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Displaying 1-10 letters out of 2416 published
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A "High Dose" Intractable Pain Patient Responds
Submit responseAs one who benefits greatly from opioid therapy and specifically high dose opioid therapy, I am compelled to respond to A. Thomas McLellan's editorial. More than just discounting one person's opinion, I hope that my disclosure here will enlighten those who are interested in treating pain as the TRUE chronic pathology it is. There is plenty of research to validate how much opioids belong as a valid part of medical treatments and are readily available to those who seek them out. My continually improving health status is the proof I offer here as a reason to NOT throw out "the baby with the bathwater", or opioid therapy for the 98.2% who are not suffering from overdose episodes, but are given some relief from suffering with otherwise unrelenting pain.I survived a plane accident in 2000 while on the job. Subsequent surgeries and a vast series of insults --including many non-opioid "treatments" -- to my already injured spine eventually caused Adhesive Arachnoiditis with Central Pain Syndrome, CRPS Type II, Cauda Equina Syndrome and significant Epidural Fibrosis. I failed the pump trial. I failed the trial for a Spinal Cord Stimulator. My pain level was so severe that my body functions were shutting down a few times a month. All of my vitals and adrenal hormone levels were erratic and rated for extreme stress: Coritsol was through the roof, RHR @ 102 and above for at least 2 years. Thyroid would not function even when taking Synthroid at 400mcg! That was my health picture in a nutshell for four years.
Then I began a non-compounded opioid schedule in September of 2004 in conjunction with other topicals and supplements for comfort and tissue healing. In direct contrast to the old wisdom that said a patient would simply become tolerant and never reach a satiated level, I was titrated to the amount of opioid I am on now after 1 1/2 years. That means for 4 years, I have been on the same dose that is a great balance between analgesia and side effects. Within those for years, I have gained a life outside of my bed. I create art, I write, I research my syndromes and the pathology of chronic pain religiously as well as advocating for the pain community at large. My RHR sits between 76 and 85, depending on where my pain flares are for the day. My thyroid is finally functioning beautifully, my Cortisol levels are now at normal. Testosterone and Pregnenolone are at normal levels without further supplementing. My co-morbid health issues continue to improve as my pain stays under control. Though disabled because of my spinal cord injury, I now have a productive, full life. I began a home based business in art. I am the picture of what successful opioid therapy looks like. And I thank God every day of my life for doctors who are willing to treat me with this condition and will cooperate to the fullest, as I KNOW other pain patients would, with any monitoring or paperwork or tests they need to show that all is going well and prove the success of my treatment outside the doctor's doors.
So much of what we know about the actions of opiates has been clouded by the fact that the research has been done from the addiction discipline, NOT strictly the therapeutic, analgesic, pain management discipline. I plead with those who read this to start now or continue researching this avenue from the "opioid pain patient=?" equation (and NOT what it does to addicts without pain) so that others can theoretically see what many of us know by experience--opioid therapy is a great tool in the pain management arsenal.
Conflict of Interest:
I am an intractable pain patient who is taking life-saving opioid treatment.
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From one Pain Patient to another: Survival vs. "Rights"
Submit responseResponse to pain patient Heather Grace
First, I would like to congratulate Dr.'s Mclellan and Turner, as well as all the other Dr.'s, who have supported their position on this long overdue attention to the responsibility/role physicians must take in prescribing opioids for chronic non-cancer pain.
I am a former medically prescribed "pain patient", treated for 8 years with high dose opioids. I say former because I took myself off of all narcotic pain relievers in 2008, much to the dismay of my "pain management" doctor. I am currently on a non-narcotic regimen to treat my pain. My etiology is 2 back surgery's, and degenerative disc disease. In 2001,within a 10 month period, I was put on OxyContin, starting with 20mg and escalating to 280mg daily, with 8 Norco breakthrough. No other medical regimen was employed. When it became evident that I was horribly addicted to this drug, my doctor abandoned me. My life was forever altered by that event. I have never taken an opioid/narcotic drug outside the medical setting. Nor have I ever "doctor shopped".
