Thank You

Thank you for all the feedback you’ve given me about my posts.  You let me know that I’m not just writing to myself.

Thank you for all the links to interesting articles you send me.  You help keep me informed and give me great ideas for posts.

Thank you for praising Jaymes, our receptionist, Nancy, our medical assistant, and Angela, our biller, when they help you.  They’re very good at what they do and I couldn’t do what I do without them.

Thank you for understanding my unusual practice model.  It has no initials; it has nothing to do with IPAs or PPOs or HMOs.  I still don’t really know what to call it, but I’m confident you’ll settle on a name eventually.

Thank you for referring your colleagues and loved ones to me.  In a year with a scary economy, in a state with over 10% unemployment, my practice has continued to grow.  I can’t express how much your loyalty and support mean to me.

As is my annual tradition, I hereby rescind all of my patients’ dietary restrictions for one day.  May we all be surrounded by loved ones and count our abundant blessings.  Happy Thanksgiving!

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Apathy about Anacetrapib

The new cholesterol medication generating hubbub this week is anacetrapib.

Why is the world holding its breath for another cholesterol medicine in an already crowded field?  Well, the most successful family of cholesterol medications is statins.  Statins have solid evidence for stroke and heart attack prevention.  Statins lower LDL, the “bad cholesterol” that you hear about whenever your doctor discusses your cholesterol results.  But another important risk factor for heart disease is low HDL.  HDL is the “good cholesterol” that protects against stroke and heart attack; so more is better.  People with HDLs below 40 are at increased risk for stroke and heart attack.

Thus far, there has not been any medication that substantially increases HDL and prevents stroke and heart attack.  That makes raising HDL an inviting target for pharmaceutical research.  Sure enough, those brainy scientists discovered a new family of medications – CETP inhibitors – which raise HDL.  More HDL should mean fewer heart attacks!  There was much rejoicing.

And this is where we get into trouble if we confuse clinical outcomes with intermediate outcomes.  (See below for a link to my post in 2007 that explains the difference.)  It’s entirely possible for a medication to lower LDL without preventing heart attacks.  (Estrogen is the most notorious example.)  It’s possible for a medicine to increase bone density without preventing fractures.  So it’s entirely possible that a medicine may raise HDL without having the intended clinical benefit – preventing strokes and heart attacks.

In 2007 a large study tested a new CETP inhibitor, torcetrapib, and found that it increased HDL substantially while also increasing heart attacks and death.  There was much grief and woe (especially at the company that makes it).  The important lesson is that fixing the intermediate outcome (low HDL) doesn’t necessarily lead to fixing the clinical outcome (heart attack risk).

This week a trial was published in the New England Journal of Medicine testing a new CETP inhibitor, anacetrapib.  Given the disaster with its older cousin torcetrapib, this trial was just designed to measure safety, not efficacy.  So the trial showed that anacetrapib lowered LDL, raised HDL substantially, and (unlike its cousin) didn’t kill people in large numbers.

That’s nice, but not a reason to pop champagne corks.  Now the large trial begins to show whether it actually prevents strokes and heart attacks.  We won’t have that answer until 2015.

Learn more:

New York Times article:  Merck Drug for Cutting Cholesterol Is Promising

Wall Street Journal Article:  Cholesterol Drug Advances

New England Journal of Medicine article:  Safety of Anacetrapib in Patients with or at High Risk for Coronary Heart Disease

My post in 2007 about the difference between clinical outcomes and intermediate outcomes:  Merck Knows More about Zetia than They’re Telling Us

Tangential miscellany:

This week’s New England Journal of Medicine published a gut-wrenching story of a medical emergency on an airplane.  The handful of doctors on board faced a difficult ethical dilemma.  If you have a few minutes, give it a read.  What would you have done?

And finally, as physicians have done for countless generations, I’m now using Twitter.  I’ll try to tweet an interesting health-related headline daily.  If you’re on Twitter, follow me!

