Many elderly people experience pain they would call 'moderate' or 'severe' in the last two years of life, with those who have arthritis reporting pain most often.  That's the sobering conclusion of a study published this week in Annals of Internal Medicine.

In this week's podcast I call the study distressing, but Rick points out that it is also the first study of its kind, and it provides some very valuable information.  Study participants were enrolled in the Health and Retirement Study, and were surveyed periodically over years.  Survey data from those who died was included 2 years retrospectively from their date of death.

Data from just over 4700 people was included in the analysis.  The results show that pain increases at the end of life, irrespective of existing conditions like cancer or others we may believe are less painful, such as congestive heart failure.  By far the most pain producing condition though was arthritis, with the majority of those with the condition reporting at least moderate pain at the end of life.

I think this is distressing because we have very effective agents for pain relief, many of which are not sedating or accompanied by a host of unwanted side effects.  Moreover, many are calling pain the "fifth vital sign," after heart rate, blood pressure, body temperature and respiration rate.  That's because how much pain one is experiencing can have an impact on the others as well as a profound psychological component.  Chronic pain is a well known risk factor for depression and even suicide.

Rick points out that many, if not most physicians are ill-equipped or perhaps ill-inclined to manage pain in their patients.  Given that many elderly patients don't metabolize medications well, pain in such a patient population is challenging indeed.  But studies such as this one illustrate the fact that pain is very common and does compromise quality of life for many elderly people.  It is humane to acknowledge and treat it.

Other topics in this week's podcast include screening for depression in adolescents in this issue of Pediatrics, no help from fish oil for slowing the progression of Alzheimer's disease in JAMA, and a lack of survival benefit with implanted defibrillators, also in Annals of Internal Medicine.  Until next week, y'all live well.

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Barbers and physicians have a cozy relationship, and here's why.  In the 14th century there were three categories of medical practitioners: barbers, physicians, and surgeons.  Then the Black Death killed off half the population, including almost all the physicians and most of the surgeons.  The remaining surgeons joined forces with the barbers to dispense medical care (such as it was).

Now that relationship continues, with barbers being enlisted to check their patrons for high blood pressure and encourage them to seek medical care and stick with their medications.  The study is in the current issue of Archives of Internal Medicine.

Seventeen black-owned barbershops participated in this study.  In eight of the shops, with 77 men who had high blood pressure participating in each shop, pamphlets were provided to explain the dangers of high blood pressure to patrons.  In nine of the shops with 75 men with high blood pressure participating, the barbers were trained to measure blood pressure and counsel men to see their physician for follow up and deliver other appropriate health messages.

Men who received blood pressure monitoring and counseling from their barbers achieved slightly better blood pressure control than men who did not, suggesting that such an intervention is effective.  It's also cost-effective from the standpoint of fewer heart attacks and other consequences of high blood pressure.  And as Rick and I agree in the podcast, barbers seem to like it.  It furthers relationship building and that is a big part of haircuts and barbershop society already.  A win-win!

Other topics this week include a British Medical Journal study on opiate substitution in helping people overcome addiction, two conflicting studies, one in JAMA and one in NEJM, on genes and response to the blood thinning agent clopidogrel, and also in the British Medical Journal, a look at reducing the risk of colorectal cancer.  Until next week, y'all live well.

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Makes you stronger.  That is, at least, the adage.  Now there's objective evidence that the old saw may really be true in the current issue of the Journal of Personality and Social Psychology.  A bit of a stretch for us, we admit in this week's podcast, but there it is.  Rick and I were both persuaded by the U-shaped curve related to life events and measures of happiness.

Researchers surveyed just about 2400 people on their exposure to lifetime stressful events, recently experienced adversity, and several measures of happiness and mental health, including global distress, functional impairment, life satisfaction and post traumatic stress symptoms.  Each respondent was queried three more times over the next several years.