As I read Ms. Grace's comment/position on her impassioned defense of taking opioids for pain, I was immediately struck with compassion for the delusions she seems to suffer from, in relation to her own medical care. It reminded me of myself 7 years ago, when I desperately tried to get medical information on the situation I found myself in. I had gone from a productive person dealing with back pain, to a zombie, for lack of a better description, constantly in need of pain medications, just to get through the day. Like her, I constantly worried more about "not getting my drugs". I sympathized with all those patients, like me, who were just trying to get some "pain relief". I was told not to worry about addiction, since I had "real" pain. I used the word "medication", not opiate or narcotic. I assumed my doctors knew what they were doing, and would not do anything to harm me. But in the long run, I had to admit that I was addicted to narcotics, regardless of whether I had pain or not, or under a physicians care. Not dependant, addicted. Physically, and emotionally addicted. A condition that, eventually, far outwieghed any benefits of relieving my back pain.
It took me years to understand what had really happened to me. And accept responsibility for my own survival. I could have been one of the thousands of medically prescribed pain patients, who have either died, or are still struggling with the added burden of an unwanted addiction. But I am here to tell you that, in my estimation, the medical profession, as well as regulatory agencies, who should have kept me safe, as well as medically informed, let me down. They allowed self-serving pharmaceutical companies to influence and manipulate standard medical practice. They over-prescribed, and under-treated my chronic pain. Through self education, I have realized the many different ways in which my pain can be treated, outside of opioid therapy
The sheer statistics regarding medically prescibed opiates in relation to overdose and addiction are self-evident. They can no longer be ignored. The once tauted "less than 1% of chronic pain patients become addicted" is, today, a medical mirage. The studies that should have been done prior to the radical change in opioid prescribing practices in the late 90's, are now emerging, and as does this editorial, they all call for "caution", not "agression" when dealing with chronic pain and opioids. For many, this common advice, is too late.
I thank all the doctors, who will speak out about this crisis, and who will work to re-engineer the education of physicians, as well as patients, on the risks and benefits of long term opiate therapy for non- cancer patients. At the very least, doctors who wish to operate in this field should be trained/educated, based on sound medical principal, not on junk science coming out of pharmaceutical companies. Perhaps then you will not hear patients or pain foundations talk to you about their concerns about the "DEA",or the odd behavior of defending the extremely small percentage of doctors, who have gone to jail, or the latest one, an analogy of diabetes to pain. Especially, since insulin, to my knowledge , does not have the side effect of addiction, as opiates do.
I hope McLellan and Turner's message is the beginning of the end of this epidemic, and that we see that there are many more dedicated doctors, who will work to turn this sorry situation around. I hope that all the Heather Grace's, who have been so obviously effected by mis-information, will learn that they must become their own advocate and that good medical practice, based in sceintific evidence, is in her best interest. They could begin by looking up the definition of iatrogenic addiction, instead of listening to Fox's John Stossel, or any of the other heavily Pharma funded pain foundations, who do not have her best interest in mind. I hope she does not ever become a name in a medical report for "accidental" overdose like the pain patient, who was found dead by her daughter recently. NCBI report below.
The "real" danger, Heather, is in being treated (for anything), without adequate, studied, reliable, and appropriate information. The protection of your supply of narcotics should not be your only medical concern. Good doctors will not dismiss your pain. Good doctors will treat your condition on the whole, not just your pain. That should be your goal also. And above all, please know that you have a "right" to proper management of your disease and your pain, not a "right" to narcotics.