Follow AlbertFuchs on Twitter

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Safety: It’s not Just for Airlines Anymore

Preventing medical errors is a subject that is belatedly attracting a lot of attention.  The way in which hospitals prevent errors and manage them after they happen is undergoing a major transformation.  (See the links below to my prior posts on medial errors.)

The traditional plan for error prevention in medicine can be summarized as “we should all be more careful”.  Physician autonomy and diversity of practice styles were thought to be sacrosanct and it was thought that errors could be minimized if physicians were simply more cautious.  But any engineer will tell you that humans can only be so careful and that any system that depends on human memory and attention to prevent errors will fail frequently.  Medicine is finally learning from aviation that safety depends on multiple redundant systems to prevent mishap and that simple strategies such as checklists and flowcharts can cut errors dramatically.

This week’s New England Journal of Medicine devotes three articles to this issue.  The first article is a Case Record, which is typically a puzzling case in which a mysterious disease is diagnosed by the brainy doctors at Mass General.  This week the case is not mysterious.  It’s a brutally honest story of a surgeon who performed the wrong surgery on a woman’s left hand – a carpal tunnel release instead of a trigger finger release.

The discussion of the case reads like a suspense thriller.  The reader knows that something bad is going to happen and multiple plot twists make the bad outcome more likely.  The surgeons were running behind schedule, necessitating some changes to the operating room team.  That meant that the team that went over the details of the surgery with the patient before the surgery would not be the same as the team in the operating room.  The surgery prior to the one in question was a carpal tunnel release.  That patient became upset and agitated in the recovery room.  The surgeon spent time consoling her, but found the encounter quite anxiety-provoking.  He promised himself that the next surgery would be “the best carpal tunnel release that I have ever performed.”

In the operating room, standard protocol calls for a “time out” in which the critical pieces of information are reviewed – the identity of the patient, the type of procedure, the specific site – by the entire team prior to the first incision.  The patient did not speak English and the surgeon (but not the rest of the team) was able to communicate to her in Spanish.  He had a brief discussion with her in Spanish before the surgery, which the anesthesiologist and the nurse mistook to be the formal “time out” but wasn’t.  A time out was never done.  Clearly, multiple lapses in procedure contributed to this error.

Immediately after the incorrect surgery, the surgeon realized his mistake, returned to the recovery room and disclosed the error to the patient.  He apologized and asked permission to perform the correct procedure which was done immediately thereafter.

The consequences of this case were relatively benign – the patient has to heal from an unnecessary surgery to her wrist.  Obviously other medical errors lead to more catastrophic losses.

The second article was a study in multiple hospitals in the Netherlands.  The study involved the adoption of a detailed checklist that covered all steps in surgical care from preoperative preparation to postoperative care.  The number of surgical complications and errors declined dramatically after the adoption of this checklist.  Surprisingly, complications even decreased in aspects of surgical care not mentioned in the checklists, suggesting that the checklist may have had some unforeseen benefits such as a less distracting operating room or less harried surgeons.

The final article was an editorial that reminded us that – compared to industries with mature safety cultures like aviation – medical safety still has a long way to go.

Learn more:

ABC News article:  Doctor Gives Public Mea Culpa after Surgical Mistake

Case Records of the Massachusetts General Hospital:  A 65-Year-Old Woman with an Incorrect Operation on the Left Hand

New England Journal of Medicine article:  Effect of a Comprehensive Surgical Safety System on Patient Outcomes

New England Journal of Medicine editorial:  Strategies for Improving Surgical Quality — Checklists and Beyond

My post in August about changing how medical errors are handled:  Admitting our Mistakes

My post in 2009 about adopting a culture of safety in healthcare: Got Safety?

My post in 2007 about teaching physicians to disclose errors: Learning to Say “I’m Sorry”

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A Screening Test for Lung Cancer

This week brings very exciting news, but everybody seems worried that we’ll misunderstand and read too much into it.