What emerged from the data crunch was a U-shaped curve.  Those who reported low levels of adverse life events had higher rates of mental distress, those who had a moderate level of stress were happier and more resilient, and those with a high level of stressful life events were predictably less well adjusted and unhappy.  Huh.  Who knew that indeed, some stressful life events could indeed result in more satisfaction over the long haul?

Clearly, along with this adage is the one about viewing the glass as half full and the silver linings in clouds and...certainly none of us would advocate for stumbling blocks in our path but it's good to know that they can have a benefit.  And it argues for thoughtful cultivation of such an attitude when the going gets tough, as it does for us all.

Other topics this week include the dangers of hormone replacement therapy in perhaps promoting more aggressive breast cancer in this week's JAMA, the modest benefit to the patient of home monitoring for a common blood thinner in NEJM, and the dangers of invasive dental treatments in this issue of Annals of Internal Medicine.  Until next week, y'all live well.

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Influenza is a killer, with tens of thousands of deaths attributed to this common viral infection each year in the United States alone, and that's just from garden variety, seasonal flu.  Add a pandemic strain to the mix and the numbers quickly become stratospheric.  Who usually dies?  The very young and the very old. 

If you're pregnant, this brief recitation of the facts should compel you to immediately receive a flu shot.  And a study in this issue of Archives of Pediatric and Adolescent Medicine confirms what other, less rigorous studies have already intimated: mothers who receive the vaccine provide protective antibodies to their unborn children.  When those infants are born and their own immune systems are just getting up to speed, they are more protected against the flu and its respiratory complications, including the need to be hospitalized, than infants whose mothers declined to be vaccinated. 

The study observed over 1100 infant/mother pairs, both those where the mother received a flu shot while pregnant and those who did not.  Subsequent development of flu-like illness and the need for hospitalization secondary to the illness were calculated for each group.  There was a 41% reduction in risk of laboratory-confirmed influenza infection and a 39% reduced risk in the need to be hospitalized among infants whose mothers were vaccinated.

The clear message is, ladies, roll up your sleeves. There are no known risks in being vaccinated during pregnancy, either for mother or fetus.  The risk of being pregnant and developing severe flu complications is known, however.  Pregnant women were one of the severe risk groups of patients in last year's H1N1 pandemic and comprised a disproportionate number of the deaths associated with this virus strain.

Why are women who are pregnant so reluctant to be vaccinated?  Myth and urban legend seem to drive the resistance, as any examination of studies to date refutes any downside.  Pregnant women are cautioned repeatedly to avoid almost everything and anything, so should immunization avoidance come as any surprise?  Perhaps not, but here is a clear case where rationality should prevail, and all women who are pregnant should expect to receive a flu shot along with prenatal vitamins and regular medical care.

Rant over.  Other topics in this week's podcast include screening for common cancers among those who are HIV positive in this issue of Annals of Internal Medicine, with cancer surveillance in adult survivors of childhood cancer in the same issue, and advanced radiology tests in the ED in JAMA.  Until next week, y'all live well.

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Is there any benefit to mass media campaigns designed to promote healthy behaviors or discourage unhealthy ones? Put aside preconceived notions about manipulation and political agendas for a moment ( 'just say no') and take a look at evidence presented in this issue of Lancet.  As Rick and I discuss in this week's podcast, turns out there can be some positive outcomes to properly targeted messaging.

Researchers in Australia took at look at media campaigns (television, radio and newspapers as well as 'outdoor media' such as billboards) intended to impact tobacco and alcohol use, heart disease prevention, cancer screening, sex-related behaviors, and others.  Both direct and indirect means to effect change were examined, as well as concurrent availability of specific services, products or additional information to support the desired behavior.

One example cited by researchers is antismoking messages accompanied by a phone number to enlist support for those desiring to quit, and additional messages extolling the social benefits of quitting.  The conclusion is that efforts are generally more successful when a combination approach is taken.  No surprise there.