NCBI report: http://www.ncbi.nlm.nih.gov/pubmed/20190634?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1
My testimony to the FDA last spring: A CHRONIC PAIN PATIENTS PERSPECTIVE ON THE DAMAGE DONE BY AN UNPREPARED AND INADEQUATE SYSTEM TO DELIVER PAIN MANAGEMENT APPROPRIATELY http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809e6c97&disposition=attachment&contentType=xml
Conflict of Interest:
None declared
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Cardiovascular Screening of Young Athletes
Submit responseThe recent articles indicating the additional value of electrocardiography (ECG) screening in detecting serious cardiovascular abnormalities and the cost-effectiveness of this addition are important to primary care physicians and parents of young athletes (1,2). The addition of ECG to the history and physical exam by non-specialized clinicians increased the overall sensitivity and negative predictive value to 99.8% and compared to cardiovascular screening by history and physical alone saved 2.1 life-years pr 1000 athletes at an incremental cost of $88 per athlete. Although the American Heart Association consensus panel, led by Dr. Maron, does not endorse this, what mandatory screening is actually currently performed in the United States and at what cost (3,4)? In Michigan student athletes in public schools are required to have yearly "Sports Physical" forms completed and on file in the school's athletic office to participate in activities. Some of these examinations are performed in mass screening centers such as auditoriums and others at individual physician offices. The fees range from $5 to routine "physical" charges of several hundred dollars. Most insurance copayments average approximately $20 making the average 4-year high school out of pocket fees approximately $80, with insurance costs much higher. There is no requirement for what is examined and many exams are very brief in noisy auditoriums.
Chelsea Community Hospital in conjunction with physician and staff volunteers have been performing athletic screening of appropriately 1,500 adolescents since 2003. The screening sessions are free and have been performed 1-2 per year. Approximately 1/4 of those screened receive limited echocardiograms. We also offer a screening of ECG and a limited echocardiogram on all weekdays for $55. This was initiated to help prevent sudden death in adolescents due to one of the author's children being involved in high school sports.
As a parent, wouldn't you want to pay $88 once in high school to screen effectively for a cardiovascular potential sudden death rather than yearly ineffective and unproven "Sports Physicals." This is less than a pair of athletic shoes. We would hope that the American Heart Association would review these articles and consider what is currently required to determine what should be recommended. We believe that at a minimum, all adolescent athletes should have a standard screening questionnaire for conditions related to sudden death in addition to blood pressure recording, auscultation in the supine and seated position, and now with this recent evidence an ECG. If there is a concern, a limited echocardiogram could be considered.
References
1. Baggish AL, Hutter AM, Wang F, Yared K, Weiner RB, Kupperman E, Picard MH, Wood MJ. Ann Intern Med. 2010;152:269-275.
2. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Ann Intern Med. 2010,152:276-286.
3. Maron BJ, Thompson PD, Ackerman MJ, Balady G. Berger S, Cohen D, et al. Circulation. 2007;115:1643-455.
4. Maron BJ. Ann Intern Med. 2010l152:324-6.
Conflict of Interest:
None declared
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Encourage Organ donors for they are Life Savers
Submit responseThe number of people who need a kidney transplant outweighs the number of kidneys available. One way to motivate more living people to donate kidneys might be to have a carefully regulated, national system that provides fixed payments to kidney donors. However, some worry that offering payment for kidneys could create problems.
First, people might donate kidneys without fully considering their own health.
Second, payment might push poor people into donating kidneys.
Third, people might be less likely to donate a kidney just to help another person.
However, because we do not have such a payment system, we do not know whether some of these unwanted results would really happen. What is payment? It is a very difficult term to define excepting to say that an incentive given to the service rendered on request. This payment could be fees, salary or professional charges. These modes of payment may be regulated through guidelines stipulated by the body that offers these payments. An attending physician or surgeon demands a fee for the services he or she renders to the patient. It is acceptable by the society and considered reasonable and respectable. When one volunteers to donate an organ the fee the donor fixes for the donation becomes a point of great controversy. This controversy arises because the donors most of them hail from economically downtrodden strata of society. The the use and abuse of such donors did exist even for blood donation. Then blood donation became a life-saving industry where national bodies regulate their function. Why not organ donation? It is so critical to save lives and patients are willing to a pay a price for such a donation. When there is a mutual consent and a regulatory body to minimize abuse and maximize organ donation, organ banks could become a reality in a world where we have sperm banks and gene banks. It is high time there is an international consensus on such a vital life- saving issue to set ethical guidelines and practical procedures to make organ donation an altruistic but a medical necessity in the ever-growing market of human industry.
