly found in North American diets, probably also works in the Mediterranean diet’s advantage.

Other components of the diet driving the mortality benefit included:
• Low intake of mean and meat products (16.6% of the effect)
• High vegetable intake (16.2% of the effect)
• High fruit and nut consumption (11.2% of the effect)
• High monounsaturated-to-saturated fat intake (10.6% of the effect)
• High intake of legumes (9.7% of the effect)
• High cereal intake and low dairy consumption were the lowest contributors to the mortality effect, accounting for 6.1% and 4.5%, respectively

Moderate alcohol intake may be the single biggest contributor to the Mediterranean diet's longevity benefit, accounting for 23.5% of the effect in a prospective cohort study. The researchers defined moderate intake as 10 to <50 grams of alcohol per day. But subtracting alcohol as a component, the Mediterranean diet still appeared to contribute significantly to a long life.

But before running to your nearest bar for your daily allotment--you must pay attention to this.
Although moderate drinking may help protect against some chronic diseases, alcohol's net effect on health is profoundly negative around the world, researchers reported in the June 27, 2009 issue of The Lancet. Rehm J, et al "Global burden of alcohol diseases.” According to this study, the harms associated with alcohol vastly outweigh the benefits both globally and in the U.S.

In 2004, alcohol cost the world nearly 71 million disability-adjusted life-years (DALYs) -- years of life lost to premature death or lived with disability, "Overall, their analysis shows that alcohol consumption is a major risk factor for burden of disease."

Alcohol is linked to many disease categories. Alcohol-use disorders, cancer, cardiovascular disease, liver cirrhosis, and injury are the most important disease categories causally affected by alcohol. Although light to moderate drinking may have a beneficial effect on cardiovascular disease, this benefit is restricted to older people only," they say. Moreover, such benefits are swamped by the negative effects of heavy drinking, which often affect younger people who have more DALYs to lose The analysis also showed that for much of the world, the beneficial effects of alcohol are essentially irrelevant because of drinking habits, demographics, and lower prevalence of diabetes and cardiovascular disease


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for SPECIAL UPDATE BULLETIN FOR MEDICAL PROVIDERS ON SWINE FLU

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CDC DATA IMPLICATE POULTRY AS MOST COMMON SOURCE OF FOOD POISONING.

CDC DATA IMPLICATE POULTRY AS MOST COMMON SOURCE OF FOOD POISONING.
Newly released CDC data indicate that "poultry was the most commonly identified source of food poisoning in the United States in 2006." During processing, chickens are at risk of being exposed to Clostridium perfringens, and the bacterium's spores can survive cooking processes, according the agency's Morbidity and Mortality Weekly Report. "Salmonella, the bacteria found in nationwide outbreaks of contaminated peanut butter, spinach, and tomatoes, was the second-leading cause of sole-source food illnesses," while, "dairy products accounted for just three percent of traceable food-related outbreaks," with 71 percent of the cases being "traced to unpasteurized milk."
But "while poultry is the most common source of illnesses among the 17 different foods tracked by federal officials...two-thirds of all food-related illnesses traced to a lone ingredient were caused by viruses, which are often added to food by restaurant workers who fail to wash their hands."

OTHER FOODBORNE INFECTIONS
Foodborne infections are mostly manifested as intestinal illnesses and are largely preventable. The World Health Organization estimates that in 2005, 1.5 million people died, worldwide, from diarrheal diseases. A separate study estimated that 70% of diarrheal diseases are foodborne. The widely cited US estimate is that there are 76 million foodborne illnesses annually, resulting in 325,000 hospitalizations and 5200 deaths. The annual cost in the USA of all foodborne diseases is estimated to be $1.4 trillion.
, humanity has become vulnerable to cross-species illnesses, thanks to modern advances such as the rapid transportation of both goods and people, increasing population density around the globe, and a growing dependence on intensified livestock production for food. The global transport of animals and animal products, which includes hundreds of species of wildlife, also provides safe passage for the harmful bacteria, viruses, and fungi they carry, not to mention the prion proteins that cause insidious illnesses such as mad cow disease and chronic wasting disease in deer and elk. Comment:

Not only is local and national health care often a problem; internationally, no agency is responsible for, or capable of, monitoring and preventing the myriad diseases that can now cross the borders between countries and species.

More specifically, no organization has the mandate to pursue policies based on a simple but critically important concept: that the health of people, animals, and the environment in which we all live are inextricably linked. Money must be found to help protect us more from foodborne infections, because these diseases are preventable. If the food production and marketing chain supplied food to consumers that were virtually free of pathogens there would be very little foodborne disease.

To produce food virtually free of pathogens the government would have to take additional actions to prevent contamination-- more than the actions taken so far which documents that even the minimal food safety regulations taken 10 years ago have been effective in reducing contamination.


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for PART I OF III -FDA ALERT ON DANGERS OF TAINTED WEIGHT LOSS PRODUCTS.

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Esophageal Adenocarcinoma-the White Man’s Disease

Development of Barrett's esophagus and esophageal adenocarcinoma appears to be strongly affected by ethnic factors, with populations resident at the west end of the Eurasian continent, such as Anglo-Celtics, being more prone to both conditions. On the other hand, ethnic groups from the eastern and southern ends of Eurasia, such as Chinese, Koreans and Japanese, and Africans might be more prone to developing esophageal squamous cell carcinoma.