There are very few cancers for which we have a good screening test.  A good screening test is a test that is done on people without any signs or symptoms of cancer and that diagnoses the cancer accurately enough at an early enough stage so that lives are saved.  Mammograms save lives from breast cancer.  Pap smears save lives from cervical cancer.  Screening for colon cancer saves lives.  And that’s about it – three cancers that we can do something about before signs or symptoms show up.  Prostate cancer screening remains controversial and we hope for more definitive answers in the next few years.  But for all the other cancers (lymphoma, sarcoma, esophageal cancer, testicular cancer, kidney cancer, ovarian cancer, leukemia…) there is no evidence that any test is better than diagnosing the disease after symptoms are present.

For decades, a screening test for lung cancer has been sought.  Though the incidence of lung cancer has been decreasing as fewer Americans smoke, it remains the leading cause of cancer death.  In the 1970s chest X rays were studied as a way to screen smokers for lung cancer.  Unfortunately chest X rays were found not to save any lives.  The patients found to have lung cancers by chest X ray died of their cancer as frequently as those whose cancer was diagnosed when it was symptomatic.  (Tangentially, that means that if you’re getting routine annual chest X rays your doctor is only 40 years behind the medical literature.  He is sure to catch up soon.)

This week a very large study called the National Lung Screening Trial showed that in the right patient population CT scans effectively screen for lung cancer.  The trial enrolled 53,000 people who were

  • aged 55 to 74,
  • were either current smokers or had quit in the last 15 years,
  • had not been diagnosed with lung cancer, and
  • had smoked at least 30 pack-years.

What’s a pack-year?  It’s 365 packs of cigarettes, or how much you smoke by smoking a pack per day for a year.  So 30 pack-years is how much you smoke by smoking 2 packs per day for 15 years, or 3 packs per day for 10 years.  The point is that risk from smoking is cumulative and is proportional to the total lifetime amount of cigarettes smoked.

The trial randomized the 53,000 people into two groups.  One group received annual chest X rays; the other received annual helical (also called spiral) CT scans of the chest.  Both groups were followed for five years.  In the group randomized to CT scans 354 died of lung cancer, compared to 442 in the chest X ray group.  This was a large enough difference that the trial was stopped early, which means that the actual benefit of CT scans might be even larger than these numbers suggest.

This means that for every 300 people screened with CT scans one life was saved from lung cancer.  That’s pretty good.  And it’s now the fourth cancer for which (in the right patient population) we have a reasonable screening test.

Unable to leave good news alone, all the national cancer gurus are terribly worried that two misunderstandings will arise from these results.  So let’s clear them up right now.

Does this mean it’s safe to smoke now?  No! First of all, CT scanning only managed to decrease mortality from lung cancer by 20%. That’s not even a quarter.  Decreasing the mortality of running across the freeway by 20% doesn’t make it safe.  That rest of the mortality – that big 80% – is still there.  Secondly, this doesn’t eliminate all the other risks of smoking: emphysema, heart disease and stroke.

Does this mean that everyone should get a spiral CT?  No! Take a second look at the criteria listed above of the patients enrolled in the study.  That is the only group of people for whom we know screening is effective.  There is no evidence that CT scanning will help anyone outside this group.

The actual scientific paper has not yet been published.  So there are a lot of details and numbers that doctors are eagerly awaiting before we can answer specific questions.  But for now it looks like there’s a fourth cancer that we can effectively catch early.

(Thanks to Robert C. and Timo K. for pointing me to his story.)

Learn more:

New York Times article:  CT Scans Cut Lung Cancer Deaths, Study Finds

MSNBC article:  ‘Spiral’ CT scans can cut lung cancer deaths

National Lung Screening Trial questions and answers

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Live Long and Prosper

“I hope I die before I get old”
— The Who
My Generation
Composed in 1965 by Pete Townshend, currently 65 years old

The good news is that people are living longer all the time.  This trend has been happening as long as records have been kept and shows no sign of stopping.  Better hygiene and sanitation, safer living environments, and antibiotics have nearly eradicated death in childhood and early adulthood.  As progress continues battling heart disease and cancer, longevity should continue to increase.