Conflict of Interest:
None declared
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Re:Nonsteroidal Anti-inflammatory Drug Treatment for Postoperative Pericardial Effusion: A Multicenter Randomized, Double-Blind Trial
Submit responseIt is very important not to mix up acute pericarditis, post pericardiotomy syndrome (which are clinical syndromes) and post operative pericardial effusions (POPEs) which are usually asymptomatic. In deed, this confusion is the reason why non steroidal anti inflammatory drugs (NSAIDs) have been frequently prescribed to treat POPEs. Indeed, if the European Society of Cardiology recommends Ibuprofen (1), this is to treat acute pericarditis (not POPEs) and if a long treatment duration is recommended, this is to prevent recurrences, not to help to reduce the volume of the effusions (which was the aim of our study) or to prevent the incidence of late tamponades (which usually occur before post operative day 30).In our study, the post study follow up clearly shows that a longer treatment would have been useless, as only 2 patients required pericardial drainage after the end of the treatment.
The choice of the drug and of its posology can be extensively discussed with multiple references; we chose diclofenac: a very classical and effective NSAID, and 100mg per day is a dose widely used in daily life practice and recommended in Guidelines as the cardiovascular risk of the drug dramatically increases at a higher dose (2).
It is wrong to say that we acknowledge the fact that our study was underpowered to detect beneficial effects of diclofenac; the sample size was calculated (172 patients) and largely reached(196 patients); we only suggested that the sample was not large enough to find small beneficial effects (i.e clinically useless in these asymptomatic patients) or to detect groups of patients in which this treatment could have been helpful (for instance patients with an important inflammatory syndrome).
It is wrong to say that a previous study demonstrated a favorable impact on the rate of significant pericardial effusion; this study (3), that was already quoted in our article, examined pericardial effusions prevention (not treatment) did not demonstrate anything: "there was no statistically significant difference in the size of post operative pericardial effusion..." and was largely underpowered. The echocardiographic classification that we used has the great advantage to help to predict the occurrence of a late tamponade in 2 large clinical studies (4.5), one of them being multicentric(5).
Finally, in a negative study as ours, it is useless and probably harmful to try to find very small post-specified subgroups in which the NSAID could seem to be effective. For instance, contrarily to what was suggested in Dr Shaikh's comments, right sided loculated effusions did not lead to a higher incidence of tamponade in our study.
In conclusion, medical history is filled with widely applied therapeutic habits that replicate longstanding practices based upon theories that have no true scientific background. Thus, challenging doctor' s lifelong habits may be good for their patients. Our study, which was properly designed and conducted, is, so far, the only one dedicated to post operative pericardial effusion treatment. It clearly shows the absence of effectiveness of an NSAID. Furthermore, we have no conflict of interest and would have been very happy to publish a positive study but scientific facts must be admitted.
References
1- Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adlery et al. Guidelines on the diagnosis and management of pericardial diseases. Full text. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology.Eur. Heart J. 2004;25:587- 610.
2- Gislason GH, Jacobsen S, Rasmussen JN, Rasmussen S, Buch P, Friberg J et al. Risk of death or reinfarction associated with the use of selective cyclooxygenase-2 inhibitors and nonselective nonsteroidal anti- inflammatory drugs after acute myocardial infarction.Circulation 2006;113;2906-13.
3- Niva M, Biancari F, Valkama J, Juvonen J, Satta J, Juvonen T Effects of diclofenac in the prevention of pericardial effusion after coronary artery bypass surgery. A prospective randomized study.J. Cardiovasc. Surg. 2002;43:449-53.
4- Meurin P, Weber H, Renaud N, Larrazet F, Tabet JY , Demolis P et al. Evolution of the post operative pericardial effusion after day 15. The problem of the late tamponade.Chest 2004;125:2182-87
5. Meurin P, Tabet JY, Thabut G, Cristofini P, Farrokhi T, Fischbach M et al. Nonsteroidal anti-inflammatory drug treatment for postoperative pericardial effusion. Ann Intern Med 2010;152:137-143
to the editor: in the Shaikh's letter, European Guidelines are misquoted: the first author is Maisch, not Seferovic.