Esophageal adenocarcinoma (EAC) is the most rapidly increasing cancer in the Western world and Barrett’s esophagus (BE) is the only known precursor lesion for this lethal cancer. Long-term survival may be improved if EAC is diagnosed early, providing an opportunity for early intervention. Surveillance of all patients with known BE is probably not cost effective and factors predictive of BE progression to dysplasia/EAC are poorly understood. Screening and surveillance examinations are also faced with challenges in the endoscopic detection of intestinal metaplasia and dysplasia. Future application of molecular biomarkers may help identify the patients with BE most likely to progress, and the use of novel imaging methods may improve outcomes of BE screening and surveillance

Esophageal squamous cell carcinoma (ESCC) used to be the dominant type of esophageal malignancy both in Western and Asian countries. The rapid increase of EAC in Western countries has occurred in parallel with an increased prevalence of gastroesophageal reflux disease (GERD) and its major determinant, obesity.
Such an increase in EAC has not yet been observed in Asia, despite a recent increase in prevalence of GERD.

Hongo, Michio et al.Journal of Gastroenterology and Hepatology, Volume 24, Number 5, May 2009 , pp. 729-735(7)
Jeff Michalak et al. Current Gastroenterology ReportsVolume 11, Number 3 / June, 2009

COMMENT: The incidence of esophageal cancer is greatest in those people with chronic heartburn. Yet the screening of these patients for cancer is not deemed “cost effective.”

Read about the controversy and how it affects medical malpractice cases in-

Book I - “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) by Perry Hookman, MD (Author) : 592 pages.27 chapters. Publisher: CRC; Potomac Press; Language: English ISBN-10: 1420058959 ISBN-13: 978-1420058956; Dimensions: 10.1 x 7.1 x 1.4 inches; Shipping Weight: 2.6 pounds; price $239.95.
For author information visit www.Hookman.com; for book purchase visit www.MedMalBook.com


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A NEW NON INVASIVE TEST FOR ALZHEIMER'S

Dementia and other cognitive problems are common. An estimated 24 million individuals in the world have dementia and the number affected will double every 20 years.1 Milder forms of cognitive dysfunction, including mild cognitive impairment, affect many more people.2 Alzheimer’s disease is the commonest form of dementia. Cognitive problems are a feature of many neurological and medical diseases including stroke, Parkinson’s disease, head injury, and epilepsy.

Assessment of a patient’s cognition is a crucial part of many medical consultations. Cognitive tests aid the diagnosis of dementia and are important in the medical and social management of patients and in the assessment of capacity. Once there are effective treatments for Alzheimer’s disease there will be an even greater need for a quick sensitive test that is suitable for use in primary care and by non-specialists. Dr.Jeremy Brown, British consultant neurologist,et al devised a cognitive test, the TYM ("test your memory"), in the detection of Alzheimer’s disease in his article named Self administered cognitive screening test (TYM) for detection of Alzheimer’s disease: cross sectional study and wich appeared in the recent BMJ 2009;338:b2030

The TYM test
The TYM is a series of 10 tasks on a double sided sheet of card with spaces for the patient to fill in (see appendix 1 on bmj.com). The patient’s ability to complete the test is an 11th task. The tasks are orientation (10 points), ability to copy a sentence (2 points), semantic knowledge (3 points), calculation (4 points), verbal fluency (4 points), similarities (4 points), naming (5 points), visuospatial abilities ( 2 tasks, total 7 points), and recall of a copied sentence (6 points). The ability to do the test is also scored (5 points), giving a possible total of 50 points. The scores for the subsets are printed on the card and the total score calculated by adding the subset scores. To ensure consistent scoring a single sheet of scoring instructions is availableControl participants completed the TYM with an average score of 47/50. Patients with Alzheimer’s disease scored an lower average of 33/50. The TYM score shows excellent correlation with the two standard tests. A score of 42/50 had a sensitivity of 93% and specificity of 86% in the diagnosis of Alzheimer’s disease. The TYM was more sensitive in detection of Alzheimer’s disease than the mini-mental examination, detecting 93% of patients compared with 52% for the mini-mental state examination. The negative and positive predictive values of the TYM with the cut off of 42 were 99% and 42% with a prevalence of Alzheimer’s disease of 10%. Thirty one patients with non-Alzheimer dementias scored an average of 39/50.

The authors concluded that the TYM can be completed quickly and accurately by normal controls. It is a powerful and valid screening test for the detection of Alzheimer’s disease.



Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for Surveillance of Barrett's Columnar-Lined Esophagus.

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INCREASED RISK OF STROKE IN PATIENTS WITH PSORIASIS

Psoriasis is a chronic Th-1 and Th-17 inflammatory disease. Chronic inflammation has also been associated with atherosclerosis and thrombosis. The authors conducted a population-based cohort study of patients seen by general practitioners participating in the General Practice Research Database in the United Kingdom, 1987–2002.

Mild psoriasis was defined as any patient with a diagnostic code of psoriasis, but no history of systemic therapy. Severe psoriasis was defined as any patient with a diagnostic code of psoriasis and a history of systemic therapy consistent with severe psoriasis.

