Although Facebook has long-since been woven into the fabric of modern life, it continues to pose ethical challenges for government officials and professionals in many fields. How much personal information should they share with others? Are their traditional codes of conduct robust enough to cover the behaviors associated with the use of Facebook and other social media outlets?

Physicians, nurses and other health professionals know they must never disclose confidential health information concerning their patients on Facebook or anywhere else. Beyond this, new media outlets create countless situations in which “acceptable” behavior for government officials and professionals remains unclear.

To their credit, some professional societies including the AMA have recently issued guidelines for acceptable behavior on social media outlets. Surprisingly however, scientists have published few studies describing professionals’ actual use of such sites.

Recognizing this gap, Ghassan Moubarak and colleagues at Hopital Lariboisiere in Paris designed a questionnaire to study the way young physicians use Facebook. Moubarak’s group mailed the survey to 405 residents and fellows at Rouen University Hospital. Nearly half of them responded, including 160 residents and 42 fellows. The mean age of respondents was 29.

Seventy-three percent of the survey respondents reported having a Facebook profile. Nearly a quarter of them, 24%, said they visited the site several times per day, and an additional 28% reported visiting it once per day.

Ninety-nine of the respondents who had a Facebook profile used their real name on it. Over 90% of the respondents also displayed their birthdates and a headshot, although only 59% listed their current university and 55% listed their current position. Sixty-one percent of the respondents had modified privacy settings on the site, and 85% said they would never accept friend requests from patients. The remaining 15% said they would decide about friend requests from patients “on an individual basis.” None of the respondents said they would automatically accept a friend request from a patient. (more…)

Just about everybody agrees that kids should eat breakfast every day. Breakfast improves their overall nutrition and their performance in school, among other things. But how helpful can breakfast really be if it consists of cereal deluged in sugar?

“Not very” is the answer.

Thankfully, a new study by Jennifer Harris and colleagues at Yale suggests that kids are perfectly willing to consume low-sugar cereals instead, particularly if they can add a pinch of table sugar or fresh fruit to the mix.

To evaluate kids’ willingness to eat low-sugar cereals, Harris’ team randomized 91 kids between the ages of 5 and 12 to two groups. Kids in the first group were offered low-sugar cereals like Cheerios, Corn Flakes and Rice Krispies which contain 1 to 4 grams of sugar per serving. Kids in the other group chose between Cocoa Pebbles, Frosted Flakes and Fruit Loops, which contain about 12 grams of sugar per serving.

Kids in both groups were also offered OJ, 1% milk, pre-cut sections of bananas and strawberries and sugar packets. The kids served themselves and then completed a questionnaire about their breakfast.

Harris’ team found that kids randomized to the low-sugar cereals consumed about half as much refined sugar as those in the high-sugar group (12.5 g versus 24.4 g). They were also more than 6 times as likely to add fresh fruit (54% versus 8%). As well, they were equally likely to “like” or “love” their breakfast. The amount of milk, orange juice and total calories consumed did not differ between the groups.

The authors concluded that “compared with serving low-sugar cereals, high-sugar cereals increase children’s total sugar consumption and reduce the overall nutritional quality of their breakfast. Children will consume low-sugar cereals when offered, and they provide a superior breakfast option.”

 The authors added that their results probably underestimat the overall impact of giving kids low-sugar cereals for breakfast. “Children’s taste preferences develop over time through continued experiences with different foods,” they wrote. “If kids are given highly sweetened cereals regularly, they are likely to learn to prefer sweetened foods in general.”

The write-up appears in Pediatrics. Cereal marketers and moms, take note!

Scientists have known for years that people with type 2 diabetes can benefit from exercise, although the precise roles played by aerobic exercise and resistance training have been somewhat of a mystery. Until now, that is.

In a paper published last month in JAMA, Timothy Church and colleagues from LSU showed that type 2 diabetes patients benefit more from an exercise regimen that combines the 2 forms of exercise than programs based on either one, alone.

To assess the relative effects of aerobic training and resistance training, Church’s group studied 262 sedentary male and female patients that had type 2 diabetes. In the 9-month study, dubbed HART-D, the average age of the patients was 56. They had diabetes for an average of 7 years. Their average HbA1c level was 7.7%, indicating moderately well controlled diabetes at study onset. Nearly half the patients were not Caucasian.

The scientists randomized enrollees into a non-exercise control group, a resistance training only group, an aerobic training only group, and a group that underwent combined aerobic and resistance training.

Participants in the 3 intervention groups spent about 140 minutes in supervised exercise per week, including time spent warming-up and cooling-down. Aerobic exercise involved walking fast enough on a treadmill to burn 12 kcal/kg per hour. Resistance training was divided into 3 sessions per week, and focused on the upper body, legs, abs and back. Participants in the combination training program engaged in resistance training only twice per week in order to keep total exercise time the same as the other groups.

The scientists found that the absolute change in HbA1c in the combination group compared to the control group was -0.34%. This compared favorably with an absolute change of -0.16% and -0.24% for the resistance only and the aerobic only groups.

Church’s group estimated that if such reductions were maintained for years, people with type 2 diabetes would reduce the risk of cardiovascular disease risk by 5% to 7% and the risk of microvascular complications by 12%.

Of great significance, Church’s group also noted that the frequency with which oral hypoglycemic drugs had to be increased was 18% in the combination group. This was significantly lower than the 22% for the aerobic training only group, 32% for the resistance training only group, and 39% in the controls. Without these aggressive interventions, the absolute improvements in HbA1c levels in the combined exercise group would almost certainly have been much greater, according to the scientists.

All exercise groups reduced waist circumference by about the same amount [-.75 to -1.1 inches] when compared to the control group.