Conflict of Interest:
None declared
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Complexities of Defibrillator Deactivation
Submit responseWe strongly agree with the authors' conclusions that hospices may improve quality of care if they routinely identify patients with implantable defibrillators (ICDs) and to address ICD deactivation. In our own hospital-based heart failure cardiology and palliative care practices, we always address ICD deactivation prior to discharging patients to hospice care. However, given the complexity and difficulty of decision- making for families and caregivers during transitions in care, we have observed the occasional patient who is not ready to deactivate their ICD at time of hospital discharge. We appreciate that hospices do accept patients with functioning ICDs with the presumed goal of addressing deactivation after enrollment in hospice. We would like to highlight the study limitation noted by the authors that this study does not directly address patient-level preferences about ICD inactivation. Goldstein et al have reported in a small study that ICD recipients have not discussed ICD deactivation and are unaware that deactivation is an option(1). In our experience, we also have observed that most patients are not made aware of the possible future burden of the ICD at the time of device implantation. We have occasionally noticed a paradox in which patients, despite preferring palliative care or hospice, remain unwilling to undergo deactivation of their ICDs. Furthermore, it is possible that hospices nurses are appropriately querying hospice patients about their preferences for ICD deactivation, irrespective of the presence of a hospice ICD deactivation policy. Further, we want to make note that the median hospice length of stay in a large sample of Medicare heart failure patients was reported at only 17 days with nearly 1/3 of patients staying less than 8 days(2. Thus, a short enrollment in hospice at end of life may be an additional barrier to establishment of highest quality conversations between cardiac patients and hospice care providers. Finally, clinicians need to be aware that, unlike cancer patients, 19% of HF patients are discharged from hospice and nearly 1 in 4 patients survive more than 180 days after hospice enrollment. Thus, admission to hospice care is not a certain indication of terminal HF, which adds to the complexity of prognostication and decision-making with this disease.
References:
1. Bain, K. T., T. L. Maxwell, et al. (2009). "Hospice use among patients with heart failure." American Heart Journal 158(1): 118-125.
2. Goldstein, N., D. Mehta, et al. (2008). "That's Like an Act of Suicide" Patients' Attitudes Toward Deactivation of Implantable Defibrillators." Journal of General Internal Medicine 23(0): 7-12.
Conflict of Interest:
None declared
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Re: Author's response: Overdose can occur at a patient's usual opioid dose
Submit responseBecker and Nahata raise valuable points regarding our paper (1). Becker makes an important observation in noting that risks of adverse effects of opioids may differ depending on changes in intercurrent illness, particularly among older patients with multiple comorbidities. About 6-7 percent of all adults age 65 or older use opioids long-term for chronic non-cancer pain (2). There is remarkably little research evaluating risks of and risk factors for adverse medical and behavioral effects of long-term opioid use, particularly among elderly patients. Possible adverse effects of opioids include: serious fractures due to falls (3), acetaminophen toxicity (4); hyperalgesia; aspiration pneumonia; complications of chronic constipation; apathy, de-activation and depression; and cognitive impairment, among others. Careful evaluation of patient suitability for long-term opioid use, cautious prescribing, clear explanation of how to use opioids safely and potential risks, close medical monitoring of patients using opioids long-term, safety reminders, and other universal precautions could conceivably reduce risks of adverse effects. However, research evaluating harm reduction interventions among patients using opioids for chronic non-cancer pain is sparse, as is research weighing long-term benefits against the full range of medical and behavioral risks.
Nahata correctly identifies a limitation of our research. We assessed overdose risk relative to estimated average daily dose. Risks could potentially differ markedly depending on the actual pattern of opioid consumption. In fact, we know little about how physicians prescribe and patients use opioids for chronic pain in community practice. Since millions of U.S. adults use opioids long-term, research is needed concerning how opioids are actually used by chronic pain patients, risks and benefits of alternative opioid treatment regimens, and the effectiveness of universal precautions for preventing adverse effects. In the absence of an adequate evidence base for current prescribing practices, a cautious and vigilant stance toward long-term opioid prescribing for chronic non-cancer pain patients seems prudent.
References 1. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic pain and overdose: a cohort study. Annals of Internal Medicine 2010; 152:85-92.
2. Campbell CI, Weisner C, LeResche L, Ray T, Saunders K, Sullivan MD, Banta-Green C, Merrill JO, Silverberg MJ, Boudreau D, Satre DD, Von Korff M. Age and sex trends in long-term opioid analgesic use for non- cancer pain. Am J Public Health, In press.
