Monday, June 27, 2011

Cutting for Stone

It’s been thirty years since the first report of a cluster of an unusual skin cancer among gay men in San Francisco appeared in the Morbidity and Mortality Weekly Report. Unfortunately, this was the harbinger of the AIDS epidemic. By 1985, AIDS had come to rural, conservative Tennessee, so very distant from The Castro or Greenwich Village. Dr. Abraham Verghese chronicled the fear and uncertainty of that era in My Own Country: A Doctor’s Story. I have been enchanted with Dr. Verghese’s work since then and have lent out my copy of The Tennis Partner often enough that it hasn’t come back to me.

I am late to the game in praising Cutting for Stone, which has been on the New York Times bestseller list for more than 73 weeks. This is the perfect book for an e-reader: the original book is 688 pages. I find my iPad a delight to read when traveling and at home (I can make the ‘print’ larger and one can read in dim light). Even better are the built-in dictionary and Google/Wiki links. There is a lot of medical terminology in Cutting for Stone as well as references to modern African history. The story is so much richer when the vocabulary and literary references are understood.

Dr. Verghese writes of what is lost and what is found and the healing of the most profound wounds. I just finished this book – now I shall read it again. Dr. Verghese has published shorter works in the New Yorker and other publications; I have never been disappointed.An open offer to my patients – you are welcome to look at my anatomy atlases if you get lost. However, the writing is so masterful you probably won’t.

Sunday, June 19, 2011

Coke versus Pepsi?

Sugar-sweetened beverages (SSBs) are the largest source of added sugars in the diet of U.S. youths; the increased caloric intake resulting from these beverages is one factor potentially contributing to the prevalence of obesity among adolescents nationwide. The Centers for Disease Control and Prevention (CDC) surveyed children in grades 9-12 in all 50 states in both public and private schools in spring 2010. The students were surveyed with an anonymous questionnaire during a regular school period.

24.3% of high school students drank a serving (e.g., can, bottle, or glass) of regular soda or pop, 16.1% drank a serving of a sports drink, and 16.9% drank a serving of another SSB one or more times per day during the same period. For all SSBs, male students were more likely than female students, and black students were more likely than white students and Hispanic students to report drinking these beverages one or more times per day.

Consumption of these beverages might be related to negative health outcomes. A recent meta-analysis (calculations using data from many different studies) found soft drink intake to be associated with increased intake of calories and increased body weight, and with lower intakes of milk, calcium, and other nutrients. Among adolescents specifically, SSB consumption can contribute to weight gain, type 2 diabetes, and the metabolic syndrome. Metabolic syndrome is a name for a group of risk factors that occur together and increase the risk for coronary artery disease and stroke.

Although changing school policy is an important first step, most calories from these drinks are consumed in the home. It is critical, therefore, to involve families, the media, and other institutions that interact with adolescents to increase their awareness of possible detrimental health effects and discourage their consumption of SSBs.

Families, schools, and youth-oriented institutions should limit SSBs among all adolescents while ensuring their access to more healthful beverages. Targeted efforts are especially needed to reduce consumption of SSBs among male and black adolescents. CDC also is encouraging schools to improve access to free drinking water.

Sunday, June 12, 2011

Detecting Ovarian Cancer

In the United States, ovarian cancer is among the 5 leading causes of cancer death in women. The high case-fatality ratio of ovarian cancer may be attributed in part to its vague and nonspecific symptoms, which usually appear when the disease has reached an advanced stage. Ovarian cancer confined to the ovary has a 5-year survival of 92%. However, most women with ovarian cancer are diagnosed with advanced stage disease, which has a 5-year survival of only 30%.

The disappointing results from a very large study (almost 80,000 women) from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial is that there was no reduction in mortality from ovarian cancer in women who were screened with six annual blood CA-125 tests and four annual trans-vaginal ultrasounds. There were also no stage-shifts (detection of cancer at an earlier stage). This suggests that CA-125 and trans-vaginal ultrasounds are not the correct tests for early detection. Evidence from modeling suggests that aggressive cancers progress rapidly through the early stages, limiting the ability to detect these cancers with yearly screening.

Similar studies are ongoing in the United Kingdom and in Japan. The authors of this article conclude that in the U.S., the screening strategy used in the PLCO trial "does not reduce disease-specific mortality in women at average risk for ovarian cancer but does increase invasive medical procedures and associated harms."

Published early on line: June 4, 2011. doi:10.1001/jama.2011.766 

No smoking, please

Smoking damages blood vessels. Smokers are more likely to have damaged blood vessels that supply the heart, leading to myocardial infarctions (heart attack). Smokers are more likely to have damaged blood vessels that supply the brain, leading to cerebral vascular accidents (strokes). While the body tries very hard to heal itself, the damage does not entirely go away and persists for years after smoking cessation.

A study published in Annals of Internal Medicine indicates that smoking increased the risk for peripheral artery disease (PAD) in women in a dose dependent manner. Peripheral artery disease is pain in the legs (calves) with walking due to an inadequate blood supply caused by narrowed arteries. Rest relieves that pain, since muscles at rest need less oxygen-rich blood than muscles at work. The greater the number of cigarettes smoked over a lifetime, the greater the risk of PAD. The risk greatly increased after ten pack-years. (A pack year is one pack of cigarettes daily for one year; ½ pack daily for two years, 2 packs daily for ½ year, etc.)

It’s still important to stop smoking, but it’s even better to never start. Long-term smoking cessation will reduce the risk of PAD, but the never-smoker is in a far better position.

Ann Intern Med June 7, 2011 154:719-726

Sunday, June 5, 2011

Only Modest Results with Lap-Band Surgery

For an obese patient, the lap-band (laparoscopic adjustable gastric banding) procedure seems to be a dream come true. New guidelines suggest that patients with a body mass index as low as 30 may be eligible for this surgery.

A study published in Archives of Surgery shows that the long-term outcomes of the lap-band appear to be relatively poor. A thirteen-year Belgian follow-up study shows that only 43% of patients maintained a loss of excess weight, nearly 60% required reoperation and obesity-related problems such as diabetes, hypertension and sleep apnea persisted. More than half the patients developed complications following the surgery. In the study group, the average weight loss was fifty pounds. Despite these relatively poor outcomes with lap-band, many patients said they were “pleased” or “very pleased” with the procedure.

Journalist Mike Mitka questioned the lead author of the study, Dr. Jacques Himpens, about the disappointing results. Himpens explains that some people have a misconception about the role of surgery in treating morbid obesity:
“Surgery is not the answer to reducing morbid obesity. Surgery can play a part, but we should be more focused on changing patient behavior—reducing the amount of food eaten at a meal and eliminating snacking.
“The increased proportion of those with the comorbid conditions—that includes people who had diabetes or hypertension when they underwent the procedure and those who developed it during the follow-up due to weight gain—reminds us that the positive effects of banding wear off and these conditions evolve and emerge over time.
“As for why most people feel satisfied after undergoing the procedure, even if they have [the gastric band] removed, I think it is because they do not feel guilty any more. They did something, and if it failed, at least they tried.”