The unexposed (control) population was composed of patients with no history of a psoriasis diagnostic code.

When adjusting for major risk factors for stroke, both mild (hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.0–1.1) and severe (1.43, 95% CI 1.1–1.9) psoriasis were independent risk factors for stroke. The excess risk of stroke attributable to psoriasis in patients with mild and severe disease was 1 in 4,115 per year and 1 in 530 per year, respectively.

Patients with psoriasis, particularly if severe, have an increased risk of stroke that is not explained by major stroke risk factors identified in routine medical care.
Joel M Gelfand et al.Investigative Dermatology advance online publication 21 May 2009; doi: 10.1038/jid.2009.112



Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for WHO SAYS THE US DOES NOT RATION CARE?.

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Cancer Care too Expensive

NEWLY INAUGURATED PRESIDENT SARAH PALIN DISCLOSES HER WINNING ELECTION STRATEGY WITH LADIES HOME JOURNAL WHITE HOUSE CORRESPONDENT AND EX-CBS NEWS ANCHOR KATIE COURIC

“I’ve always maintained, that if you give the Democrats enough rope they’ll hang themselves” said the triumphant new President of the U.S. Sarah Palin. The last straw was denying cancer treatment to her former running mate John McCain when his melanoma returned to the left side of his face. The treatment was denied because of his age by the head Washington D.C. agency established for Equitable Health Distribution (EHD) under the Obama Health reform acts. They did because of his advanced age of being past 70 years old and on the basis of these four developments which in retrospect dynamically converted many pro-lifers into pro-choice.
The inevitable shift in public opinion tipped the balance to Palin’s pro-life winning election theme. Unfortunately it was too late for the former war hero and presidential candidate McCain.


1. First “IOM released top 100 comparative effectiveness priorities”
The stimulus bill "earmarked $400 million for 'comparativeness effectiveness research,'" HHS "asked the Institute of Medicine (IOM), created by Congress to provide advice to policymakers, health professionals, the private sector, and the public, to identify the top priorities on which [healthcare services] to spend the money." In a report , the IOM "listed the top 100 areas of medicine in which research is needed to determine which treatments or preventive measures work best. One of the major areas was cancer treatment. The IOM's research priorities include "remedies for back pain, obesity, and preventing falls in the eldery, as well as studies about how to disseminate the findings to doctors and patients." The 100 recommendations "were selected from some 2,600 suggestions submitted to the committee from professional groups, policy makers and the public

The NYT praised the IOM's "report as one of the first concrete steps in a broad effort by administration officials and health experts to shift the focus of medical practice toward scientific evidence -- rather than a physician's personal views or treatments promoted by medical product companies.". Insurers, unions, consumer groups, and "many medical researchers" are cited as proponents of comparative effectiveness research, who "say such studies are essential to curbing the widespread use of ineffective treatments."

2. This was followed by the NEJM.1056/NEJMp0904133) published on June 30, 2009, which stated “This unique opportunity to invest in a major component of the scientific infrastructure for improving health care delivery will be indispensable for achieving a health care system that delivers affordable, high-quality care for all Americans. Physicians and patients deserve the best patient-centered evidence regarding what works, so that Americans can receive care of the highest quality and the best possible outcomes can be achieved.” Also the NEJM explained (10.1056/NEJMp0905631) that the American Recovery and Reinvestment Act of 2009 (ARRA). “which was the $787 billion economic stimulus package that President Barack Obama signed into law on February 17, 2009, included $1.1 billion for Comparative Effectiveness Research [CER]. The research priorities developed by the IOM committee — delivered as Congress requested only 19 weeks after Obama signed the measure — must be taken into account by the DHHS as it allocates $400 million in support of CER projects over the next 2 years. (A Federal Coordinating Council for Comparative Effectiveness Research, a new advisory group created by the ARRA, is also providing input to the DHHS [http://hhs.gov/recovery/programs/cer/cerannualrpt.pdf].)

3. The third article was a successful trial balloon from the NIH -- Medical Oncology Branch, Center for Cancer Research, National Cancer Institute (TF), and Department of Bioethics, The Clinical Center (CG), National Institutes of Health, Bethesda, MD. Tito Fojo of the National Cancer Institute and Christine Grady at the National Institutes of Health. wrote [Fojo.T.et al How Much Is Life Worth: Cetuximab, Non–Small Cell Lung Cancer, and the $440 Billion Question] that “The high price of some of the newest cancer medicines are coming under scrutiny as part of an effort by lawmakers and health officials to rein in overall medical costs.”. Fojo is calling into question the widespread use of expensive cancer drugs to prolong patients' lives by just weeks or months. Fojo states that a study showed that "treating a lung-cancer patient with Erbitux [cetuximab], a drug that costs $80,000 for an 18-week regimen, only prolongs survival by 1.2 months." The authors noted that "based on that estimate, extending the lives of the 550,000 Americans who die of cancer annually by one year would cost $440 billion." The authors argued that "health professionals and researchers cannot ignore costs in setting treatment standards.These authors also "questioned the cost-benefit calculus for other big cancer drugs " calling "for changes in the testing and practice of medicine—despite the fact drugmakers say this article exaggerated the overall costs of their treatments because few patients are on them for extended periods of time."

