Vegetable Fat Slashes Prostate Cancer Deaths

prostate cancerThe link between cancer and diet has been extensively studied, It is known for example that being overweight is related to as many as one in five cancer-related deaths. Weight is most closely connected with cancers of the breast and uterus in postmenopausal women. Other cancers associated with obesity include:

              • Esophagus
              • Pancreas
              • Colon and rectum
              • Kidney
              • Thyroid
              • Gallbladder

But less is known about the association between diet and prostate cancer.  The three well-established risk factors for prostate cancer: are race (specifically, African American race), family history, and age. Unfortunately, these are three things we cannot change. So given this reality, there is much interest in identifying modifiable risk factors for prostate cancer, not least among the roughly 2.5 million men in the United States currently live with prostate cancer.

Now, a new study might provide some hope. It showed that replacing carbohydrates and animal fat with vegetable fat may be associated with a lower risk of death in men with non-metastatic prostate cancer.

olive-oil-walnuts-healthy-fatsErin Richman, a postdoctoral scholar at the University of California, San Francisco, and colleagues at UCSF examined fat intake after a diagnosis of prostate cancer in relation to lethal prostate cancer and all-cause mortality in 4,577 men diagnosed with non-metastatic prostate cancer. Their findings have just been published in Online First by JAMA Internal Medicine.

Between 1986 and 2010, the researchers noted 315 lethal prostate cancer events and 1,064 deaths during a median follow-up of 8.4 years. They also discovered that replacing 10% of calories from carbohydrates with vegetable fat, such as oil or nuts, was associated with a 29% lower risk of lethal prostate cancer and a 26% lower risk of death from all-cause mortality.

Overall, the findings suggest that men with prostate cancer should be advised to follow a heart-healthy diet in which carbohydrate calories are replaced with unsaturated oils and nuts to reduce the risk of all-cause mortality.

And although the exact reason for the reduction in mortality is unknown, the authors conclude; “the potential benefit of vegetable fat consumption for prostate cancer-specific outcomes merits further research.”

SRxA’s Word on Health agrees.

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The Ultimate Life Test?

Imagine a simple blood test that could tell you if you’re going to die. Would that be super cool or super scary?  Well, imagine no more, it turns out there is such a test.

Researchers at McMaster University have found a test that can identify people who are at high risk of dying in the month after surgery.  Apparently elevated levels of troponin T (a protein marker of heart injury) correlate with an increased risk of death.

Currently, troponin levels are not commonly measured after most types of surgery.

The results from the Vascular Events In Non-cardiac Surgery Patients Cohort Evaluation (VISION) study, the largest international prospective study evaluating complications after surgery, have just been published in the Journal of the American Medical Association (JAMA).

VISION enrolled 15,133 adult patients in North and South America, Asia, Australia, and Europe.  Troponin T was measured daily during the first three days after surgery. Patients were followed while in the hospital and at 30 days after surgery.

VISION demonstrated that a simple blood test strongly identifies which non-cardiac surgery patients are at high risk of dying in the next 30 days,” said Dr. P.J. Devereaux, VISION principal investigator.

According to Devereaux the results also demonstrated that most patients did not die until an average of six or more days after their troponin T blood test was identified as elevated. “This holds out great hope that there is time to intervene.”

Knowing who is at risk through the test can help physicians target patients who need enhanced observation or interventions.

Surgery activates pathways of inflammation, stress, and clotting that predispose the heart to injury. As a result, many patients suffer heart attacks after surgery. The majority of these patients, however, will not experience chest pain. Evidence from this study supports experts who have advocated the use of troponin blood tests after surgery.

The VISION study suggests that myocardial injury detected through elevated troponin T may explain 42% of deaths that occur after surgery.

This study has substantial potential to change how patients are monitored after surgery,” said Dr. Jean Rouleau, scientific director of the Institute for Circulatory and Respiratory Health of the Canadian Institutes of Health Research. “These results hold substantial promise that through measuring troponin blood tests after surgery, physicians can identify which patients are at high-risk of dying and this can allow them to consider enhanced monitoring and interventions in an attempt to improve outcomes. This is a good example of how a carefully conducted clinical study can impact  patient care.”

SRxA’s Word on Health would like to know if you would take the test.

20/20 on the Vanishing American Hospital

Most Americans are born in hospitals. Hospitals also provide care during many other intimate and extraordinary circumstances in our lives – serious injuries, severe sickness and mental breakdown. Hospitals are also, by and large where we go to die.

As such, hospitals serve as a cornerstone of our communities and our very existence.

According to the American Hospital Association, there are 5,754 registered hospitals in the U.S. In 2011, almost 37 million people were admitted to a hospital in the U.S. – that’s more than 1:10 people.

Yet despite all this history, hospitals are in the midst of massive and disruptive change.