3. Saunders KW, Dunn KM, Merrill JO, Sullivan MD, Weisner CM, Braden JB, Psaty BM, Von Korff M. Relationship of opioid use and dosage levels to fractures in older chronic pain patients. Journal of General Internal Medicine, Published online, January 5,2010.
4. Committee on the Safety of Medicines of the UK. Overdose risk prompts UK withdrawal of propoxyphene combination. J Pain Palliat Care Pharmacother. 2006;20:49-50.
Conflict of Interest:
None declared
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Does reducing salt intake really reduce health care spending in the long term?
Submit responseMarch 9, 2010
Smith-Spangler et al. (1) argue that a reduction in the sodium content of food will prevent many cases of hearts attack and strokes. Population health strategies and policy approaches such as this can undoubtedly be highly cost-effective (i.e., they prevent disease at low cost). The authors also argue that this action will lead to a reduction in health-care spending. This claim is repeated in the accompanying editorial by Frieden and Briss (2). Unfortunately, their claim is erroneous.
Smith-Spangler et al. (1) appear to have considered only the reduced health-care spending as a result of fewer cases of hearts attack and strokes. They state that their analysis predicts an increase in "life-years lived by more than 1.3 million over the lifetime of U.S. adults aged 40 to 85 years alive today." However, they do not appear to have deducted the health-care costs for continuing to care for these people over time. These costs could easily cancel out the estimated savings of $32.1 billion in direct medical costs resulting from fewer cardiovascular cases.
Quite apart from actual health-care spending, the inevitable result of people living longer is increased government spending on social security and other social programs. When this is factored in, the bottom line will most certainly reveal that the "savings" have turned into higher spending. If people wish to make financial estimates based on various policy options, then it is essential that they provide the whole story.
There have been many previous analyses of the likely result of implementation of interventions designed to prevent disease or improve health. Overall, most such medical interventions result in an increase in health-care spending (3). This is especially likely to be the case when dealing with diseases that are commonly fatal and the analysis extends far enough into old age (4). It is unavoidable that the extra years of life generated inevitably result in an increased need for the treatment of chronic conditions and for long-term nursing care. For example, when people quit smoking, there is eventually an increase in health-care spending (5-7). Surprisingly, this is even seen with the prevention of obesity (8).
Of course, the prevention of fatal diseases is undeniably of great value with regard to population health. If we consider the impact of salt reduction strategies on improved quality of life, the benefits are obvious; people with strokes and heart attacks experience considerable suffering, disability and frequently death. If this can be avoided any preventative strategies may be worthwhile in terms of the health benefits. However, this is altogether different from decreasing health-care spending.
Should the government therefore implement policies that target the excessive salt content of food and thereby help to reduce the incidence of hearts attacks and strokes even if the intervention fails to save health care dollars over time? To do anything else would be heartless and a no- brainer!
REFERENCES
1. Smith-Spangler CM, Juusola JL, Enns EA, Owens DK, Garber AM. Population strategies to decrease sodium intake and the burden of cardiovascular disease in the United States. A cost-effectiveness analysis. Ann Intern Med. 2010;152.
2. FriedenTR, Briss PA. We can reduce dietary sodium, save money, and save lives. Ann Intern Med. 2010.
3. Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med. 2008;358:661-3.
4. Bonneux L, Barendregt JJ, Nusselder WJ, der Maas PJ. Preventing fatal diseases increases healthcare costs: cause elimination life table approach. BMJ. 1998;316:26-9.
5. Rasmussen SR, Prescott E, S rensen TIA, S, gaard J. The total lifetime health cost savings of smoking cessation to society. Eur J Public Health. 2005;15:601-6.
6. Elixhauser A. The costs of smoking and the cost effectiveness of smoking-cessation programs. J Public Health Policy. 1990;11:218-37.
7. Barendregt JJ, Bonneux L, van der Maas PJ. The health care costs of smoking. N Engl J Med. 1997;337:1052-7.
8. van Baal PH, Polder JJ, de Wit GA, et al. Lifetime medical costs of obesity: prevention no cure for increasing health expenditure. PLoS Med. 2008;5:e29.