4. Going even further the NIH authors stated that “Studies of cancer drugs that are expected to find survival advantages of two months or less should be undertaken only if the treatment costs less than $20,000.” Otherwise, they say the research community will waste valuable resources pursuing therapies that the healthcare system can't afford to provide. "We naturally avoid confronting the tension between not wanting to put a value on a life and having limited resources. But the spiraling cost of cancer care in particular makes this dilemma inescapable."They continued, "We must stop deluding ourselves into thinking that prescribing expensive chemotherapies and tests is an aberration, a temporary deviation from an otherwise reasonable cost trajectory."More than 90% of all new anticancer drugs receiving FDA approval in the past four years cost more than $20,000 for a 12-week course of treatment, they said.Drs. Fojo and Grady even rejected the argument that cost-benefit ratios will improve through identification of patient subgroups who are more or less likely than average to respond to a given drug.

5. Drs. Fojo and Grady recommended a series of policies that were immediately implemented with the new health reform acts.:

• Anticipated treatment costs should be coupled to trial designs, such that the endpoint benefit should cost no more for a quality-adjusted life-year than renal dialysis -- currently $129,000.

• Drugs that work for a particular patient subset "should be advocated, approved, and prescribed for that subset only."

• Clinicians should not prescribe beyond FDA-approved indications -- such as giving treatment-resistant or refractory patients a drug approved only as first-line therapy.

• "The all too common practice of administering a new, marginally beneficial drug to a patient with advanced cancer should be strongly discouraged. In cases where there are no further treatment options, emphasis should be first on quality of life and then cost."

• Toxicities should receive extra scrutiny for drugs with marginal benefits.
Fojo T, et al "How much is life worth: cetuximab, non-small cell lung cancer, and the $440 billion question" J NATL CANCER INST 2009; DOI: 10.1093/jnci/djp177.


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for How to Find a Good Hospital.

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Don't spend your life trying to impress others

Because even if you convince others that you're great, have you convinced yourself?

I’ve heard a great sermon. It’s this.

Next time you're in a conversation, see how long it takes the other person (and yourself!) to start mentioning personal accomplishments. A movie star who believes his fan mail is in trouble. Because he's built a house of cards. And when he falls, he'll fall hard. Chasing after honor is a sign that you don't sufficiently respect yourself. It's like saying, "I might not amount to much, but if I can make others think I do, then I'm worth something."

One of the most destructive ways of trying to impress others is by role-playing. We act out characters that we think others will like. Did you ever notice how your personality can change in the presence of different people? We may go through 10 or 20 roles per day!

But it's not true. It's chasing "fool's gold" -- yellow and glittery, but worthless. Deep down you feel like a fraud. People who are satisfied with themselves don't need public recognition to reassure their worth. If you depend upon the opinions of others to determine how good you are, then you become like a leaf in the wind, fluttering in whichever direction the fads of the time blow you. If you have confidence in your own worth, you'll be better able to follow opinions that are your own and not society's.

Always ask yourself: "What is my real motive?"
Advice.
• Don't get trapped in the obsessive need for recognition.
• Seeking the approval of others harms you, because it keeps you from the real work of becoming great.
• If you need others to verify your significance, it's time to examine your self-esteem.
• When you act to impress others, you feel the emptiness inside.
• When you get the urge to toot your own horn, ask yourself: Who am I trying to impress?
• Even if you convince people that you're the greatest person in the world, have you convinced yourself?

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for Cancer Care too Expensive.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

IMPORTANCE OF CHLAMYDIA SCREENING

"One of the biggest frustrations in public-health circles today involves a tiny bacterium called Chlamydia trachomatis." some CDC experts "estimate that twice that many cases go undetected." Thus far, "efforts to screen for chlamydia have run into a number of obstacles," with one issue being "simple awareness." And, "many primary-care doctors may be too time-pressed to bring up chlamydia screening during office visits," or do not think it is an issue affecting their patient demographics. Therefore, the "CDC, along with the National Chlamydia Coalition, an umbrella group of nearly 40 medical associations, are working to spread the word about the importance of screening for chlamydia."

Chlamydia infection is the most common sexually transmitted disease, responsible for a record 1.1 million cases reported to the Centers for Disease Control and Prevention in 2007, and experts there estimate that twice that many cases go undetected. Left untreated, chlamydia can cause infertility or potentially fatal ectopic pregnancies. But many women aren’t even aware that they were exposed to it—possibly years ago—until they try to have a baby and can’t.

Chlamydia can be detected with a simple urine test. It can be treated with a single dose of antibiotics, and the CDC has been urging all sexually active women under 26 years old to be tested for it annually, as well as older women who have had a change of sexual partner. Yet fewer than 40 % of women in those categories are being screened. “You’d think this would be a no-brainer,” says John Douglas, director of the CDC’s division of STD prevention. “That’s why we’re trying to get the message out.”
The CDC, along with the National Chlamydia Coalition, an umbrella group of nearly 40 medical associations, are working to spread the word about the importance of screening for chlamydia.

