May 22, 2015

Tread Carefully on Treadmills

A couple of weeks ago, renowned Silicon Valley executive Dave Goldberg died of severe head trauma and blood loss after a gym accident involving a treadmill. His untimely death at 47 raised the profile of a device whose risks had previously gone mostly unnoticed.

Treadmill accidents, according to the Boston Globe, injure thousands of people in the U.S. every year. They’re very popular for maintaining fitness, but they also pose a risk of injury if you’re not paying attention or if the machine isn’t maintained properly.

In 2014, according to the Consumer Product Safety Commission, 24,400 injuries associated with treadmills were treated in hospital emergency rooms. In 2012, treadmills topped the list of exercise equipment that sent people to the emergency room.

Deaths are rare, but in addition to Goldberg, another well-known fatality associated with a treadmill was that of the 4-year-old daughter of heavyweight boxer Mike Tyson, who died in 2009 after she accidentally was strangled by a treadmill cord.

Keith Mills, a 50-something resident of Massachusetts, suffered a more common treadmill injury a few years ago. He stepped onto a treadmill at the gym one day, but didn’t notice it was already running. He fell face first, then was thrown backward against the wall. He suffered a concussion, broken nose and wrist injury.

Treadmills can give you a great aerobic workout, especially when the weather is too awful to exercise outdoors. But you must start and stop them properly, and avoid distractions during your workout. If you feel lightheaded, weak or unstable, know how to stop the machine immediately with the pull cord that disrupts the power supply.

Don’t use a cellphone while working out on a treadmill, and if you’re not completely familiar and comfortable with the device, don’t even listen to music through headphones or earbuds. Any distraction can cause an injury.

More tips for treadmill safety:

  • Look forward during the whole workout.

  • Don’t rely on the handrails to keep you upright and stable; if you can’t walk without rail assistance, slow the machine down.

  • Start by straddling the deck, begin slowly and increase speed gradually.

  • Always wear closed shoes (no bare feet, sandals or flip-flops).

  • Minimize side-to-side head movement.

  • Don’t don’t step off a moving treadmill; always stop the moving belt before dismounting.

  • Keep children away from the machine.

  • Don’t back the machine up against the wall; leave plenty of space behind it.

Treadmills are safe if you place and use them properly. Mills continues to work out on the treadmill four times a week, according to The Globe, but never with a cellphone, listening to music “or anything I think would be a distraction,” he told the paper.

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May 20, 2015

The Mediterranean Diet Might Be Good for an Aging Brain

Like every other body part, the aging brain isn’t as proficient as it used to be; it’s not as adept at learning, reacting and remembering. But like other lifestyle choices, what you eat might have an effect on how well your brain continues to remember things.

A new study published in the Journal of the American Medical Association (JAMA), shows an intriguing connection between eating what’s commonly known as the “Mediterranean” diet and holding off those “senior moments” somewhat longer.

As explained in a story on NPR, a Mediterranean diet, or one rich in vegetables, fish, whole grains, daily servings of nuts and olive oil, can help fend off age-related cognitive decline. Patrick discussed this nutritional profile in a recent newsletter.

The JAMA researchers analyzed the brain health of people in Spain who were in their 60s and 70s and had enrolled in a randomized clinical trial. That means they were assigned randomly to different groups — one ate a Mediterranean diet, plus either extra daily servings of olive oil (about four tablespoons) or daily servings of nuts. The other group ate a lower-fat diet.

All study subjects were given cognitive tests to determine various aspects of brain health, including working memory, processing speed and executive function. The latter is the ability to reason, plan, solve problems, etc. The tests were repeated after about four years.

The researchers found that the control diet group, or the people eating the lower-fat diet, did worse on their cognitive tests. The people consuming the nut-and-oil-rich Mediterranean diet retained the same cognitive test scores from several years earlier. So, although their memories didn’t improve, there was no measurable age-related decline.

Dr. JoAnn Manson, chief of the division of preventive medicine at Brigham and Women's Hospital and a professor of medicine at Harvard University, told NPR that the study suggests that older people who make changes in their diet can benefit; that you don’t have to be a lifelong olive-oil eater to realize these results. An old dog, in other words, can learn new nutritional tricks.

The JAMA study followed up a long-term nutritional study of the effectiveness of the Mediterranean diet in seven communities in Spain. In 2013, those researchers documented that the Mediterranean diet cut the risk of heart attacks and strokes by about 30%. So a diet that seems to benefit the heart also might benefit the brain.

The Mediterranean diet also is associated with improvements in cholesterol levels, blood pressure and blood glucose regulation, which is key to keeping diabetes in check.

Still, the findings of these Mediterranean diet studies are preliminary; other factors not associated with what you eat might well affect how your cognitive skills decline, including exercise and smoking.