Conflict of Interest:
None declared
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National ECG screening is feasible.
Submit responseDear Editor,
I read with interest the editorial by Dr. Maron, however I take serious issue with many of his assertions and I am in fundamental disagreement with his conclusions.(1) I believe his efforts to relate the Italian system of ECG athlete screening to the U.S. are meaningfully flawed in fact and logic.
Granted, national ECG screening is a complex problem. But it is not insurmountable. I argue that it can be efficiently and successfully achieved with a "can do" problem-solving attitude. I offer these insights based on my first-person experience with screenings in a multi- county region in suburban Chicago. Since 2006 our program, Young Hearts for Life, has screened more than 44,000 high school students.
Dr. Maron contends there is a dramatic disparity in physician resources between Italy and the U.S. I suggest that this is a misinterpretation of the evidence. Of course the absolute number of athletes in this country is larger but in terms of percentage of population, U.S. athletic participation is statistically about half that of Italy, 5% in the U.S. vs.10% in Italy.(1) Moreover, the number of primary care physicians per capita is similar at 1/1000 in the U.S. vs. 0.9/1,000 in Italy. (2) Furthermore current AHA recommendations already expect all young adult athletes to be seen by a physician. (3)
Notably, Dr. Maron exaggerates the magnitude of national ECG screening in the U.S. He cites 75 million as the total population of American persons under the age of 18. In point of fact, testing is recommended for only those 12-25 yrs of age, which puts the total closer to 40 million, according to U.S. census data from 2005.
On the issue of SCD incidence, Dr. Maron's estimates are highly debatable. The <100 athlete deaths/year statistic he references is based not on a scientific registry like the Italian data but rather on a compilation of media reports, which can be a hit or miss approach. (5)
Dr. Maron's concern with excessively high rates of abnormal results does not reflect more contemporary standards of ECG interpretation that report these rates at 5% or less.(6) In our regional screening programs, we have been able to refine our testing with stratified screening to reduce the number of false positives. Our "abnormal" rate of 2.3% is certainly a number manageable by the medical community. (7) Moreover I do not understand the preoccupation with false positives when similar issues have not impeded testing in other areas of medicine (for example, mammography and nuclear stress testing). The approach of the medical community has always been that of pursuing improvement that reduces the false positive rate by refinement in techniques and experience. It should be no different with ECG screening.
As for economic feasibility issues, Dr. Maron mentioned that the American Heart Association's panel estimates a national program would initially cost about $2 billion a year to screen U.S. athletes. I believe this calculation is based on flawed assumptions related to the cost of performing ECGs. Clearly, ECGs done as a screening test can be done at a much lower cost than the $50 figure assumed in the AHA guideline's economic analysis. And even if it is proven to be correct, our government has spent vastly larger sums on medical issues of more suspect value. H1N1 and meningitis vaccination programs come to mind.
Our program strongly maintains that the focus on athletes-only screenings as defined in the AHA guidelines is too restrictive and deserves more consideration. Shouldn't we be concerned about SCD in all young adults and not just the deaths in a restrictively defined subgroup called athletes? The Italians have a more practical definition of athlete in their studies that more accurately reflects the typical active American high school student. Atkins' prospective study on the incidence of SCD in children from 11 U.S. and Canadian cities reported a death rate that is much higher than that claimed by Dr. Maron and would translate to over 2,500 SCDs in young adults annually in the U.S. (4)
Finally, we should not assume that our only choices are either mandated screening as in Italy or no screening at all. America is a country with a tradition of ingenuity. The medical community is at its best when it faces challenges by persistently working to find solutions. We did not abandon PTCA when the initial experience had a 5% emergency surgery rate in the hands of a small number of highly skilled operators. Ingenuity, skill, determination, cooperation with the device industry and physician education brought us to our current standard where emergency surgery is now rare and excellent PTCA service is delivered in most hospitals. Solutions to problems are not found by saying how we can't achieve a worthy goal but rather by asking how we can. Until we change this mindset we will continue to unnecessarily lose too many of our precious youth to potentially preventable causes of sudden death.