The bad news is that we’re unprepared for this.  We live as if life is short, and then are unprepared for the decades of life still before us.  Just as failing to plan financially for our later years may make us dependent on others, failing to manage our health may mean spending our last decades disabled.  A terrific article in the New York Times this week (see the link below) reviews very simple common-sense suggestions that all of us can use to minimize the likelihood of disability later in life.

The first theme of the article is physiologic reserve.  Young people have much more lung function, cardiac function, brain cells and muscle mass than they use in a typical day.  The difference between how much you have and how much you need is the reserve.  But all of these functions slowly decline with age.  The article stresses that the simple habits that we develop now will have a major impact when we age.

For example, someone who does moderate cardiovascular exercise a few times a week in her 40s and 50s will enter her 70s with much more cardiovascular reserve than someone who is sedentary.  Even though she’ll notice that her walking (or biking or swimming) gets a little slower every year, she’ll still be maintaining a huge difference between what she can do (walk 3 miles) and the minimum required to be independent (walk safely in the home).  That is, she’ll maintain a large reserve.  Her sedentary neighbor who only does his activities of daily living won’t notice a decline in function until he’s too weak to walk from the living room to the bedroom.  At that point, regaining the lost strength through physical therapy will be much more difficult.

There’s also an important diagnostic difference between the two people.  The active woman will notice symptoms warning of heart disease or lung disease much sooner than the sedentary neighbor, since she’s putting her cardiovascular system through a mini stress test every time she takes a walk.  If, on the other hand, all you do is sit, you’ll only notice your lungs getting worse when they’re not absorbing enough oxygen to sit.

So now is the time for all us middle-aged folks to build the muscle mass reserve and cardiovascular reserve that we will “spend” in our 70s and 80s.  That doesn’t have to mean running marathons.  But it does mean a commitment to at least walking several times a week.  Obviously, if you can do more, all the better.

The second point of the article is safety.  Older people frequently become disabled as the result of preventable accidents.  The article lists common danger spots in the home that can be modified to prevent falls and injuries.  A home safety evaluation from a geriatric case manager is another way to make sure that your home is safe for your level of physical functioning.

The challenge of mortality isn’t that we all die; it’s that we don’t know when.  Ultimately we are only in control of what we do with the years we get.

I’ll leave you with some philosophy.  The Roman philosopher Seneca mused about the brevity of life about two millennia ago (link below).  Give it a read when you’re feeling contemplative, after you’ve exercised.

(Thanks to Rachel G. for pointing me to the NY Times article.)

Learn more:

New York Times article:  What to Do Now to Feel Better at 100

Lucius Annaeus Seneca:  On the Shortness of Life

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A Meta-Post about Meta-Research

… or, How to Love the Null Hypothesis

First, bear with me for an important definition.  “Meta” used as a prefix, has come to mean self-reference, or “an X about X”.  For example, meta-analysis is an analysis of other analyses.  If you are arguing with your boyfriend about how unfairly he argues, you’re having a meta-argument, an argument about other arguments.  You with me?

I usually write about a current study in the medical literature, but this week I’m writing about a researcher, John Ioannidis, whose field of study is other medical research.  He researches the biases, flaws and errors that shape medical research.  He is a meta-researcher, and is a leading expert on the credibility of medical research.  Next month’s issue of The Atlantic has a fascinating article about his work (link below).  If you have any interest in medicine or science I urge you to read it.

The Atlantic article highlights the many problems in published peer-reviewed medical studies and the reasons that many of the studies’ conclusions are false.  So that even doctors who are doing their best to stay current with the latest findings are frequently following misleading information.  Once the medical studies are distorted and exaggerated in the general press, it’s no wonder that much of the public believes that medical science is no better than reading tealeaves.  How many times have we heard one year that some medicine is a panacea, and the next year that it’s poison?  How can we argue against unproven alternative medicine when traditional medicine is constantly self-contradicting?