But diet clearly can be important in a process known as oxidative stress, when aging cells are damaged by free radicals. The JAMA researchers said that it might be possible to counteract free radicals by eating antioxidant-rich foods, thereby adding a layer of protection against "neurodegenerative disorders."

Lots of components common in the Mediterranean diet are rich in antioxidants, including fruits, vegetables and fish, as well as nuts. Some research indicates that certain compounds in olive oil are beneficial because they might limit inflammation, a response to damaged cells.

Further studies are required to track the effect of this diet over a longer period in order to determine its effect on rates of dementia and Alzheimer’s disease. But there clearly is no downside to following this nutrition regimen, which not only is tasty, it’s healthful.

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May 19, 2015

‘Performance’ Supplement BMPEA Linked to Strokes

In April, the FDA sent warning letters to five nutritional supplement companies demanding that they stop selling products containing BMPEA, an amphetaminelike stimulant. This month, a report in the Annals of Internal Medicine showed that this dangerous compound might cause a stroke.

We blogged last month about BMPEA-containing supplements promoted for weight-loss and sports performance, and how that ingredient often is disguised as a plant extract. Last week, a CBS News report recounted how a woman who took BMPEA before exercising suffered a stroke that might have been caused, said the journal report, by the supplement.

The 53-year-old was healthy when she took Jacked Power before her workout, as the label directed. Less than an hour later, her left hand was numb. She sought medical care, and a CT scan showed a brain hemorrhage.

Researchers analyzed the supplement in a lab. It contained a high dose of BMPEA, which was not listed in the ingredients on the label.

The woman went home after five days of hospitalization, but others might not be so lucky. If you experience an adverse event with any medicine or supplement, submit a safety report to the Department of Health and Human Services here, and to the FDA’s MedWatch site. And see Patrick’s newsletter, “Eat. Drink and Be Wary: The Truth About Diet Supplements and Sports Drinks.”

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May 18, 2015

Ordering Your Own Lab Tests

Most people have medical lab work done when their doctor prescribes it. But what if you could have blood or urine analyzed simply by showing up at a lab that serves retail consumers? Is that a good idea?

LabCorp is one of the country’s largest providers of outpatient laboratory services, and it’s planning to allow anyone to drop in without having to visit a doctor first.

Dr. Roy Benaroch, a pediatrician, has mixed feelings about this direct-to-consumer opportunity. Writing on, he said that although, “there are some tests that seem reasonable for people to do on their own — pregnancy and HIV tests come to mind — others may lead to problems. … People imagine tests are simple things that give you a reliable, yes or no answer. In reality, many tests are far from perfect. And their results might be more misleading than accurate.”

We agree with Benaroch’s reasoning even if we don’t love the patronizing flourish — sure, many people expect a lab test result to paint a complete picture of their situation (like a pregnancy test), but to presume that they’re incapable of understanding that a numerical value often offers only a guideline and not a definition is patronizing.

These days, people can get an accurate result from a drug store urine pregnancy or saliva HIV test if it’s timed it properly. But finding out what’s going on from lots of other kinds of tests is a lot more complicated. In those situations, it’s not just “buyer beware,” it’s “buyer be informed.”

For example, Benaroch noted that there are many kinds of thyroid function tests, but thyroid antibodies often are positive in people who don’t have thyroid disease. A test for lupus, known widely as ANA (antinuclear antibodies) often is positive in people who don’t have that chronic inflammatory disorder, which is caused by an immune dysfunction.

And don’t get Benaroch started on blood tests for allergies. “A recent study,” he wrote, “showed that even among those with a positive food allergy blood test, only 2.2% actually had a food allergy. If you do big panels of food allergy tests, at least some of them are going to be positive in anyone — that’s just the nature of that kind of test. That’s why allergy testing is such a bad idea, unless there’s a specific clinical indication.”

Not all lab tests, of course, are directed toward a diagnosis of something wrong or concerning; some are done for screening purposes. Benaroch maps somes tricky terrain there, too, if consumers have them done without reasonable medical intervention.

The prostate specific antigen (PSA) test is used to screen for prostate cancer, but a lot of men get positive results when they don’t have cancer or have cancer that will never prove threatening. That is, they’ll die of something else long before the prostate cancer become problematic. Of course, some prostate cancers should be treated, some aggressively, but, as Benaroch said, “appropriate screening for it involves more than just getting a blood test.”

A few other real problems that have gained a sort of “trendy” testing popularity could enter into this equation — celiac disease and Epstein-Barr virus, among them. About 1 in 100 people are affected by celiac disease, another immune disorder in which the body cannot process gluten, a certain kind of protein. Definitive testing for celiac disease is complicated, and most of the people who test positive will never develop celiac. “In other words,” Benaroch explained, “a negative tells you something (you’re unlikely to ever get celiac), but a positive tells you nothing (you may or may not currently have celiac, and you may or may not ever develop it.)”