Even knowing this, SRxA’s Word on Health was shocked to read an article suggesting that by 2020 one in three hospitals will close or reorganize into an entirely different type of health care service provider.

Writing on KevinMD.com, a leading physician voice blog, authors David Houle and Jonathan Fleece suggest that that there are four significant forces and factors are driving this inevitable and historical shift.

First, America must bring down its crippling health care costs. The average American worker costs their employer $12,000 annually for health care benefits and this figure is increasing more than 10 percent every year. U.S. businesses cannot compete in a globally competitive market place at this level of spending. Federal and state budgets are getting crushed by the costs of health care entitlement programs, such as Medicare and Medicaid. Given this cost problem, hospitals are vulnerable as they are generally regarded as the most expensive part of the delivery system for health care in America.

Second, statistically speaking hospitals are just about the most dangerous places to be in the United States. Three times as many people die every year due to medical errors in hospitals as die on our highways — 100,000 deaths compared to 34,000.

The Journal of the American Medical Association reports that nearly 100,000 people die annually in hospitals from medical errors. Of this group, 80,000 die from hospital acquired infections, many of which can be prevented. Given the above number of admissions that means that 1 out of every 370 people admitted to a hospital dies due to medical errors.

In other words, hospitals are very dangerous places.  It would take about 200 747 airplanes to crash annually to equal 100,000 preventable deaths. Imagine the American outcry if one 747 crashed every day for 200 consecutive days in the U.S. The airlines would stand before the nation and the world in disgrace.

Currently in our non-transparent health care delivery system, Americans have no way of knowing which hospitals are the most dangerous. We simply take uninformed chances with our lives at stake.

Third, hospital customer care is abysmal. Recent studies reveal that the average wait time in American hospital emergency rooms is approximately 4 hours. Name one other business where Americans would tolerate this low level of value and service.

Fourth, health care reform will make connectivity, electronic medical records, and transparency commonplace in health care. This means that in several years, and certainly before 2020, any American considering a hospital stay will simply go on-line to compare hospitals relative to infection rates, degrees of surgical success, and many other metrics. Isn’t this what we do in America, comparison shop? Our health is our greatest and most important asset. Would we not want to compare performance relative to any health and medical care the way we compare roofers or carpet installers? Inevitably when we are able to do this, hospitals will be driven by quality, service, and cost — all of which will be necessary to compete.

So hospitals are about to enter the open competitive marketplace. And as we know there will be winners and losers.  According to Houle and Fleece a third of today’s hospitals will fall into the latter category.

Will your hospital be among them?  Let us know what you think.

Pharma Ads Under Fire

Although the back-to-school season has barely begun, both the pharmaceutical industry and the FDA have already received “could do better” report cards. According to researchers from Mount Sinai School of Medicine, only 18% of 192 pharmaceutical advertisements in biomedical journals were compliant with FDA guidelines.  And, over half failed to include serious risks including death. The study, was the first in almost 20 years to provide a systematic assessment of the adherence of US pharmaceutical ads to FDA guidance. Researchers looked at prescription pharmaceutical ads published in nine major peer-reviewed journals, including: the Annals of Internal Medicine,  Blood,  JAMA and the New England Journal of Medicine, during the month of November 2008.  They evaluated adherence to FDA standards and the presence of safety information.  Of the 192 advertisements for 82 unique products, only 15 fully adhered to all 20 FDA Prescription Drug Advertising Guidelines. Advertisements contained bias with regard to a wide variety of issues:

  • 57.8% of the advertisements did not quantify serious risks
  • 48.2% lacked verifiable references
  • 28.9% failed to present adequate efficacy quantification

However, despite the high rates of FDA non-adherence, the mean number of biased features in each advertisement was low and most advertisements they reviewed satisfied the majority of FDA guidelines. Part of the problem it seems is that the FDA emphasizes avoiding frankly false information and balancing efficacy and safety information  but does little to encourage the presentation of useful and accurate information.  For example, an ad containing no specific efficacy claim, no quantification of drug safety and no verifiable references would adhere fully to FDA guidelines, despite presenting no practical information for clinicians.