One way for medicine to reclaim its credibility is for doctors to more clearly explain why we know what we think we know, and to be honest about the many things that we don’t know.  Another way for the public to regain trust in medical science is for the general media and the public to become more sophisticated consumers of scientific findings, which is to say to build a more scientifically literate public.

Which brings me to the purpose of these weekly posts.  Obviously the main purpose is to highlight some new and hopefully interesting finding.  But a longer-term purpose is to teach all of you how to separate important findings from hype, speculation from evidence, correlation from cause.  Obviously none of us are going to become statisticians or experts in evaluating scientific experiments, but here are three suggestions that will go a long way to helping you ignore bad studies.

Ignore all non-randomized studies. John Ioannidis in the Atlantic article also agrees with that strategy.  Not sure what the difference is between an observational study and a randomized study?  See the link my post on epidemiology, below.  This simple step will allow you to blissfully forget about 90% of the health related hype you hear.

If possible, read the original scientific article. If you read a scintillating newspaper article about an exciting new finding, try to find the original scientific publication.  The news story will frequently cite the scientific journal, and you’ll usually be able to at least find the abstract online.  Read it.  You may not understand all the statistics, but you’ll have a good sense of what the researchers did and the conclusions they drew, which may be much more modest than what the newspaper is suggesting.

Practice skepticism. The null hypothesis is the assertion that two things have nothing to do with each other.  For example, if I’m trying to prove that eating carrots cures insomnia, the null hypothesis is “eating carrots has no effect on insomnia.”  The null hypothesis is what scientists have to disprove to show a connection between any two things.  People love making connections.  Our brain has evolved to believe in the interrelatedness of things.  We unfortunately instinctively reject the null hypothesis.  If I remember once that I ate carrots with dinner and slept well, then I may have an overwhelmingly compelling belief that the carrots were the cause of my uninterrupted sleep, even though the two are likely coincidental.  We should remember that most pairs of things have nothing to do with each other, which is to say, the null hypothesis is usually right.  Even for pairs of things that are tightly linked in the popular imagination (like cell phones and cancer, or pesticides and health problems) the scientific link is frequently nonexistent.  We should assume that things are not interconnected unless we are presented with repeated large randomized trials showing that one thing is linked to the other.

The problem is that skepticism is hard to do, since our brain is wired for belief, not for skepticism.  That means that we all believe things that are false, but we don’t know which of our beliefs these are.  And since science is a human endeavor it progresses slowly and takes wrong turns and frequently disproves what it earlier believed.  But we don’t have a better tool for getting at the truth than science.  So with all its contradictions, evidence-based medicine is still the best defense against quackery.

So I have to live with the fact that many of the conclusions of my posts are probably wrong, but it’ll take years to figure out which.  But I hope the conclusion of this post is true.  It’s a meta-conclusion.

(Thanks to Timo K. for pointing me to the Atlantic Article.)

Learn more:

The Atlantic article:  Lies, Damned Lies, and Medical Science

My previous post on the importance of ignoring non-randomized studies:  Ignore Epidemiology, Maybe It’ll Go Away

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Meridia Withdrawn from US Market

… or, So Long Sibutramine

Over two thirds of Americans are overweight.  A safe and effective medication that helps people lose weight would be a boon for the health of millions who are struggling to take off the pounds.  Unfortunately, this has been an extremely tough nut to crack for the pharmaceutical industry.

The existing medications for weight loss have been only modestly effective, and last week the choices became fewer.  Meridia (the brand name of the medicine sibutramine) was voluntarily withdrawn from the market last week after a study in the New England Journal of Medicine last month showed that it increased the risk of heart attacks and strokes.

The study randomized over 9,000 overweight adults to sibutramine or placebo.  Though the increase in heart attack and stroke risk was only small, the benefit was even smaller.  The patients on sibutramine lost an average of only 5 lb more than the placebo group over more than 3 years of follow up.  The FDA decided that the risk was not worth the tiny benefit.  The medicine has also been withdrawn from Europe.