The Epstein-Barr virus is a type of herpes virus well known for causing infectious mononucleosis. Some people appear to suffer from it chronically, with severe fatigue as its signature symptom. It has been misunderstood by both medical professionals and patients, and Benaroch is right to wonder if LabCorp can or will explain sufficiently to consumers what their possible Epstein-Barr results mean.

And don’t forget that labs, like any other medical provider, make mistakes. Any concerning lab result a consumer receives independent of medical analysis should be investigated, and probably repeated.

Then there’s the profit motive. Apart from any useful information or guidance in diagnosis and treatment of problems that can puzzle even trained scientists, what else do publicly available labs offer to patients except a convenient way to separate them from their money?

Unless doctors have a financial stake in a lab to which they refers patients, they don’t have a conflict of interest in prescribing a test. But, as Benaroch questioned, “Once LabCorp is profiting off more and more tests, won’t the logical next step be to market them more heavily?

It’s already happening, in my neighborhood, especially with allergy testing — LabCorp really wants me to order more. What happens when they skip me and market straight to you?”

Pharmaceutical companies now do so with their drug marketing. What’s to stop LabCorp, and any other such businesses that begin reaching out to you and me directly, from claiming that access to their services help people stay healthier? See our blog about providers who promote consumer screenings not just for health reasons, but to juice profits.

Still, maybe some such claims about better health through lab tests could be true. Especially if patients do enough objective research about what they want to know and the best ways to find out if it pertains to them. Especially if they understand all the motives a lab has in issuing the invitation to be tested, and the complications that numerical results can have.

But, honestly, most people won’t go to the considerable lengths they should to improve their chances of getting good, useful information from a lab test. Don’t engage in lab tests unless you know what you’re doing, and why.

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May 17, 2015

The Potentially Lethal Risk of a ‘Gentle’ Powder

Talcum powder is a common grooming product for women and it’s often used in baby care as well. But disturbing reports of its possible association with ovarian cancer went largely unnoticed for years. The investigative news site recently explained how such a seemingly benign personal product threatened so many people.

Eight years ago, Deane Berg learned that she had stage III ovarian cancer, and a poor prognosis. Berg was a medical professional, a physician’s assistant who studied the risk factors for ovarian cancer, and found only one that could apply to her: regular use of talcum powder for feminine hygiene.

“Berg was stunned to learn that since the early 1980s” according to FairWarning, “a slew of studies had found that women who regularly used talc powder for feminine hygiene had higher than average rates of ovarian cancer. Yet the evidence – which fell short of proving causation – was mostly confined to medical journals and had barely made a blip on the public radar."

Products including Johnson & Johnson’s Baby Powder and Shower to Shower were marketed heavily to women. “A sprinkle a day keeps odor away,” the ads said. “Your body perspires in more places than just under your arms.”

Berg wondered how a product meant for babies could be dangerous, and why women weren’t warned.

According to the Centers for Disease Control and Prevention (CDC), approximately 20,000 U.S. women are diagnosed with ovarian cancer every year; more than 14,000 die from it.

“Studies showing a higher rate of the disease with talc use,” said FairWarning, generally “found an increased risk of about 35%.”

Talc is a soft mineral with many industrial and consumer product uses. It’s found in paint, paper, rubber, cosmetics, roofing and ceramic materials; it’s a food additive and a filler in capsules and pills.

Talc often is interlaced with other minerals, including asbestos, so potential danger could be due to impurities, rather than talc itself. Some talc miners and factory workers who use talc have gotten sick from asbestos exposure.

So proving a talc-cancer risk is tricky.

Still, after undergoing chemotherapy, Berg sued J&J. The verdict in 2013, FairWarning explained, “enabled both sides to declare victory.” The jury found J&J guilty of negligence for failing to warn of the risk of ovarian cancer, but Berg received no monetary damages.

But the case increased visibility about the issue, and since Berg’s complaint, claims have been brought for about 700 ovarian cancer victims or their survivors over their sickness, ostensibly because of exposure to talc powder.

The defendants say that statistical associations between talc use and ovarian cancer are weak, and could result from biased studies. We’ve discussed the difference between an association and a cause, which the talcum powder manufacturers also lean on. They claim nothing proves that talc particles can pass through the genital tract to the ovaries, or if they did, that they’re responsible for malignant growths. Because no causal link can be proved, they argue, label warnings are not necessary.

Lawsuits also accuse J&J of not taking the precaution of replacing talc with cornstarch, which has similar skin-soothing properties but is not associated with health risks. The first trials are scheduled for early 2016.

Suspicions about a talc-ovarian cancer link have endured since 1971, when British researchers analyzed 13 ovarian tumors and found talc particles deeply embedded in 10. In 1982, the journal Cancer published the first study showing a statistical link between genital talc use and ovarian cancer, after which lead author Dr. Daniel Cramer, a gynecologist and Harvard Medical School professor, tried to persuade J&J that women should be advised of the potential risk.

