U.S. Customs and Border patrol officials seized a record amount of fentanyl and other synthetic opioids in the fiscal year that ends tonight. Most of the illegal packages were found in the mailroom at New York's JFK Airport. Tony Dokoupil reports.
From: http://www.cbsnews.com/videos/u-s-customs-and-border-patrol-seize-record-amount-of-fentanyl-and-other-opioids/
Saturday, September 30, 2017
Mayo Clinic Minute: 'HALT' before you grab a snack
From: Mayo Clinic https://www.youtube.com/watch?v=5DFp4MgycWs
Time to rethink the debate on PSA testing
For most of us, whether to screen for cancer is a no-brainer. Who wouldn’t want a simple test to prevent cancer or identify it at an earlier, more treatable stage? However, as with many things, the screening decision is more complex than it may appear. For example, the test may not be particularly “simple,” such as undergoing screening colonoscopy. For prostate cancer, even after 30-plus years of using a screening blood test called the prostate specific antigen, or PSA, it still isn’t clear how well it prevents prostate cancer deaths. This has led to conflicting and changing recommendations about whether to screen or not. Earlier this year, I commented on revised recommendations from the US Preventive Services Task Force (USPSTF) — a group that advises primary care physician such as myself about a wide range of topics including cancer screening.
A new look at old studies
The PSA test was used for many years without any clear evidence for or against it, and without the USPSTF providing a specific recommendation. This changed in 2009 after the publication of two large trials, one from the US and the other from Europe. Unfortunately, they showed conflicting results — no benefit in the US trial versus a small benefit in the European one. This led the USPSTF to recommend against PSA screening based on the negative results from the US trial, as well as evidence of potential harms of PSA testing from overdiagnosis and treatment of small, benign-appearing cancers unlikely to spread or lead to death. Earlier this year, the USPSTF proposed changing its recommendations to say that health care providers should now discuss the pros and cons of the test with eligible male patients to help them decide whether to have the test or not, using a process called shared decision making.
If all this wasn’t confusing enough, a new study recently re-examined these two (now old) trials and concluded that they really aren’t as different as we thought. The authors of the new study did new analyses showing that PSA testing decreased prostate cancer deaths similarly in these trials. So, what’s going on, and will the USPSTF again change its recommendation?
In brief, the new study used original data from these two trials and computer modeling to control for important differences. These differences included lower rates of prostate cancer overall and more control patients getting a PSA test done (who shouldn’t have) in the US trial. The European trial performed PSA screening less frequently but called the test result abnormal at a lower value than the US trial. After accounting for all these differences, the new study reported that men in both trials who underwent screening as recommended had lower rates of death due to prostate cancer.
What now?
Though this new study may explain why these two trial results differed, I don’t expect the USPSTF will change its recommendation. Personally, I have long favored shared decision making with my patients, and think the USPSTF finally got it right. Why? First, despite all the fancy modeling in this study, it sought to examine the benefit of the PSA test under ideal circumstances, rather than what actually took place. Moreover, the benefit of PSA testing seems large in relative terms (20-30%), but is small in absolute terms. I’d have to screen over 1,000 men with the PSA test to prevent one prostate cancer death. Moreover, decades of using the test have also uncovered real harms — many men are being diagnosed and treated for prostate cancers that otherwise never would have been detected or caused harm. Finally, prostate cancer therapies for those with serious disease needing treatment have improved a great deal since these trials were done, lowering the value of earlier detection.
I support calls to move on from the overly simplistic debate of PSA test: yes or no. Rather, it is time to figure out how to better inform all eligible men about the benefits and harms of PSA testing. For those who elect to have the test, we need to do a better job figuring out who needs treatment when prostate cancer is found, and how to make sure we avoid harming those without such disease — harm that can be both psychologic in terms of worry and physical in terms of side effects from treatment.
The post Time to rethink the debate on PSA testing appeared first on Harvard Health Blog.