That leaves only one prescription weight loss medication on the market, orlistat (sold as Xenical by prescription and Ali over the counter).  I wrote about it when I reviewed the available options in July (see link below).  It is also only modestly effective and the side effects, while not dangerous, can be annoying and rather icky.

So for now, the best advice for weight loss is to eat less, exercise more and get enough sleep.  And for those who are extremely overweight weight loss surgery deserves consideration.

Learn more:

FDA Alert:  Meridia (sibutramine): Market Withdrawal Due to Risk of Serious Cardiovascular Events

Wall Street Journal Health Blog:  Hasta La Vista, Meridia: Another Diet Drug Bites the Dust

New England Journal of Medicine article:  Effect of Sibutramine on Cardiovascular Outcomes in Overweight and Obese Subjects

My post in July about lorcaserin (which may not win FDA approval): A New Medication for Weight Loss

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Sleep Deprivation Sabotages Dieting

The correlation between obesity and inadequate sleep has been known for some time.  But does one cause the other or are they coincidental?  It’s also known that inadequate sleep increases hunger, an effect I can attest to from my memories of medical training.  I always ate more than usual on the days following nights spent in the hospital.

So people who don’t sleep enough feel hungrier and presumably eat more than people who get enough sleep.  Is that the only mechanism connecting poor sleep to weight gain?  To answer this question investigators performed a small but fascinating study which was published in the current issue of Annals of Internal Medicine.  Ten overweight sedentary adults spent 14 consecutive days in a sleep lab, where their activity, sleep, and food intake could be continuously monitored.  (Why hasn’t this been made into a reality show?)  They were provided with a calorie-restricted diet containing 90% of their daily metabolic rate.  They had no access to other food.  They were randomized to be allowed to spend either 8.5 hours in bed nightly (normal sleep group) or only 5.5 hours nightly (sleep-deprived group).  Their weight, hunger, percent body fat, and multiple metabolic factors were measured before and after the 14 days.  Several months later the same adults repeated the 14 day stay in the sleep lab, this time in the other sleep group.  They did not engage in any exercise, and just did typical home or office activities.

As expected, the subjects who were being sleep deprived reported greater hunger, but since their diet was controlled, they could not compensate for their hunger by eating more.  Interestingly, subjects lost equal amounts of weight whether sleep deprived or not – an average of 6.6 lb over the 14 days.  That’s over 3 lb per week, which demonstrates the effective weight loss possible in a controlled environment.  Obviously, in the real world people have access to food, and refraining from eating despite hunger is exceedingly difficult.  The dramatic difference was that when the subjects were allowed 8.5 hours of sleep, they lost an average of 3 lb of fat, compared to only 1.3 lb from fat when sleep-deprived.

These findings suggest a few interesting observations.  First, when sleep deprived, most of the lost weight was lean mass, presumably muscle.  That means that the sleep-deprived state switches our metabolism to preferentially burn protein rather than fat, a serious setback for someone trying to lose weight.  Second, even when subjects were sleeping normally, significant lean mass was lost, suggesting that preservation of lean mass when dieting must involve exercise.

So what have we learned?  You’ll definitely lose weight if you don’t have access to as much food as you’d like.  (Ask anyone in North Korea.)  You’ll lose more fat weight if you restrict your calories and get enough sleep.  And if you restrict your calories and don’t exercise you’ll lose almost as much lean mass as fat.

So if you’re overweight, eat less, exercise more, and get enough sleep.

Learn more:

Wall Street Journal Health Blog:  Study: Dieters Foregoing Sleep May Lose Muscle, Not Fat

Annals of Internal Medicine article:  Insufficient Sleep Undermines Dietary Efforts to Reduce Adiposity

Annals of Internal Medicine editorial:  Sleep Well and Stay Slim: Dream or Reality?