Chlamydia is especially prevalent among women ages 15 to 19 and African-Americans, but sample studies have found the infection in nearly 10% of all female Army recruits, 10% of female college freshmen and 14% of women in managed-care plans. Experts say it’s about three times as prevalent in women than men, but it may be that men eliminate it from their bodies more readily, while it goes on to cause far more damage in women.

Many girls in the prime chlamydia age group are under the care of pediatricians, who may be uncomfortable bringing up sex with patients they’ve treated since infancy. Even when pediatricians discuss the human papilloma virus (HPV) vaccine with adolescents and parents, it’s often in the context of preventing cancer in the future, not current sexual activity.“But to pretend that teenagers aren’t having sex is very dangerous.”

Even when women are treated for chlamydia, about 25% become reinfected within six months—probably due to a partner who wasn’t treated. So the CDC recommends that doctors give women a second course of antibiotics for their partners, even without being seen by a doctor themselves. It can be treated either with a weekly dose of doxycycline or a single dose of azithromycin, which goes by the brand name Zithromax, made by Pfizer Inc., in many countries.

Chlamydia can be spread by oral or anal sex, as well as vaginal sex; condoms greatly reduce the transmission rate. No one knows for sure how long an infected person remains contagious. But experts advise caution. More insidiously, even when a woman no longer tests positive for an active infection, the chlamydia bacteria may have moved into her upper genital tract and set off pelvic inflammatory disease. PID can cause pelvic pain—or it can be asymptomatic—but it often leaves inflammation and scar tissue that blocks a woman’s fallopian tubes, preventing fertilization. PID is also the most common cause of ectopic pregnancy, which can be fatal. “It’s not the infection itself but the body’s response to get rid of the bacteria that causes the scarring,” There is also evidence of old chlamydia infections in women with endometriosis—a condition in which bits of uterine lining tissue grow outside the uterus, which can also cause pain and infertility. Chlamydia infecting the uterine wall can cause miscarriages, and that it can invade ovaries and lead to early ovarian decline and early menopause. Such scarring can sometimes be seen with a hysterosalpingogram. Severe scar tissue may need to be removed surgically before a woman can get pregnant or to resolve pelvic pain.

The CDC recommends that all pregnant women be tested for chlamydia at the first prenatal visit, although if you are planning to become pregnant, it’s a good idea to be tested for all STDs well in advance. Older women who are experiencing pelvic pain, intermittent bleeding, unusual vaginal discharge or signs of early menopause should ask their doctor if chlamydia could be involved

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for WHICH ORAL ANTIBIOTICS ARE SAFE DURING PREGNANCY AND BREASTFEEDING?

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Part I of II: IS IT SAFE TO TAKE ENTERIC COATED ASPIRIN?

Even low-dose aspirin (acetylsalicylic acid [ASA]) produces intestinal damage.

The small bowel was shown to be damaged by low-dose ASA even on a short-term basis in twenty healthy volunteers (age range, 19-64 years) who underwent video capsule endoscopy (VCE), fecal calprotectin, and permeability tests (sucrose and lactulose/mannitol [lac/man] ratio) before and after ingestion of 100 mg of enteric-coated ASA daily for 14 days.

Video capsule images were assessed by 2 independent expert endoscopists, fully blinded to the treatment group, by using an endoscopic scale.

Post-ASA VCE detected 10 cases (50%) with mucosal damage not apparent in baseline studies (6 cases had petechiae, 3 had erosions, and 1 had bleeding stigmata in 2 ulcers). The median baseline lac/man ratio (0.021; range, 0.011-0.045) increased after ASA use (0.036; range, 0.007-0.258; P = .08), and the post-ASA lac/man ratio was above the upper end of normal (>0.025) in 10 of 20 volunteers (vs baseline, P < .02). The median baseline fecal calprotectin concentration (6.05 microg/g; range, 1.9-79.2) also increased significantly after ASA use (23.9 microg/g; range, 3.1-75.3; P < .0005), with 3 patients having values above the cutoff (>50 microg/g). Five of 10 subjects with abnormal findings at VCE also had lac/man ratios above the cutoff. Median baseline sucrose urinary excretion (70.0 mg; range, 11.8-151.3) increased significantly after ASA administration (107.0 mg; range, 22.9-411.3; P < .05).

CONCLUSIONS: The short-term administration of low-dose ASA is associated with mucosal abnormalities of the small bowel mucosa, which might have implications in clinical practice.

E. Smecuol Low-dose aspirin affects the small bowel mucosa: results of a pilot study with a multidimensional assessment. Clin Gastroenterol Hepatol 7(5):524-9 (2009)

COMMENT:

The efforts to generate safer NSAIDS and aspirins includes enteric coated and slow release formulations. But these “safer” formulations simply shift the damage of these agents to a more distal site in the intestinal tract.

This study documents that even in the short term and in healthy controls a short course of enteric coated ASA can damage the small intestinal mucosa.

Half of the healthy study population showed mucosal damage.
This study must be taken into consideration by patients and their providers.

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for PART II of II SHOULD EVERYONE TAKE ASA?

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COMMONLY USED DRUGS THAT INCREASE PHOTOSENSITIVITY

You surely know that this is summer the great season of the year of cook-outs, the beach and lots of sun. But you should also be aware of the following medicaltions that you may be taking that increases photosensitivity—and take extra precautions if you fit in this picture.