From: Steven J. Atlas, MD, MPH https://www.health.harvard.edu/blog/time-to-rethink-the-psa-to-test-or-not-to-test-debate-2017092912463
Members of Congress ask HHS to remove burdensome regulations to help providers, patients
Washington — Members of Congress are asking the U.S. Department of Health and Human Services to remove regulations that “specifically and adversely impact dentists and their patients.”
From: http://www.ada.org/en/publications/ada-news/2017-archive/september/members-of-congress-ask-hhs-to-remove-burdensome-regulations-to-help-providers-patients
From: http://www.ada.org/en/publications/ada-news/2017-archive/september/members-of-congress-ask-hhs-to-remove-burdensome-regulations-to-help-providers-patients
Nurses Believe (Trailer) - Healthy Nurse, Healthy Nation Grand Challenge
From: Mayo Clinic https://www.youtube.com/watch?v=G8uOazJAAiE
Nurses Believe - Healthy Nurse, Healthy Nation Grand Challenge
From: Mayo Clinic https://www.youtube.com/watch?v=Z6YqHBQsAXE
Mayo Clinic Minute: Sleep and Alzheimer's disease connection
From: Mayo Clinic https://www.youtube.com/watch?v=-gfEepYk92I
Diabetes: Adding lifestyle changes to medication can deliver a knockout punch
Plenty of research supports the common-sense notion that a healthy lifestyle can prevent or treat many diseases. A diet high in fruits, veggies, whole grains, and plant protein and low in processed carbs, added sugars, saturated fats; regular physical activity; and emotional well-being are the potent treatments that can prevent the need for or even replace many prescription medications.
Yet lifestyle interventions are still not “mainstreamed” into primary care.
The power of lifestyle changes for diabetes
Here is yet another study supporting intensive lifestyle intervention, this time for diabetes. The study authors seem to downplay their findings, which, frankly, baffled me. I’m happy to enthusiastically report that this study strongly confirms what I’ve often observed over the past 15 years in medicine: the way we live and what we put in our mouths can be way more powerful than many of the pills we’re prescribed.
Basically, the study authors recruited 98 people with type 2 (adult-onset) diabetes who were all pretty similar. They had had diabetes for less than 10 years and their blood sugars were not completely out of control (HbA1c* less than 9%); they were not on insulin; they all had a body mass index between 25 and 40 (that is, they were overweight).
They divided people into two groups for a year. Both groups stayed on their regular medications. The standard care group (34 people) received basic counseling and education in type 2 diabetes, including lifestyle advice by a nurse at the start of the study and again every three months.
The other group (64 people) also received a pretty intensive lifestyle intervention:
- five to six exercise sessions per week, consisting of 30 to 60 minutes of supervised aerobic activity, along with two to three sessions of weight training
- an individualized nutrition plan with dietary counseling, including calorie restriction for the first four months
- a smart watch/step counter and encouragement to be physically active in their leisure time (with a goal of at least 10,000 steps per day).
The lifestyle group did have slightly better overall blood sugar control after a year, but the real kicker was this: 73% of the lifestyle participants were able to decrease the dosage of their diabetes medications, compared to only 26% of the standard care group. And, over half of the lifestyle participants could safely discontinue their medications! As a matter of fact, 44% of the standard care group had to have their medications increased during the study, compared to only 11% in the lifestyle group.
*HbA1C is the abbreviation for hemoglobin A1c, the product formed by the attachment of glucose (blood sugar) to hemoglobin (a protein in red blood cells). A test for HbA1c is a useful measure of blood sugar control over time. An HbA1C level between 4% and 5.6% means that blood sugar has been in a good range over the past few months.