Dr. Deborah Korenstein, lead author of the study and Associate Professor of Medicine at Mount Sinai School of Medicine is concerned by the lack of adherence. “While the majority of physicians deny that advertisements inform their prescribing marketing research has consistently shown that journal advertising is the most profitable form of drug marketing, with an estimated return on investment of $5 for every dollar spent.” She does however acknowledge that it may be unrealistic to expect  ads to inform rational prescribing by presenting complete drug safety and efficacy, since they primarily serve a marketing function and are not designed to train physicians to prescribe.  Her advice?  “Physicians should ensure that their prescribing is informed by the clinical literature and not by marketing materials.” She also notes that the findings have important policy implications. Although he FDA has already demonstrated a desire to improve the quality of pharma ads, by enlisting doctors to review advertisements through its “Bad Ad” program, Korenstein suggests that the current FDA guidelines are subjective, challenging to enforce and do not emphasize transparency and the inclusion of basic information relevant to prescribing. She suggests that the FDA should update and simplify its guidelines for physician ads. According to her, guidelines should be straightforward and objective. They should ensure that ads present clear risk quantification, absolute benefit information, description of the appropriate population to receive the drug, and verifiable references to published peer-reviewed  literature. In other words, the FDA may hold the key to improving the quality of pharmaceutical advertisements rather than the industry itself.

All Aboard for the Doctor on Board

How many of you have been settled, albeit uncomfortably, at 30,000 feet enjoying a movie or hastily putting the finishing touches to the PowerPoint presentation you are due to give in a couple of hours when you hear a familiar chime, followed by the flight attendant asking: “Is there a medical professional on board this aircraft?” Every year, more than 500 million people travel by air in the U.S. Not surprising then, that medical emergencies aboard aircrafts occur.  In fact, an estimated 1:10-40,000 passengers will experience one. With commercial air traffic increasing, these emergencies are expected to become more frequent, especially as the percentage of older people increases. Although flight attendants are required to undergo initial and recurrent training on aviation medicine, first aid, CPR and automated external defibrillator (AED) usage every 12–24 months, EMTs, paramedics and other medical professionals are still called upon to provide assessment and treatment of passengers who become ill in flight. Now, two U.S. physicians from Boston’s Beth Israel Deaconess Medical Center have called for a standardization of the processes and the equipment for dealing with in-flight medical emergencies. Within the current issue of the Journal of the American Medical Association, Melissa Mattison, MD and Mark Zeidel, MD, note that the kinds of approaches that have improved flight safety have not been extended to providing optimal care for passengers who become acutely ill while on board airplanes. Each airline has its own reporting system and protocol. And while emergency medical kits are mandated to contain medications and equipment, actual kits vary by airline. As a result, paramedics and physicians responding to emergencies can face a broad array of challenges including cramped physical space, emergency kits whose contents are unfamiliar, inadequate, and poorly organized, and flight crews unaware of how best to assist the physicians. Mattison and Zeidel offer a four-step plan to improve the treatment of passengers who become ill in-flight:

  • A standardized recording system for all in-flight medical emergencies, with mandatory reporting of each incident to the National Transportation Safety Board. This approach should include a systematic debriefing of anyone directly involved with the in-flight medical emergency.
  • Airlines should create a standard emergency medical kit with identical elements available in identical locations on every flight.
  • Enhanced and standardized training for flight attendants, including the clear obligation that a single flight attendant is assigned during emergencies and stay nearby until the patient is safe.
  • Standardized flight crew communication with ground-to-air medical support available on all flights when there are no health care professionals available.

As both a frequent flyer and paramedic, I applaud the authors for this long overdue common sense approach. Have you ever helped with an in-flight emergency or perhaps been the victim of one?  If so, SRxA’s Word on Health would love to hear from you.

Oral Corticosteroids as Effective as Intravenous Dosing in COPD

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States.  It affects more than 6 percent of adults in the US, and accounts for $32 billion in direct health care costs. Each year there are approximately 600,000 hospital admissions for acute exacerbation COPD, making this 1 of the 10 leading causes of hospitalization nationwide.

Systemic corticosteroids are known to be beneficial for patients hospitalized with acute exacerbation of COPD; however, their optimal dose and route of administration has, until now, been uncertain.

According to a new study published in JAMA , despite guidelines recommending use of the low-dose oral route, a higher-dose intravenous route was used in 92% of patients admitted to over 400 U.S. hospitals.

Researchers compared the outcomes of those initially treated with low doses of steroids administered orally to those initially administered high dose intravenous steroids during the first 2 hospital days.

The primary outcome analyzed was a composite measure of treatment failure, defined as the initiation of mechanical ventilation, in-patient mortality, or readmission for acute exacerbation of COPD within 30 days of discharge.

After results were adjusted for various factors including patient, hospital, and physician characteristics, the risk of treatment failure among patients given low doses of steroids orally was not significantly different from those treated with high-dose steroids intravenously. Also, pa­tients treated with low doses of steroids administered orally had shorter lengths of hospital stay and lower costs.

The authors concluded that the use of high dose intravenous steroids does not appear to be associated with any measurable clinical benefit and at the same time exposes patients to the risks and inconvenience of an intravenous line, potentially unnecessarily high doses of steroids, greater hospital costs, and longer lengths of stay.

An editorial in the same journal added that the results “are sufficient to take action to change practice now.”

Or as we frequently say here at Word on Health – less is sometimes more!