One surprising finding, however, is that some forms of messaging may actually promote the undesired behavior.  Such a conclusion may be drawn related to some appropriate alcohol use campaigns, with one reason given for such an outcome the preponderance of advertising undertaken by manufacturers countering the public health message.  What's a responsible society to do?

We can hardly outlaw advertising by manufacturers of legal goods, cigarettes and alcohol included.  But we can create effective messages to counter the ads, hopefully with exposure early enough in life to help people make educated choices.  As Rick points out, now that traditional media doesn't have the sway it used to, social media has an opportunity to not just convey information but create opinion.  When opinion becomes widespread it can impact policy making as well.  So we choose to be optimistic about the enabling power of information.  That's why we podcast!

Other topics this week include compression only CPR in JAMA, the dangers of low blood sugar in NEJM, and sleep and weight loss in Annals of Internal Medicine.  Until next week, y'all live well.

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End stage renal disease, or what is known in the common vernacular as kidney failure, isn't a diagnosis anyone wants to hear.  The definitive treatment is kidney transplant, but organ availability and compatibility fall woefully short of need.  Enter dialysis, hopefully as a temporary bridge to transplant.

Dialysis is, of course, a man made way to cleanse the blood of multiple toxins built up by normal metabolism, a task usually undertaken by the kidneys.  Two methods are routine:  hemodialysis, where one's blood is circulated through a machine, cleansed, and returned.  The other requires a catheter to be placed permanently into the abdominal space called the peritoneum.  Fluid is periodically run through the catheter into the abdomen and removed later.  The fluid exchanges waste products out of the blood.  This method is called peritoneal dialysis.

Is peritoneal or hemodialysis better?  That's the question being addressed in this study in Archives of Internal Medicine. The question is important because although people who need dialysis comprise only 1% of the Medicare population, they account for almost 6% of the cost of the program.  That's huge.  Then there's the human factor.  People who require dialysis are literally tethered to a life-sustaining routine.  Those who choose hemodialysis must have a surgery to create an access to their bloodstream, usually travel to a dialysis center at least several times a week, and spend several hours there each time.  Peritoneal dialysis requires the previously mentioned abdominal catheter and also frequent changes of the fluid in the abdomen.  Peritoneal dialysis is undeniably more flexible, since people do the majority of the heavy lifting themselves, at home.  Yet only about 7% of those who require dialysis choose this method.

The study examined short and long term outcomes data from two huge populations of dialysis patients, and found that there was essentially no difference in survival related to which method of dialysis was chosen.  Rick and I agree in this week's podcast that the evidence is compelling on the benefits of peritoneal dialysis.  We would of course love the see the need for dialysis reduced by better control of high blood pressure and diabetes, the two major bad actors involved in kidney failure.  In the meantime encouraging people to consider the peritoneal method for dialysis would help control healthcare costs and empower patients.

Other topics this week include more evidence on the benefits of breastfeeding in one BMJ journal, lack of benefit from early detection and treatment of recurrent ovarian cancer in the Lancet and a urine marker for detection of a very common cause of pneumonia, also in Archives of Internal Medicine.  Until next week, y'all live well.

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How's this for a scientific study?  Recruit women who are tanning at the beach to participate in a trial using sunless tanning products along with education and public health messaging on the dangers of UV exposure, or just completion of a survey regarding tanning behavior.  That's in this issue of Archives of Dermatology. Rick waxes very enthusiastic about the study in this week's podcast.  I guess that should be expected from someone who studies stenting and the like.  In any case, the study looked at short and longer term changes in behavior, and found that those women who used the products and became educated regarding the dangers of tanning reduced their risk taking behavior significantly with respect to sun exposure.

Researchers recruited 250 women at two public beaches in Massachusetts.  Half received a photograph of their skin showing damage related to UV exposure, instruction on how to use sunless tanning products containing a dye approved by the FDA in the 1970s called dihydroxyacetone, and free samples of products containing the dye.  The control group filled out a questionnaire, had an instant picture taken and were given free samples of products unrelated to skin care.