Analgesic Agents
NSAIDs: celecoxib (Celebrex), diclofenac (Voltaren, Cataflam), diflunisal (Dolobid), etodolac (Lodine), ibuprofen (Motrin), indomethacin, ketoprofen (Orudis), mefenamic acid (Ponstel), meloxicam (Mobic), nabumetone (Relafen), naproxen (Anaprox), oxaprozin (Daypro), piroxicam (Feldene), sulindac (Clinoril)
Other: cyclobenzaprine (Flexeril), dantrolene (Dantrium), sumatriptan (Imitrex)

Antibiotics
Fluoroquinolones: ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), lomefloxacin (Maxaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), ofloxacin (Floxin) Tetracyclines: demeclocycline (Declomycin), doxycycline (Vibramycin), minocycline (Minocin), oxytetracycline (Terramycin), tetracycline (Achromycin), tigecycline (Tygacil) Other: azithromycin (Zithromax), capreomycin (Capastat), ceftazidime (Fortaz), cefazolin (Ancef), cycloserine (Seromycin), dapsone, gentamicin, griseofulvin, ethionamide (Trecator), isoniazid (Nydrazid), metronidazole (Flagyl), nalidixic acid (NegGram), pyrazinamide, sulfamethoxazole/trimethoprim (Bactrim), sulfasalazine (Azulfidine), sulfisoxazole (Gantrisin)

Antidepressants
Tricyclic Antidepressants: amitriptyline (Elavil), amoxapine (Asendin), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), maprotiline (Ludiomil), nortriptyline (Pamelor), protriptyline (Vivactil), trimipramine (Surmontil)
Selective serotonin reuptake inhibitors: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft)
Antidepressant, Other: bupropion (Wellbutrin), mirtazapine (Remeron), nefazodone (Serzone), trazodone (Desyrel), venlafaxine (Effexor)

Antidiabetic Agents
Sulfonylureas: acetohexamide (Dymelor), chlorpropamide (Diabinese), glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta, Micronase), tolazamide (Tolinase), tolbutamide (Orinase)

Antihistamines
cetirizine (Zyrtec), cyproheptadine (Periactin), diphenhydramine (Benadryl), loratadine (Claritin), promethazine (Phenergan)

Antiplatelet
clopidogrel (Plavix)

Cardiovascular
Thiazide diuretics: bendroflumethiazide (Corzide), chlorthalidone (Thalitone), hydrochlorothiazide (Microzide), hydroflumethiazide (Diucardin), indapamide (Lozol), methyclothiazide (Enduron), metolazone (Zaroxolyn) Diuretics, Other: bumetanide (Bumex), furosemide (Lasix), triamterene (Dyrenium)
Antihypertensives: amlodipine (Norvasc), captopril (Capoten), diltiazem (Cardizem, Tiazac), enalapril (Vasotec), hydralazine, labetalol, minoxidil, nifedipine (Procardia), sotalol (Betapace) Statins: atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor)
Other: acetazolamide, amiodarone (Cordarone, Pacerone), fenofibrate (Tricor), methyldopa, quinidine

Vitamins
pyridoxine (vitamin B6), vitamin A

REFERENCES:
Dukes MNG, Aronson JK. Meyler's side effects of drugs. 14th ed. Amsterdam: Elsevier; 2000.
Moore DE. Drug-induced cutaneous photosensitivity. Drug Saf 2002;25:345-72.
Allen JE. Drug-induced photosensitivity. Clin Pharm 1993;12:580-7
Pharmacist's Letter/Prescriber's Letter 2009;25(6):250606.


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for PART I of II DETRIMENTAL EFFECTS OF ASPIRIN

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TOP 10 Laws and Rules Every Physician Should Know

The following information is being provided as a resource to remind you of important laws and rules that affect your medical practice, but is not all inclusive. Although this applies to my state of Florida it is still your responsibility to read and become familiar with the laws and rules of your state.


Florida Law and/or Rule
1. You must update your Practitioner Profile within 15 days

Description
s. 456.042, F.S. This includes changes in –
• Address
• Staff privileges
• Medical malpractice history
• Financial responsibility
• Board certification
• Education
• Disciplinary/criminal history


Florida Law and/or Rule
2. Before you move to a new practice, notify the Board

Description
s. 456.035, F.S.; s. 458.319(3), F.S.; s. 458.327(2)(e), F.S. No current address on file? Here is what can happen:
• crisis at renewal time
• late renewal may mean practicing on an inactive license
• practice on inactive license = criminal offense


Florida Law and/or Rule
3. Do not pre-sign prescriptions

Description
s. 458.331(1)(aa), F.S. Board of Medicine Disciplinary Guidelines provide a maximum penalty of -
• Reprimand
• $5,000 fine
• 2 years probation

Florida Law and/or Rule
4. At license renewal, read the fine print before you renew

Description
s. 458.319, F.S. • It is your license on the line, not your office manager’s!
• CME and Financial Responsibility requirements are audited
• Maintain copies of your CME certificates for at least 2 biennium
• DIDN’T RECEIVE YOUR RENEWAL POSTCARD? Call (850) 488-0595 extension #3
• RENEW ONLINE at https://ww2.doh.state.fl.us/mqaservices/login.asp
• The Preventing of Medical Errors course has specific requirements including a study of root cause analysis, error reduction, prevention and patient safety, and the 5 most mis-diagnosed medical conditions which are:
• cancer
• cardiac
• acute abdomen
• timely diagnosis of surgical complications
• stroke and related cranial conditions

• CME providers may be located on the Internet by typing “continuing medical education” in the search field, or by contacting the American Medical Association at (312) 464-4952.