About 20 epidemiological studies have found increased rates of ovarian cancer risk among women who use talc for hygiene purposes.

In 1994, the Cancer Prevention Coalition, an advocacy group, asked the FDA to require warnings against talc use for genital hygiene, but the feds declined, claiming a lack of evidence, and in 2005, the U.S. Department of Health and Human Services’ National Toxicology Program ruled that existing data were insufficient to list talc as a cancer-causing agent.

Tell that to Deane Berg, who lost months of work time and suffered permanent hearing loss and numbness in her hands and feet from chemotherapy, not to mention the endless fear of her cancer coming back.

The jury is still out on a talc-cancer risk.

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May 15, 2015

VA Illegally Substituted Cheaper Drugs in Psychiatric Care

Substituting one drug for another — say, a generic version for a brand name — often is perfectly fine in terms of what’s best for the patient. But when a Veterans Affairs hospital in West Virginia replaced certain psychotropic drugs with older versions, it put patients at risk, because the priority wasn’t good care, it was cheaper care.

As told by the Washington Post, a federal investigation last month concluded that the drug switch was a violation of VA policy, and that it resulted in a “substantial and specific danger to public health and safety,” according to the VA’s Office of Medical Inspector. The probe was aided by a whistle-blower within the department.

The U.S. special counsel acknowledged the important role of the whistle-blower, which is doubly interesting, given that so often, as we wrote recently, people working in military medicine who identify its shortcomings often are ignored at best, and suffer retribution at worst.

“At a time when many veterans are grappling with mental-health issues, this VA facility was cutting corners on needed drug therapy to save money,” the counsel said in a statement.

The Department of Veterans Affairs is not allowed to restrict drugs based solely on how much they cost, The Post story said. It’s required to supply certain medications when they are necessary for a patient’s health.

But that’s not what happened at a VA clinic in Beckley, W.Va. It had established what the investigation called a “blanket restriction” on administering two antipsychotic drugs, aripiprazole and ziprasidone, to help meet its cost-saving goals for fiscal 2013.

Aripiprazole is the generic name for the brand drug Abilify. It’s prescribed for schizophrenia, bipolar disorder and depression. Ziprasidone, which also can treat those disorders, is known by the brand name Geodon. Drugs in this class alter the activity of certain substances in the brain.

The West Virginia clinic’s pharmacy committee, which makes decisions about what drugs may be used, restricted the use of those two without allowing doctors to make a clinical determination about potential health effects on their patients. The sole reason the panel said “no” was to help meet cost-saving goals for its fiscal year (2013). To add insult to arrogant injury, when the committee made the decision, its chair wasn’t even a physician.

According to The Post, the Office of Medical Inspector “recommended” that the clinic study how the drug substitutions affected patients’ health. Wouldn’t you expect the adults in the room to demand such analysis?

The inspector also sought discipline of the pharmacy committee’s leadership, and installation of a physician as its leader. That seems to be the least anyone could do to rectify such a breach of medical ethics and patient safety.

The U.S. special counsel called these recommendations “immediate and appropriate measures” for resolving the drug-substitution problem, but also said that the whistle-blower has claimed that wrongdoing might be ongoing at the clinic.

The VA said it has initiated an investigation based on the findings and recommendations of the medical inspector’s report. In a statement, it said, “We will immediately take action where it is warranted to ensure the most current medical standards are strictly followed. We applaud the VA employee who contacted the OSC on this matter. [VA] Secretary [Robert A.] McDonald has made clear that employees who step forward to raise concerns have a direct bearing on the veteran outcomes we deliver, and this is an example of why that is important.”

The special counsel has closed the case “conditionally,” pending a follow-up report to address the allegations of continued wrongdoing. The analysis is due to be completed by May 11.

Wow, that’s fast even for a balky, bureaucratic federal agency that’s responsible, responsive and efficient (are there any?), so let’s hope this glass is half full and will be topped off this month not only with problem resolution, but by sending a strong message throughout the system of military medicine that such serious issues of patient safety will not go unnoticed or unpunished.

Learn more about military malpractice here.

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May 14, 2015

Medicare Continues to Complicate Patient Status and Billing

Hospital bills are more complicated and impenetrable than gravitational wave theory. As a study by AARP recently found, Medicare only adds to the confusion, leaving patients at risk of overpayment and undertreatment.

If you get Medicare, and you go to the hospital, there’s a huge financial difference between a being classified as an inpatient or as a patient “under observation.” But because the treatment for both often seems identical, you might not be able to tell until you get the bill which class you’re in. Even people under observation can spend several days in a hospital without achieving inpatient status, and that’s expensive.

As noted by, “Of all the complex rules that plague fee-for-service Medicare, few are harder to understand and potentially more important for seniors than observation status.”

The magazine reviewed the AARP study whose purpose was to clarify the consequences for seniors of staying in a hospital under observation. The rules not only are complex, but make it impossible for patients to know whether an observation stay is financially more or less beneficial than an admission.