Other improvements in measure of health
In addition, the lifestyle group enjoyed significant improvements in pretty much all their measurements: weight (13.2 lbs. lost, compared to 4.4 lbs.), BMI (31 to 29, compared to 32.5 to 32), and abdominal fat (2 lbs. lost, as compared to 0.2 lbs.), with a gain in lean body mass (i.e. muscle). Over a third of the lifestyle group lost over 10% of their body weight, compared with 3% of the standard care group. And the lifestyle folks also experienced a significant improvement in their physical fitness, as measured by a fancy machine measuring oxygen uptake by the body during intense exercise.
The study authors seemed to emphasize that lifestyle improved blood sugar only modestly better than standard care at 12 months. What was incredibly striking, though, was the trend in the blood sugars over the entire year. At six months, the lifestyle group’s HbA1c levels decreased very significantly, from 6.6% to 6.2%, while the standard care group’s HbA1c increased from 6.7% to 6.9%. At 12 months, both groups drifted closer to where they had started, with the lifestyle group still a bit better than the standard care group at 6.3% as compared to 6.6%.
Why is this?
There are two possible reasons. One was that the lifestyle group had fully supervised exercise and dietary counseling sessions (including calorie restriction) for only the first four months, and after that, supervision was progressively decreased, and as a result people were less likely to stick with the program. In fact, the article shows that participation in the exercise and dietary counseling sessions dropped off over the year.
Another factor is that the participants’ diabetes medication was being adjusted throughout the study for health and safety reasons. If the HbA1c dropped below 6.5%, then their medication was decreased, and if it stayed that low or went lower, the medication was discontinued. Likewise, if the HbA1c went above 7.5%, then the medication was increased. The lifestyle group did have more episodes of low blood sugar than the standard care side, and while that can be dangerous, it also signals that the lifestyle participants needed less medication as time went on.
So, it’s reasonable to speculate that if the exercise and dietary session supervision was continuous throughout the study, and if the medications were not continually adjusted, then the results would have shown even greater improvements for the people in the lifestyle group.
And that jibes with previous studies looking at lifestyle intervention for the prevention and treatment of heart disease. There’s so much accumulated evidence supporting lifestyle intervention as a very effective treatment, that major insurance carriers will now cover such programs.
I do hope that patients will realize that lifestyle changes are as good as, and sometimes better than, prescription medications. Primary care doctors need to help them do just that.
Resources
Lifestyle medicine potential for reversing a world of chronic disease epidemics: from cell to community. International Journal of Clinical Practice, October 2014.
Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association. Circulation, August 2012.
Effect of an Intensive Lifestyle Intervention on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial. JAMA, August 2017.
Effects of Lifestyle Modification Programs on Cardiac Risk Factors. PLoS One, December 2014.
The post Diabetes: Adding lifestyle changes to medication can deliver a knockout punch appeared first on Harvard Health Blog.
From: Monique Tello, MD, MPH https://www.health.harvard.edu/blog/diabetes-adding-lifestyle-changes-medication-can-deliver-knockout-punch-2017092812468
Time to rethink the debate on PSA testing
For most of us, whether to screen for cancer is a no-brainer. Who wouldn’t want a simple test to prevent cancer or identify it at an earlier, more treatable stage? However, as with many things, the screening decision is more complex than it may appear. For example, the test may not be particularly “simple,” such as undergoing screening colonoscopy. For prostate cancer, even after 30-plus years of using a screening blood test called the prostate specific antigen, or PSA, it still isn’t clear how well it prevents prostate cancer deaths. This has led to conflicting and changing recommendations about whether to screen or not. Earlier this year, I commented on revised recommendations from the US Preventive Services Task Force (USPSTF) — a group that advises primary care physician such as myself about a wide range of topics including cancer screening.
A new look at old studies
The PSA test was used for many years without any clear evidence for or against it, and without the USPSTF providing a specific recommendation. This changed in 2009 after the publication of two large trials, one from the US and the other from Europe. Unfortunately, they showed conflicting results — no benefit in the US trial versus a small benefit in the European one. This led the USPSTF to recommend against PSA screening based on the negative results from the US trial, as well as evidence of potential harms of PSA testing from overdiagnosis and treatment of small, benign-appearing cancers unlikely to spread or lead to death. Earlier this year, the USPSTF proposed changing its recommendations to say that health care providers should now discuss the pros and cons of the test with eligible male patients to help them decide whether to have the test or not, using a process called shared decision making.