References
1. Barry J. Maron National Electrocardiography Screening for Competitive Athletes: Feasible in the United States? Ann Intern Med 2010 152:324-326.
2. OECD Health Data 2009; General practitioners and specialists in OECD countries 2007
3. Maron et al; Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update Circulation. 2007;115:1643-1655.
4. Atkins et al; Epidemiology and Outcomes From Out-of-Hospital Cardiac Arrest in Children. The Resuscitation Outcomes Consortium Epistry- Cardiac Arrest Circulation. 2009;119:1484-1491.
5. Maron et al; Sudden Deaths in Young Competitive Athletes Analysis of 1866 Deaths in the United States, 1980-2006 Circulation. 2009;119:1085-1092.
6. Pelliccia et al; Prevalence of abnormal ECGs in a large, unselected population undergoing pre-participation cardiovascular screening Europ Heart J. 28: 2006-2010, 2007.
7. Nora et al; Preliminary Findings of ECG Screening in 9,125 Young Adults Oral Abstract Presentation; AHA annual scientific session, Circulation. 2007;116:II_845.
Conflict of Interest:
None declared
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Duration and Timing Effects on Risks and Benefits of Menopausal Hormones
Submit responseWe applaud the efforts of Toh et al. (1) to delve deeper into the still controversial issue of inconsistencies in the cardiovascular disease (CVD) outcomes between the Women's Health Initiative (WHI) E P hormone trial and previous large observational studies. Current evidence supports the concept that both timing of menopausal hormone therapy (MHT) initiation and duration of treatment (2, 3) are important determinants of the risk:benefit ratio. The data presented by Toh et al., suggesting that the slightly higher CVD event risk in the first two years of treatment transitions to a lower risk after six or more years of use only in study drug-compliant WHI women initiating treatment less than ten years postmenopausally, are relevant to both of these questions. We regret that the authors focused on the statistically nonsignificant early increase in risk and discounted possible long-term benefits by stating that, "Because the typical duration of use of hormone therapy is short, most women contemplating estrogen plus progestin therapy for the relief of menopausal symptoms should not expect protection against CHD." On the contrary, before publication of the original WHI report in 2002 (4), MHT was frequently prescribed long-term to reduce both risks of osteoporotic fractures and CVD. Ironically, the WHI conclusion that MHT produced net harm was the primary basis for the change in the FDA official guidance and subsequent clinical practice discouraging long-term MHT use. This change owed precisely to the lack of distinction between risks and benefits for recently vs. remotely menopausal women in the initial report, an issue that WHI investigators and others performing follow-up analyses have attempted to address (5). Thus, it seems to us that an alternative interpretation of the new analysis by Toh et al. would be that recently menopausal women have little to fear in the early period of hormone treatment when incident CVD rates are low, and they may stand to benefit from long-term continuation of MHT into the later postmenopausal years when CVD risk is much higher. This may be seen as simply a matter of perspective (glass half-empty vs. glass half-full), but the health and lives of millions of women will depend on how the results of this and future research are interpreted by the medical community and the public.
References
1. Toh S, Hernandez-Diaz S, Logan R, Rossouw JE, Hernan MA. Coronary heart disease in postmenopausal recipients of estrogen plus progestin therapy: does the increased risk ever disappear? A randomized trial. Ann Intern Med. 2010;152(4):211-7.
2. Grodstein F, Manson JE, Stampfer MJ. Postmenopausal hormone use and secondary prevention of coronary events in the nurses' health study. a prospective, observational study. Ann Intern Med. 2001;135(1):1-8.
3. Chilvers CE, Knibb RC, Armstrong SJ, Woods KL, Logan RF. Post menopausal hormone replacement therapy and risk of acute myocardial infarction--a case control study of women in the East Midlands, UK. Eur Heart J. 2003;24(24):2197-205.
4. WHI Trials Group. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-33.
5. Manson JE, Hsia J, Johnson KC, et al. Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med. 2003;349:523-534.
Conflict of Interest:
Authors are co-PI's of the Kronos Early Estrogen Prevention Study (KEEPS) investigating cardiovascular effects of oral vs. transdermal hormone treatment in recently menopausal women