It’s a muddle, Forbes concluded, “in part because Medicare pays for hundreds of millions of dollars of skilled nursing facility care that probably should be billed to patients.”

Wait. What? You get burned if you pay for the same care under hospital observation that would have been subsidized if you had been classified as an inpatient, but the feds also are wasting public money because they’re not charging you if you are sent to a skilled nursing facility (SNF)?

Sort of. Did we mention that Medicare’s subsidy formulas are complicated?

To illustrate observation status, Forbes offered a hypothetical patient who presents in the ER with tightness in the chest. The ER doctor determines that he didn’t have a heart attack, but advises him to remain in the hospital for a day or so to get checked out more thoroughly.

“You are not being admitted,” Forbes explained, “but are staying to be observed.” In this scenario, Medicare considers you to be an outpatient even though you are staying in a hospital room, eating hospital food, being administered hospital drugs and being cared for by hospital nurses.

There’s no difference in the quality of the care, only in who pays for it. Typically, Medicare spends about one-third less on a patient under observation than one who is admitted, although it varies according to why the patient is there in the first place.

“There was no question that Medicare was overpaying for patients who did not need to be admitted,” Forbes said. “But in an attempt to fix the problem, it has gone way overboard.”

Whether or not to admit someone to the hospital is determined by a doctor, not the hospital, which usually advises practitioners to be conservative in making this decision. They take this position not for altruistic reasons, but because they get audited, and their Medicare subsidies often are tied to what the number-crunchers find.

If an audit concludes that an admitted patient should have been kept under observation instead, the hospital must refund the entire payment to the government.

But other factors besides observation vs. inpatient status drive Medicare hospital reimbursements. One big one is how much seniors must pay out-of-pocket for hospital services and post-acute care at an SNF.

Objections have been voiced over hospital patient status for a long time, but the AARP study found that only about 1 in 10 of observation patients had a higher bill than if they had been admitted. So although observation patients are more vulnerable to higher bills, the study found that few actually paid more.

But the financial exposure for post-acute patients also is high. “If you need follow-up care at a SNF,” according to Forbes, “Medicare will usually pay. But only if that care follows a hospital admission of at least three days. And observation stays don’t count, even if you spend 72 hours in an observation bed.”

Such follow-up SNF care could cost tens of thousands of dollars.

But Forbes referred to a 2012 study that found that only about 7 in 100 observation patients are discharged to an SNF. The AARP research found that about 2 in 3 of those people were ineligible for Medicare coverage. If SNF care was denied by Medicare, those patients shelled out, on average, more than $12,000.

But only about 3 in 100 post-observation SNF patients ever paid out of pocket. Medicare covered more than 97% of those claims, even though its own rules say the feds should not have. That breach cost taxpayers about $270 million in 2009.

Tellingly, according to the study, about 1 in 3 observation patients who were referred to an SNF for follow-up care did not go. It’s reasonable to assume that at least some made that decision because they were afraid they couldn’t afford that care.

Forbes raised the issue that although AARP’s results were stunning, its data were from the most recent available Medicare claims — which was 2009. A lot can happen in six years, and MedPAC, an independent board that advises Congress on Medicare issues, estimated that observation stays more than doubled between 2006 and 2012, and increased by about 15% from 2011 to 2012.

So it’s possible that out-of-pocket costs, both in hospitals and SNFs, have changed. Also, the magazine suggested, Medicare might be less willing to reimburse SNFs for these patients.

“The bottom line is the system is a mess,” Forbes concluded. “Hospitals, doctors, nursing facilities and patients all hate it. Nobody understands it. And Medicare may not be saving nearly as much money as it hoped.”

Eventually, Medicare could replace the fee-for-service system with one that pays for high-quality outcomes, and dopey situations like observation will go by the wayside. Until then, Forbes said, “Medicare should drop the three-day rule and let docs order post-acute SNF care if they think it is appropriate, and if they can justify it.”

For more information about how to choose Medicare plans, see Patrick’s newsletter, “Welcome to Medicare.”

If you’re caught in the Medicare status/billing mess, it might be worth your while to seek advice from a patient advocate, a professional who helps patients and families navigate all kinds of medical billing issues. Sometimes they’re called medical billing advocates. There’s usually a charge for their services, but generally you end up paying a lot less even with their fees than you would on your own.

You can find a patient advocate with the help of several organizations:

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May 13, 2015

Dialysis May Not Be the Best Choice for Older People with Kidney Failure

Dialysis is a life-saving process that filters impurities from the blood when the kidneys no longer are able to perform that vital function. But a lot of older people whose conditions require kidney dialysis are opting out, choosing a better quality of life over a longer life.