The intervention group was contacted at two months and one year after recruitment.  By all measures, including hours sunbathing, sunburns, use of protective clothing and use of sunless tanning products, the intervention was a success.  Since UV exposure is now ranked at the highest category of carcinogens, along with arsenic and mustard gas (!) this is no doubt a good thing.

We all know that sun exposure increases the risk of skin cancer dramatically, and skin cancers of all types are epidemic.  If use of sunless tanning products allows people to achieve the look they want without the risk, it seems like a win-win.  One issue is long term exposure to dihydroxyacetone, but no data exist on that potential risk.  Since the dye binds to dead cells very close to the skin surface which will soon be sloughed off anyway, the risk/benefit ratio seems to fall in favor of sunless tanning.  And to add my own public health message at this point, I think it's an indictment of our profit driven society that tanning salons are even allowed to remain in business.

Other topics this week include replacing the aortic valve in the heart via a skin incision in NEJM, screening for testicular cancer and a common antacid and anticlotting medicine taken together in Annals of Internal Medicine.  Sorry, hyperlinks not working this week.  Until next week, y'all live well.

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Just in time for Prostate Cancer Awareness Week (September 19-25, 2010) the British Medical Journal has stepped into the considerable fray regarding using prostate specific antigen (PSA) to screen men for prostate cancer. What pluck!  Before discussing these two huge studies, let's first define the issue.

Some years ago, men who developed prostate cancer would be diagnosed at an advanced stage, when treatment amounted to palliation at best.  Then along came the observation that much of the time, as prostate cancer develops the antigen PSA is dumped into the blood and can be easily detected.  Years of testing, measuring and correlating later, we now have PSA used to screen men for the disease.  But we've also noted that higher PSA levels can also be seen in that very common consequence of aging, benign prostatic hyperplasia or BPH.  (Loving the acronyms yet?). So rising or high PSAs may or may not signal cancer of the prostate.

Much effort and research has gone into better ways to use the marker, such as measuring its rate of increase rather than an absolute value, limiting screening to men younger than 75, and other strategies.  But the fact remains that finding a true marker of prostate cancer rather than simply an antigen produced by the prostate gland all the time, albeit at variable levels, would be infinitely preferable.

What has all this screening given us?  Critics would say massive overtreatment of the disease, since along with its other charming attributes, most cancers of the prostate are slow growing and unlikely to kill a man before something else does.  And overtreatment can come with unpleasant and expensive consequences, such as urinary incontinence and erectile dysfunction.

Enter our two studies for this week: Screening for prostate cancer, and PSA levels at age 60 and death or metastasis from prostate cancer. The first study was a meta-analysis of almost 400,000 patients and reached the sobering conclusion that PSA screening did not reduce deaths due to prostate cancer or overall mortality.  The second study is a great use of blood samples collected from almost 1200 men for another purpose.  The men were age 60 at the time of collection, and were followed to age 85. Retrospective measurement of PSA in these samples revealed that when men had a PSA value of 1 ng/ml or less at age 60, their risk of dying from prostate cancer was 0.2% or less.  The authors conclude that this finding supports measuring PSA at age 60, then not rescreening men whose levels were 1 or less, effectively eliminating a huge pool of men who may otherwise be overdiagnosed and overtreated.  Roar!

Rick and I share the opinion in this week's podcast that any way to decrease the substantial overdiagnosis and overtreatment issues with regard to prostate cancer will help everyone.  In previous podcasts Rick has stated that he hasn't been tested and is unlikely to do so.  It's worth reminding all concerned that a careful look at each man's risk, including family history and other factors, should be weighed before PSA testing is done.

Other studies this week include factors that may predict who may experience sudden worsening or exacerbation of chronic obstructive pulmonary disease (COPD) in NEJM, and in the same issue, the effect of public smoking bans on hospitalization due to chronic asthma in children  Finally, we also talk about best strategies to avoid blood clotting in people at risk but without causing an increased risk of internal bleeding, especially in the gastrointestinal tract in this issue of Archives of Internal Medicine.  Until next week, y'all well.