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Spiriva: A New Option for Asthma Patients

Patients whose asthma symptoms are only mild and intermittent usually don’t need daily asthma medications.  They just use a rescue inhaler, like albuterol, whenever symptoms come up.

Patients with daily or almost daily symptoms, on the other hand, need daily preventive medications to control their asthma.  The first choice for a preventive asthma medicine is a low dose of an inhaled steroid.  If this first choice doesn’t control symptoms well, patients generally face a choice between increasing the inhaled steroid dose and adding an inhaled long-acting beta agonist (LABA).  LABAs have fallen under some disfavor recently as studies have shown that they can increase the risk of severe asthma exacerbations and, rarely, death.  (See the link to my post, below.)

This month, the New England Journal of Medicine published a study that gives asthma patients a new option.  In the study, asthma patients who were not adequately controlled on a low dose steroid inhaler were randomized to three groups.  One group received a higher dose inhaled steroid.  A second group received a low dose inhaled steroid plus a LABA.  The third group received a low dose inhaled steroid plus Spiriva (tiotropium).  Spiriva is a once-daily inhaled medicine that has been proven effective in emphysema but has not been tested in asthma until now.

Asthma symptoms and lung function were better in the Spiriva group than in the high-dose steroid group.  And the Spiriva group did no worse than the LABA group.

Spiriva is already the first-line medication of choice in emphysema. If longer trials demonstrate its safety in asthma, it may be the ideal medicine to add if a low-dose inhaled steroid isn’t enough.

Learn more:

LA Times article:  Spiriva is an alternative for adult asthmatics, researchers say

New England Journal of Medicine article:  Tiotropium Bromide Step-Up Therapy for Adults with Uncontrolled Asthma

New England Journal of Medicine editorial:  Anticholinergics for Patients with Asthma?

My post about the dangers of long acting beta-agonists:  Alarms about Asthma Agents

Tangential miscellany:

US Airways Magazine just republished my post Rethinking Calcium Supplements.  So if you’re flying US Airways in October, grab a copy.

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California’s Whooping Cough Epidemic

Pertussis or whooping cough is a bacterial respiratory disease marked by a runny nose for a week or two followed by a severe persistent cough.  In adults it rarely causes severe illness, and usually resolves even without treatment, but in infants the disease can be life-threatening.

California is currently experiencing a whooping cough epidemic.  Over 4,000 cases have been reported this year, the most since 1955.  Nine have died, all babies.  Three quarters of the patients that required hospitalization were 6 months old or younger.

The best protection from pertussis is vaccination, and children should routinely get 5 doses of pertussis vaccine between the ages of 2 months and 6 years.  But since the first dose is given at two months, newborns are particularly vulnerable.  And since not all children receive their immunizations on schedule, there is a larger group of vulnerable kids.

Many adults are no longer protected by the vaccinations they received in childhood, and though adults typically have much milder symptoms, they are a common gateway to infection for the children in their environment.  Because of this the LA County Health Department has expanded recommendations for adult pertussis vaccinations to include all adults.

Pertussis vaccines are recommended for:

  • Infants, children and pre-teens, (See the link to the patient leaflet below for the specific immunization schedule.)
  • Adults and teens who have never received a Tdap vaccine, especially:
    • Women of childbearing age before, during, or immediately after pregnancy
    • Healthcare workers
    • People who have close contact with infants including parents, grandparents, siblings, and childcare providers

Adults only need one Tdap in their lifetime.  As an added bonus, the Tdap vaccine also includes the tetanus and diphtheria boosters, which you then won’t need for another ten years.  So go to your doctor and get one.

Learn more:

NPR Health Blog:  Calif. Whooping Cough Cases Near 55-Year High

Los Angeles Times LA Now Blog:  Whooping cough data from state show babies hardest hit, epidemic worst since 1955

County of Los Angeles Public Health Department pertussis vaccination patient leaflet

County of Los Angeles Public Health Department letter to healthcare providers

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