A recent story in the New York Times noted that people older than 75 are the fastest-growing segment of patients on dialysis, and that for them, the value of its benefits versus its side effects is not as clear as they are for younger patients. “A growing number of nephrologists [kidney specialists] and researchers are pushing for more educated and deliberative decision making when seniors contemplate dialysis,” The Times said.

Dialysis is a life saver; the mortality rate for people with chronic kidney disease decreased 42% from 1995 to 2012, according to the United States Renal Data System.

But that’s not true across all age brackets. About 4 in 10 patients older than 75 with end-stage renal disease (advanced kidney failure) die within a year, and not even 1 in 5 live longer than four years. Mostly that’s because they have other dire conditions besides kidney failure that compromise their health, including diabetes, heart disease and lung disease.

“Dialysis only treats the kidney disease,” Dr. Ann O’Hare, a nephrologist, told The Times. “It doesn’t treat the other problems an older person may have. It may even make them more challenging to deal with.”

So although most older adults on dialysis die from a chronic condition other than kidney disease, the process of dialysis has a significant impact on how they spend their remaining months or years. Many of them don’t want to be tied to a time-sucking process while they’re also dealing with other health issues, or would be engaged in other activities if they weren’t married to a dialysis machine.

Dialysis used to be a temporary procedure for people with kidney disease who were awaiting a transplant. But it has become the standard treatment for advanced kidney failure. Although it’s time-consuming and must be undergone frequently, it can happen at home or in a facility.

Fewer than 1 in 10 patients choose peritoneal dialysis, which can be done at home and requires special preparation and training. Hemodialysis occurs at a center.

Usually, a patient undergoes hemodialysis three times a week for three to four hours each time. That doesn’t include the time it takes to get to and from the dialysis center.

Side effects can include cramping, dizziness, pain, nausea and lethargy. A lot of older patients go directly from dialysis to bed.

Dialysis patients are hospitalized a lot, and if they live in a nursing home, their ability to eat, dress, use a toilet and perform other daily activities generally declines noticeably. One study The Times mentioned found that nearly 6 in 10 patients in this situation died within a year of beginning dialysis.

“They’ve bought into a very intensive pattern of medical care that tends to escalate towards the end of their lives,” O’Hare said. She participated in one study that found that 3 in 4 of older dialysis patients were hospitalized in the final month of their life and that half of them were admitted to an intensive care unit.

If you probably have a short lifespan anyway, is dialysis worth it?

A lot of people have decided it isn't. More than 6 in 10 participants in a Canadian survey said they regretted starting dialysis, which they underwent largely because their doctors and families wanted them to. In an Australian study, 105 patients approaching end-stage kidney disease said it would be worth seven fewer months of life to be able to reduce their number of dialysis visits. They would trade 15 months of longevity for greater freedom to travel.

But those concrete options are only theoretical when you’re in a doctor’s office trying to decide how to treat your progressive kidney failure. “People drift into these decisions because they’re presented as the only recourse,” Dr. V. J. Periyakoil, a geriatrician and palliative care physician, said in The Times story.

Older kidney patients must be informed that there are more conservative approaches than dialysis to treat the disease and improve their quality of life. Medication to control blood pressure, treat anemia and reduce swelling and pain not only can help people feel better for quite a while, but keep them out of the hospital and other medical facilities.

But you can’t make this important decision without being fully informed of all the pros and cons of dialysis. At one dialysis center in North Carolina, 2 in 3 patients at dialysis centers in North Carolina told researchers that their doctors had not mentioned the treatment’s risks or burdens.

The same proportion said they felt they had no choice but to undergo the procedure.

Choosing Wisely is a public campaign to identify procedures that physicians and patients should discuss fully with the idea that they might not be appropriate for their circumstances. The American Society of Nephrology’s advice for Choosing Wisely is not to initiate chronic dialysis without full communication about what it entails among patients, their families and their physicians.

Seventy-four-year-old Gerald J. Hladik was one patient who chose not to have the procedure. His kidneys, The Times reported, had lost 85% of their function when his doctor suggested it was time for dialysis.

But he liked to fish, boat and garden, he liked to spend time at home with his dog, and go to the beach. His son, a nephrologist, understood how drastically his father’s life would change if he spent the time necessary to undergo dialysis. “Dialysis may have prolonged his life, but I suspect only by a couple of months,” Dr. Hladik told The Times.

So Hladik just said no. His doctors managed his other health issues, including heart disease and hypertension, with drugs. He died at home a year and a half after later, with no regrets.

For more information about kidney disease, visit the website of the Coalition for Supportive Care of Kidney Patients Read our blog about problems with kidney dialysis here.

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May 11, 2015

Cataract Surgery Does Not Require the Pre-Op Tests Doctors Like to Perform

Surgery to remove cataracts is a common procedure accompanied by, apparently, an equally common preoperative routine of testing that appears to be wholly unnecessary.

According to a study in the New England Journal of Medicine, (NEJM) “preoperative testing is not recommended for patients undergoing cataract surgery, because testing neither decreases adverse events nor improves outcomes.”