Florida Law and/or Rule
5. You must keep charts on the family, employees and friends that you treat

Description
s. 458.331(1)(r), F.S. and s. 458.331(1)(m), F.S. • A prescription creates the physician/patient relationship
• Records are required even for family
• Spouses/friends may become adverse parties
• Cannot self-prescribe controlled substances

Florida Law and/or Rule
6. Patient Boundaries

Description
S. 458.329, F.S. and s. 458.331(1)(j), F.S. State Boards of Medicine should have a zero tolerance policy on physician/patient sexual misconduct
• Typical penalty is suspension/revocation
• Remember: A prescription creates a physician/patient relationship


Florida Law and/or Rule
7. Pause before you make the incision on the correct site of the correct patient

Description
s. 458.331(1)(t), F.S.; s. 456.072, F.S.; and Rule 64B8-9.007, F.A.C. • The “pause” before the procedure must be in the patient chart
• If you make the mistake, inform the patient and/or the patient’s representative and document it or the Board will increase the penalty.
• Read the rule at 64B8-9.007 Standards of Practice.

Florida Law and/or Rule
8. Internet Prescribing

Description
s. 458.331(1)(t), F.S. and Rule 64B8-9.014, FAC • Prescribing without a history and physical is both a standard of care violation and a violation of Board rule
• Physician have been disciplined for this with penalties ranging from revocation to suspension, reprimands and fines
• DO NOT JEOPARDIZE YOUR LICENSE – DON’T PRESCRIBE BASED ON INTERNET & QUESTIONNAIRES!


Florida Law and/or Rule
9. Relocating Practice?

Description
Rule 64B8-10.002, FAC You are responsible to:
• hold patient records for 5 years
• notify patients in letters or by sign as to where to pick up records
• place a notice in newspapers and notify the Board of Medicine 30 days before you move
• complete your hospital charts if leaving the area!

Florida Law and/or Rule
10. Help for impaired practitioners

Description
s. 456.076, F.S. Do you know a colleague with drug, alcohol, or psychiatric problems?
• You can get them help without subjecting them to disciplinary action
• Most state Boards have an excellent evaluation and rehabilitation programs that is a phone call away: Call your state’s Professional Resource Network
• For most practitioners, this is and remains a confidential process that offers help to those willing to change
• This program was recently expanded to include medical students as well


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for Circumcision Prevents Sexual Transmitted Diseases (STDs)

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A GREAT IDEA -- SPECIALIZED HEALTH CARE COURTS

“Never events are now the going payment standard of care as far as hospital re-imbursement. But that means to many a never event will probably also be viewed as representing “below standard medical care.” Thus "the mere designation of never events will likely result in both more numerous and more valuable plaintiffs’ verdicts nationwide,” says Charles Brown.

In an op-ed in the New York Times Philip K. Howard, chairman of Common Good, a legal reform coalition, writes that currently, "fear of possible claims leads medical professionals to squander billions in unnecessary tests and procedures." This practice, known as "defensive medicine," is now "so prevalent that it has become part of standard protocol," Howard notes.

And, "under instructions from lawyers," physicians "don't apologize or offer explanations when things go wrong." As a result, "patients, sensing distrust, demand second opinions." "it would be relatively easy to create a new [health] system of reliable justice, one that could support broader reforms to contain costs." But, with "special health courts aimed...delivering fair and reliable decisions," patients and physicians would have "expedited proceedings with knowledgeable staff."

He also points out that "one benefit" of a "quicker, streamlined system would" be "drastically lower legal costs." Howard concludes that "restoring trust in law," an "essential reform, can be accomplished with the creation of reliable courts." Restoring a foundation of trust requires a new system of medical justice, says Howard. Medical cases are now decided jury by jury, without consistent application of medical standards. According to a 2006 study in the New England Journal of Medicine, around 25 percent of cases where there was no identifiable error resulted in malpractice payments. Nor is the system effective for injured patients — according to the same study, 54 cents of every dollar paid in malpractice cases goes to administrative expenses like lawyers, experts and courts.

America needs special health courts aimed not at stopping lawsuits but at delivering fair and reliable decisions. A special court would provide expedited proceedings with knowledgeable staff that would work to settle claims quickly. Trials would be conducted before a judge who is advised by a neutral expert, with written rulings on standards of care.

All information about each incident, including details learned in settlements, would be compiled and disseminated so that doctors and hospitals could learn from their errors.

Proponents of special health courts have estimated that the total cost of such a new liability system would be about the same as the existing system — less than 2 percent of America’s total health care costs. One benefit would be that the quicker, streamlined system would compensate far more people, with drastically lower legal costs. Most important, it would restore faith in the reliability of medical justice. This country has a long tradition of courts and tribunals to deal with issues like bankruptcy that require special expertise. Nowhere is that expertise, along with the stability and trust it would bring, more needed than in health care.