If all this wasn’t confusing enough, a new study recently re-examined these two (now old) trials and concluded that they really aren’t as different as we thought. The authors of the new study did new analyses showing that PSA testing decreased prostate cancer deaths similarly in these trials. So, what’s going on, and will the USPSTF again change its recommendation?
In brief, the new study used original data from these two trials and computer modeling to control for important differences. These differences included lower rates of prostate cancer overall and more control patients getting a PSA test done (who shouldn’t have) in the US trial. The European trial performed PSA screening less frequently but called the test result abnormal at a lower value than the US trial. After accounting for all these differences, the new study reported that men in both trials who underwent screening as recommended had lower rates of death due to prostate cancer.
What now?
Though this new study may explain why these two trial results differed, I don’t expect the USPSTF will change its recommendation. Personally, I have long favored shared decision making with my patients, and think the USPSTF finally got it right. Why? First, despite all the fancy modeling in this study, it sought to examine the benefit of the PSA test under ideal circumstances, rather than what actually took place. Moreover, the benefit of PSA testing seems large in relative terms (20-30%), but is small in absolute terms. I’d have to screen over 1,000 men with the PSA test to prevent one prostate cancer death. Moreover, decades of using the test have also uncovered real harms — many men are being diagnosed and treated for prostate cancers that otherwise never would have been detected or caused harm. Finally, prostate cancer therapies for those with serious disease needing treatment have improved a great deal since these trials were done, lowering the value of earlier detection.
I support calls to move on from the overly simplistic debate of PSA test: yes or no. Rather, it is time to figure out how to better inform all eligible men about the benefits and harms of PSA testing. For those who elect to have the test, we need to do a better job figuring out who needs treatment when prostate cancer is found, and how to make sure we avoid harming those without such disease — harm that can be both psychologic in terms of worry and physical in terms of side effects from treatment.
The post Time to rethink the debate on PSA testing appeared first on Harvard Health Blog.
From: Steven J. Atlas, MD, MPH https://www.health.harvard.edu/blog/time-to-rethink-the-psa-to-test-or-not-to-test-debate-2017092912463
Diabetes: Adding lifestyle changes to medication can deliver a knockout punch
Plenty of research supports the common-sense notion that a healthy lifestyle can prevent or treat many diseases. A diet high in fruits, veggies, whole grains, and plant protein and low in processed carbs, added sugars, saturated fats; regular physical activity; and emotional well-being are the potent treatments that can prevent the need for or even replace many prescription medications.
Yet lifestyle interventions are still not “mainstreamed” into primary care.
The power of lifestyle changes for diabetes
Here is yet another study supporting intensive lifestyle intervention, this time for diabetes. The study authors seem to downplay their findings, which, frankly, baffled me. I’m happy to enthusiastically report that this study strongly confirms what I’ve often observed over the past 15 years in medicine: the way we live and what we put in our mouths can be way more powerful than many of the pills we’re prescribed.
Basically, the study authors recruited 98 people with type 2 (adult-onset) diabetes who were all pretty similar. They had had diabetes for less than 10 years and their blood sugars were not completely out of control (HbA1c* less than 9%); they were not on insulin; they all had a body mass index between 25 and 40 (that is, they were overweight).
They divided people into two groups for a year. Both groups stayed on their regular medications. The standard care group (34 people) received basic counseling and education in type 2 diabetes, including lifestyle advice by a nurse at the start of the study and again every three months.
The other group (64 people) also received a pretty intensive lifestyle intervention:
- five to six exercise sessions per week, consisting of 30 to 60 minutes of supervised aerobic activity, along with two to three sessions of weight training
- an individualized nutrition plan with dietary counseling, including calorie restriction for the first four months
- a smart watch/step counter and encouragement to be physically active in their leisure time (with a goal of at least 10,000 steps per day).