You can’t get much clearer than that: Testing doesn’t lower the rate of complication, and it doesn’t elevate the rate of success. So why do eye surgeons seem to love it so much?

The study indicates that it’s, well, a habit. Providers do it because they’ve always done it. It’s not about the patient, it’s about the specialty and its perpetual motion machine-like mind-set.

As the NEJM said, “Preoperative testing before cataract surgery occurred frequently and was more strongly associated with provider practice patterns than with patient characteristics.”

Cataracts make the normally clear, transparent lens of the eye vision cloudy or opaque. Not only do they compromise vision, they can, eventually, lead to blindness.

Cataract surgery removes the natural lens of the eye and replaces it with an artificial lens. Typically, it’s done on an outpatient basis.

According to, preoperative testing can include blood work, urinalysis, cardiac stress tests, etc., that haven’t been recommended “for more than a dozen years.

“There’s good reason for that: The eye surgery generally takes less time than watching a rerun of ‘Marcus Welby, MD’ — just 18 minutes, on average. It’s also incredibly safe, with a less than 1 percent risk of major cardiac problems or death.”

The researchers looked at the data of Medicare beneficiaries undergoing cataract surgery in 2011. They determined the prevalence and cost of preoperative testing in the month before surgery, and compared it with the prevalence of preoperative testing and office visits with beneficiaries who underwent tests and had office visits during the preceding 11 months. They looked at the relationship between preoperative testing and characteristics of patients, health system characteristics, surgical setting, care team and occurrence of a preoperative office visit.

Of 440,857 patients, slightly more than half had at least one preoperative test in the month before surgery. Those tests cost $4.8 million more and the cost of office visits was $12.4 million more than the monthly costs during the preceding 11 months.

More than 1 in 3 ophthalmologists ordered preoperative tests for more than 3 in 4 of their patients. “A patient’s probability of undergoing testing,” said the NEJM, “was associated mainly with the ophthalmologist who managed the preoperative evaluation.”

Cataract surgery, according to KHN, used to take hours and require general anesthesia, which would make preoperative testing more reasonable. Today, patients often receive only a topical anesthetic eye drop or sometimes a local anesthetic that may include a sedative for relaxation.

“It’s so low risk,” Dr. Catherine Chen, an anesthesiologist, told KHN, “ it’s almost like saying you’re going to get your nails done. There’s always a chance you’ll get hit by a car or have a heart attack on the way,” but not likely to happen at the nail salon.

For all its ardor for new technology, medicine can still be like the ocean ship so large that it can’t respond in time when a course change is required to avoid danger. It seems certain medical procedures are the same, and it’s inexcusable to waste money and run the risk of complications by performing tests that have been demonstrated clearly not to help.

If you are scheduled for cataract surgery, and your ophthalmologist wants you to have pre-op tests, find out why. According to this study, it’s could be for no reason whatsoever.

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May 10, 2015

Patients Undergoing Scans Seldom Told of Full Radiation Risks

Another unsettling study indicates that people undergoing diagnostic scans involving radiation are not given information about the risks of the procedure. As reported by, less than half of those patients are aware of the scan’s potential health risks.

The study, published in the Journal of the American College of Radiology, found that 1 in 3 patients did not have a full understanding of testing procedures to which they were about to submit, and they were particularly unaware of the radiation risks.

The inappropriate or overuse of nuclear scans (those involving radioactive agents) and X-rays when diagnosing an injury or disease, over time, can cause cancer.

The researchers gave surveys to about 200 patients awaiting CT scans, ultrasounds and nuclear medicine examinations.

The survey questions concerned their knowledge of various aspects of the examination, the examination experience and their satisfaction and preferences about the doctor-patient communication throughout the process.

Nearly everyone correctly identified the type of examination they were having, and what body party was being imaged. Almost 8 in 10 said the doctor who prescribed the test explained it, but only about 7 in 10 indicated that they were satisfied with that explanation.

Only half of patients receiving intravenous contrast dye correctly indicated that they understood the procedure they were about to undergo, although 7 in 10 people receiving a contrast procedure by mouth demonstrated that they understood it.

About half of the survey respondents wanted to discuss the examination with a radiologist before the procedure, and about 2 in 10 said they had done Web searches for information about the exam instead of speaking with their doctor about it. Others indicated that they had consulted people they knew about the procedures.

The highest level of understanding about the tests was among patients undergoing CT scans; patients undergoing examinations involving nuclear medicine had the least understanding.

This study follows on the heels of one earlier this year published in the journal Radiology. It analyzed cancer patients, and also concluded that generally, they don’t receive enough information about the potential risks associated with CT scans and other exams involving radiation. It found that many doctors don’t even initiate a conversation with their patients about the risks of radiation from imaging tests.