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Have you ever consulted Consumer Reports before buying a new appliance or car?  I have.  Now you can pick up the latest issue (September 7, 2010) and decide where, among the 221 centers that participated, you'd like to have your coronary artery bypass grafting (CABG) surgery performed.

Rick opines in the podcast (and btw, also agrees with the editorialists in the New England Journal of Medicine) that this is a seminal event in medicine, and that the Society of Thoracic Surgeons (STS) deserves kudos for compiling and crunching this data.  The story is this:  beginning in 1989 the STS began to gather data on many aspects of cardiac surgery, including coexisting medical conditions in their patients, rates of death, use of medications, complications, and surgical techniques.  They analyzed and refined their methods with the objective of improving the standard of care for all concerned.  Wow!  That's what medicine is supposed to do!

Now Consumer Reports has compiled a rating system using stars that depends on 11 of these performance measures.  One, two or three stars are awarded depending on these factors.  Actual scores on four of the subcategories can also been seen.

What's good about this?  I think it helps patients become more informed, and therefore better at participating in decisions related to their own medical care.  Rick believes the real benefit lies in allowing standards against which all programs can be measured to be developed and assessed. For programs that fall short it provides a benchmark for improvement.

One concern is that critics may say we don't have physician or surgeon-specific scores and can't compare individuals, but Rick points out that early attempts to rate physicians in this way had the undesirable result of causing them to refuse difficult cases in order to avoid compromising their scores.  Program wide ratings may largely avoid this problem.

The STS program and willingness to reveal data to a large consumer magazine provides new transparency in medicine that will hopefully encourage adoption of such methods in many more medical arenas. 

Other topics this week include differences in patient and physician expectations when it comes to stent placement in the issue of Annals of Internal Medicine, the risks of carotid stenting in those over 70 in the Lancet, and sleep and obesity in kids in Archives of Pediatric and Adolescent Medicine.  Until next week,y'all live well.

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by Richard Wilkinson

Almost five in 100 adults in the US have attention deficit hyperactivity disorder or ADHD.  In the last few years more focus has come to the fact that for females, the disorder may not be apparent until later in life since the hyperactivity component may be missing.  Treatment for both genders usually involves medication, but challenges remain for most with the condition.  What to do?  Add cognitive behavioral therapy to the mix, a study in the Journal of the American Medical Association seems to conclude.

Researchers studied an admittedly small number of adults (86) who were diagnosed with ADHD, were already taking medication for the condition, but had residual symptoms.  They were randomized to either cognitive behavioral therapy (CBT) or relaxation techniques with educational support.  Those who had CBT experienced greater improvement of their symptoms, and this improvement persisted for 12 months.

Rick and I agree in this week's podcast that this is a great result.  It utilizes a low risk, non-pharmacologic technique to help people with a very common condition gain more control of their symptoms.  And I would add, likely has a positive impact on their mood as well, although that wasn't addressed in this study.

CBT has gained ground in the last several years as a very defined, time limited form of therapy that doesn't start folks off with analyzing early childhood trauma or the like.  Rather it seeks to provide specific skills and coping strategies to allow people to move forward in their lives. 

In this study the CBT took place over 12 sessions of 50 minutes each (that psychiatric truncated hour).  The sessions covered education about the condition, then moved through organizing, planning, problem-solving, and learning skills to reduce distractibility and think creatively in distress-producing situations.  Wow!  I think I need to sign up.  People who completed the sessions reported persistent improvement in symptoms out to the 12 month follow up.

No doubt this sounds great for those with ADHD.  Rick recommends finding someone trained in CBT technniques specific to ADHD by consulting a pediatrician or local medical school or teaching hospital.

Other topics in this week's podcast (while Rick is cycling in France) include underinsurance among American children in NEJM, the interaction of vitamin D with the genome in Genome Research and the true cost of prostate cancer treatments in Cancer Online  .  Until next week, y'all live well.

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