Several prominent hospitals, including New York Presbyterian, have said they are interested in being part of a health court pilot project. Some large consumer and patient safety groups support the idea. The fastest way to do this would be for Congress to authorize and finance pilot courts around the country. These ideas already have some bipartisan support: Bills for alternative medical justice systems have been introduced in Congress.

Cutting back on the notorious inefficiency of American health care is essential to achieve universal care, as well as make the American economy more competitive.
Part of the solution — overhauling the reimbursement model so that doctors get paid only for what is needed — is unavoidably complex.
But restoring trust in law, the other essential reform, can be accomplished with the creation of reliable courts.

* Tune in tomorrow for Recommendations on Managing Infection Passed from Pets to Humans via Bite Injuries

Deepen your understanding of How to Be an Effective Medical Expert www.medmalbook.com

SUBOPTIMAL RATES OF CERVICAL TESTING

It is estimated that over 11,000 women will be diagnosed with cervical cancer and nearly 4000 women will die of cancer of the cervix this year. A high percentage of women will develop abnormal cervical pathology-a precursor to cervical cancer. Guidelines recommend Pap screening at least every 3 years for all women and annual screening for women greater than 30 years of age.

According to a study published in Clinical Gastroenterology and Hepatology, women with IBD like ulcerative colitis and Crohns disease have a high incidence of abnormal cervical cytology. However they are tested for cervical abnormalities at suboptimal rates.

Using the PharMetrics Patient-Centric Database (1996 to 2005), doctors identified cases of IBD and matched controls via a validated algorithm. With logistic regression, they compared utilization of cervical testing with IBD case status, patients' age, use of immunosuppressive medications, Medicaid insurance status and use of primary care services.

Although Cervical malignancy is largely preventable through proper screening half of all women –especially those with IBD who receive the diagnosis of cervical cancer have never been screened. This has to be changed through proper education. Quality improvement initiatives are needed to improve disease prevention services for women with IBD.

Clinical Gastroenterology and Hepatology; 2009: 7(5): 549-553

CAN WE BELIEVE HOSPITAL STATISTICS?

Reporting of Mistakes by Hospitals Is Faulted

A.Hatocollis reports that at least in one city--New York City-- hospitals are the least reliable in the state at reporting preventable mistakes and adverse incidents for patients like heart attacks, blood clots, hospital infections and medication errors, according to a new report by the office of City Comptroller.

The comptroller also expressed concern that the New York City data on medication errors appear to run counter to the national trend, citing estimates by the Institute of Medicine of the National Academies that at least 400,000 hospital patients are harmed and 7,000 killed by medication errors annually. In contrast, the report said, from 2004 through 2007, city hospitals rarely reported medication errors: 37 that resulted in death, near death or permanent harm to patients, with 22 hospitals, including four very large ones, reporting none.

The lack of accurate reporting makes it virtually impossible for consumers to judge accurately the quality of a hospital or for the hospital to compare itself with its peers and make improvements, the comptroller’s office argues, saying the consequences include longer hospital stays and higher health-care costs. “Without the fullest possible reporting, hospitals cannot identify areas where systematic improvement may be needed,” reads the report. “Weak enforcement and flagging commitment to a broad-based effort has compromised the whole program.”

NewYork-Presbyterian/Weill Cornell Medical Center one of New York City’s major academic medical centers, reported only about 20 adverse incidents per 10,000 patient discharges, while a comparable institution outside the city, which was not named, reported about 166 incidents per 10,000, a rate more than eight times higher.

Within New York City’s 60-plus hospitals, there was great range: 17 reported no heart attacks unrelated to a cardiac procedure while one had more than 40; six hospitals reported 2 blood clots or acute pulmonary embolisms per 10,000 patient discharges while two others had more than 60 per 10,000; one major academic medical center reported 3.6 post-operative infections per 10,000 discharges and a similar hospital had 32 per 10,000. None of these hospitals were named in the report.

The report, which looks at data from 2004 through 2006, with some additional data from 2007, echoes a state Health Department study in 2001 that similarly concluded that New York City underreported adverse incidents, with 6 of the 11 city-run public hospitals among the 25 lowest reporters. The new analysis faulted the state for not being more aggressive in enforcing penalties such as fines against hospitals with lax reporting, and cited “enormous and inexplicable disparities among individual hospitals.”

A hospital’s size and the type of procedures it performs do not seem to explain the differences in reporting rates.

The report does not name individual hospitals, but the comptroller’s office separately released a list of the 12 lowest reporters in the city based on 2006 data. The top three — St. Vincent’s Midtown and Cabrini Medical Center in Manhattan, and Mary Immaculate in Jamaica, Queens — have all since closed.

The others include some of New York’s biggest and most prestigious hospitals: Lenox Hill, on the Upper East Side (No. 7); Bellevue, the flagship hospital of the city’s Health and Hospitals Corporation (10); Weill-Cornell (11); and Mount Sinai (12).

COMMENT:
It’s not difficult to believe that NYC is not an isolated city. I believe that hospital statistics reported from other cities will have to also be investigated—with severe sanctions applied to violaters.