Sometimes, the best imaging scan requires radiation. But no test, whether it’s a simple blood draw or a complicated intravenous procedure involving radioactive dye, should escape full communication between the doctor and the patient. It’s not the doctor, but the patient who should decide if the risk/reward tradeoff is worth it, and when radiation is part of that equation, there’s simply no excuse for practitioners not to fully air its potential, good or ill.

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May 8, 2015

Confused by Use-by/Sell-by Dates?

Unless your sense of smell is on vacation, it’s pretty clear when you stick your nose into a quart of milk if it’s still safe to drink. But as the 48 million estimated cases of food poisoning every year attest, smell and taste are not good indicators of whether or not a food is safe to eat.

Sometimes, the guides that are supposed to help us determine when to eat and when to toss food are confusing. The Institute of Food Technologists has addressed the problem by explaining the differences among food expiration terms.

  • Use by: Food bearing this label offers the date by which the product should be eaten for the best quality, not necessarily because if you eat it later it will make you sick. Safety might be reduced after this date, but quality definitely will be.

  • Sell by: Food bearing this label tells retailers the date by which the product should be sold or removed from the shelves. It doesn’t indicate that the product is unsafe to consume later than the date, because typically one-third of a product’s shelf-life remains after the sell-by date. If you don’t intend to use the product soon after purchase, you probably should opt for one with a later sell-by date if the one you’re considering is soon.

  • Best by: Food bearing this label suggests to the consumer on which date the product should be consumed to assure best quality. In other words, it’s similar to a “use-by” date.

For more information about food safety, see our blogs on the topic.

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May 7, 2015

Genetic Testing for Cancer Can Help ... and Confuse

The more we know about genetics, the better we get at diagnosing and treating disease. At least that’s the way it’s supposed to work. But the line from someone’s genetic profile to a personalized cancer treatment is hardly straight.

Genomic tests look for thousands of gene mutations that might cause or promote cancer growth, but such scans uncover not only problematic mutations, but some that might be harmless.

So, according to a story on NPR, the routine genetic tests a doctor orders to help focus treatment on someone’s tumor can give results that fall into the “too much information” category. They can be ambiguous, and ambiguity is not your friend when targeting a tumor.

But if science is complicated, and invariably it is, a study in Science Translational Medicine indicates there’s a way to make the expensive genetic tests more useful for treating cancer.

The researchers found that about half of patients whose tumors are subjected to genetic testing get results that potentially are misleading. The consequences of misinterpreting the results could be severe.

As the lead researcher told NPR, “You can imagine patients being placed on a particular therapy, with all the side effects of that therapy but without any of the benefits," said Dr. Victor Velculescu, a professor of oncology and pathology and co-director of cancer biology at the Johns Hopkins Kimmel Cancer Center. "You can imagine that it prevents the patient from getting the right therapy. And then, finally, there are the additional costs of having therapies that aren't really useful in any way."

Velculescu’s team believes that there's a way to refine genetic test results: Study the DNA of the patient’s healthy tissue at the same time the tumor is sampled. It’s a contrast-and-compare approach that, the researchers believe, should help doctors tell the difference between mutations that are unique to the cancer and those that aren’t.

As NPR noted, Velculescu isn’t purely a scientist in this field — he is co-founder of a company that performs these cell comparison tests. So he has an economic interest in this protocol. Still, he’s not the only scientist that supports comparison testing.

And the tests generally do appear to be accurate when properly performed. They reliably identify mutations linked to certain cancers, "and those are the ones that are used clinically for making decisions about what to do for a patient and what's the optimal way to take care of that patient," Dr. Neal Lindeman told NPR. He’s a Harvard University pathology professor who runs a cancer genome program at Dana Farber Cancer Center and Brigham and Women's Hospital.

Lindeman also said that genetic tests pick up a lot of ambiguous information that can lead people into clinical trials that are wrong for them. So comparison testing with healthy tissue could help avoid this by focusing only on the mutated genes more likely to contribute to the cancer.

Today, according to NPR, many companies that perform these genomic tests don't run the additional comparison. The genome test by itself can cost more than $5,000, and adding another to analyze normal tissue would increase that cost substantially, which insurance often won't cover.

Some companies sort genetic testing results to enable doctors to easily distinguish between clear and speculative results, but others don’t. As one doctor told NPR, “that does create this potential where one could be treating the patient on the basis of something that is not a cancer-driving alteration."

Genetic testing is a wonderful tool, but because the cancer genomics industry is not tightly regulated by the FDA, providers and patients are often on their own to sort out the good, the possibly good, the extraneous and the potentially harmful.

If you are advised to undergo genetic testing as a way to target your treatment for cancer, find out which company is doing the testing, and ask if any measures are taken for sorting out all the results among the known, unknown and potentially harmful. Ask about comparison testing of tumor and healthy tissue.

You probably won’t get a clear, obvious answer to how best to treat your disease, but at least you’ll have information to help you and your doctor make as informed a decision as possible.

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