The lifestyle group did have slightly better overall blood sugar control after a year, but the real kicker was this: 73% of the lifestyle participants were able to decrease the dosage of their diabetes medications, compared to only 26% of the standard care group. And, over half of the lifestyle participants could safely discontinue their medications! As a matter of fact, 44% of the standard care group had to have their medications increased during the study, compared to only 11% in the lifestyle group.
*HbA1C is the abbreviation for hemoglobin A1c, the product formed by the attachment of glucose (blood sugar) to hemoglobin (a protein in red blood cells). A test for HbA1c is a useful measure of blood sugar control over time. An HbA1C level between 4% and 5.6% means that blood sugar has been in a good range over the past few months.
Other improvements in measure of health
In addition, the lifestyle group enjoyed significant improvements in pretty much all their measurements: weight (13.2 lbs. lost, compared to 4.4 lbs.), BMI (31 to 29, compared to 32.5 to 32), and abdominal fat (2 lbs. lost, as compared to 0.2 lbs.), with a gain in lean body mass (i.e. muscle). Over a third of the lifestyle group lost over 10% of their body weight, compared with 3% of the standard care group. And the lifestyle folks also experienced a significant improvement in their physical fitness, as measured by a fancy machine measuring oxygen uptake by the body during intense exercise.
The study authors seemed to emphasize that lifestyle improved blood sugar only modestly better than standard care at 12 months. What was incredibly striking, though, was the trend in the blood sugars over the entire year. At six months, the lifestyle group’s HbA1c levels decreased very significantly, from 6.6% to 6.2%, while the standard care group’s HbA1c increased from 6.7% to 6.9%. At 12 months, both groups drifted closer to where they had started, with the lifestyle group still a bit better than the standard care group at 6.3% as compared to 6.6%.
Why is this?
There are two possible reasons. One was that the lifestyle group had fully supervised exercise and dietary counseling sessions (including calorie restriction) for only the first four months, and after that, supervision was progressively decreased, and as a result people were less likely to stick with the program. In fact, the article shows that participation in the exercise and dietary counseling sessions dropped off over the year.
Another factor is that the participants’ diabetes medication was being adjusted throughout the study for health and safety reasons. If the HbA1c dropped below 6.5%, then their medication was decreased, and if it stayed that low or went lower, the medication was discontinued. Likewise, if the HbA1c went above 7.5%, then the medication was increased. The lifestyle group did have more episodes of low blood sugar than the standard care side, and while that can be dangerous, it also signals that the lifestyle participants needed less medication as time went on.
So, it’s reasonable to speculate that if the exercise and dietary session supervision was continuous throughout the study, and if the medications were not continually adjusted, then the results would have shown even greater improvements for the people in the lifestyle group.
And that jibes with previous studies looking at lifestyle intervention for the prevention and treatment of heart disease. There’s so much accumulated evidence supporting lifestyle intervention as a very effective treatment, that major insurance carriers will now cover such programs.
I do hope that patients will realize that lifestyle changes are as good as, and sometimes better than, prescription medications. Primary care doctors need to help them do just that.
Resources
Lifestyle medicine potential for reversing a world of chronic disease epidemics: from cell to community. International Journal of Clinical Practice, October 2014.
Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association. Circulation, August 2012.
Effect of an Intensive Lifestyle Intervention on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial. JAMA, August 2017.
Effects of Lifestyle Modification Programs on Cardiac Risk Factors. PLoS One, December 2014.
The post Diabetes: Adding lifestyle changes to medication can deliver a knockout punch appeared first on Harvard Health Blog.
From: Monique Tello, MD, MPH https://www.health.harvard.edu/blog/diabetes-adding-lifestyle-changes-medication-can-deliver-knockout-punch-2017092812468
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