In an accompanying editorial, Canadian researchers, Ronald  Sigal and Glen Kenny concluded that, “based on the results of the HART-D trial, patients with type 2 diabetes who wish to maximize the effects of exercise on their glycemic control should perform both aerobic and resistance exercise. The HART-D trial clarifies that, given a specific amount of time to invest in exercise, it is more beneficial to devote some time to each form of exercise rather than devoting all the time to just one form of exercise.”

One note of caution: Although this is clearly good news, the study may not be easily generalizable to the population at large because the study design required that all exercise sessions be supervised.  It turns out that without that pesky trainer and the forced adherence to an exercise regimen, many folks, whether they have diabetes or not, can’t manage to stick with an exercise plan.

The US health care system is generally recognized to be obscenely wasteful and to deliver poor value for the money. But even the most jaded observers are likely to be shocked by the results of a new study which shows that many patients with advanced or metastatic cancer and a correspondingly short life expectancy undergo routine screening tests like cholesterol checks, Pap smears, mammograms and PSA tests.

For example, 14% of male Medicare beneficiaries with advanced pancreatic cancer underwent PSA testing. Similarly, 18% of women with this condition had at least one mammogram and 5.4% had a Pap smear. Nearly 20% of these patients had a cholesterol test.

The appalling findings come from a study by Camelia Sima and colleagues at the Memorial Sloan-Kettering Cancer Center. These scientists looked at Medicare billing data from 88,000 beneficiaries that had been diagnosed with advanced cancer between 1998 and 2005.

The scientists compared utilization rates for screening tests in this group with a control group of Medicare enrollees that did not have cancer, but were matched by gender, age, race and area of residence.

The first group included patients with stage IIIb to IV lung cancer, advanced stage pancreatic cancer and stage IV breast,colorectal, and gastroesophageal cancer. The vast majority of these patients have a life expectancy of less than 2 years.

Screening rates for the cancer patients were about half that of their matched controls. There were no differences in screening rates for patients with each kind of cancer. Married and more affluent cancer patients tended to get more screening tests than their counterparts.

“In an ideal healthcare system, healthcare practitioners would discontinue cancer screening for patients whose prognosis is too limited for the benefits of early detection to be realized,” Sima’s team wrote. “Each medical specialty needs to engage in thoughtful self-scrutiny to identify episodes of unnecessary care,” they added.

The write-up appears in JAMA.

Amid the burgeoning worldwide epidemic of obesity, scientists and pharmaceutical companies have spent hundreds of millions of dollars to develop drugs to help people lose weight. The effort has failed spectacularly so far, and 2 recent setbacks have fueled increasing pessimism that things will change for the better anytime soon. 

The first setback occurred last month when the FDA put the kibosh on Arena Pharmaceuticals’ New Drug Application for lorcaserin, an investigational weight loss drug. In rejecting the application, the FDA  cited several concerns including low efficacy and the results of animal studies which suggested that it increased the risk of breast cancer.

In its letter to the San Diego-based drug company, the FDA said “the weight loss efficacy of lorcaserin in overweight and obese individuals without type 2 diabetes is marginal.” The letter also said the regulatory agency needed more information from a study that is now underway before considering the matter further, and that if Arena could not provide data to “alleviate concern regarding clinical relevance of the tumor findings in rats, additional clinical studies may be required to obtain a more robust assessment of lorcaserin’s benefit-risk profile.”

The FDA’s snub of lorcaserin was followed in short order by an announcement by Abbott Laboratories that it was withdrawing the diet drug Meridia from the market. Abbott’s decision was prompted by FDA findings that showed the drug’s limited efficacy was outweighed by significant risks associated with the drug.

Meridia had long-since been known to increase blood pressure, but the death knell came in the form of a European study which showed it was associated with a 16% increased risk of cardiovascular problems including heart attacks, strokes and death.

Nearly 100,000 Americans take Meridia at the moment. The FDA advised all of them to stop taking the drug, and instructed physicians to stop prescribing it. European regulators had taken Meridia off the market in January.

“It’s been very frustrating,” Jennifer Lovejoy, the incoming president of the Obesity Society told the Washington Post. “We desperately need safe new drugs so we can begin to have something effective against this public health epidemic.”

Meanwhile, experts continue to emphasize that the best way to stay healthy is to avoid gaining weight in the first place by eating well and exercising regularly…

Millions of people consume red yeast rice to lower their cholesterol levels. The dietary supplement contains monacolins, which are known to inhibit cholesterol synthesis in the liver. A purified version of one member of the monacolin family, monacolin K, is also known as lovastatin, the widely prescribed, highly effective cholesterol-lowering drug.

Studies of some (but not all) red yeast rice formulations have shown that they do in fact reduce blood levels of low-density lipoprotein (LDL, or “bad”) cholesterol, and reduce the risk of heart attacks and cardiovascular disease.

Does anybody have a problem with this?

Well, yes. The problem is that since red yeast rice products are classified as dietary supplements and not drugs, they are not regulated by the FDA and hence not always subjected to quality and safety checks that legit drugs get before hitting the shelves. With dietary supplements, you don’t know how much of the “good stuff” you’re getting, and you don’t know what else you may be getting with it.

Ram Gordon and colleagues at the University of Pennsylvania highlighted the problem in a recent study, which they published in the Archives of Internal Medicine.  For their study, Gordon’s team asked an independent laboratory to measure monacolin levels in 12 commercially available formulations of red yeast rice. They also asked the lab to test for citrinin, a byproduct of fungal metabolism of red yeast rice, which is how monacolins are produced from rice in the first place.

Citrinin is toxic: it causes kidney damage, at least in animals.

The label on each formulation in Gordon’s study said it contained “600 mg capsules” of active product, yet Gordon’s team found that the total monacolins per capsule varied by more than 30-fold across the 12 preparations (lowest = 0.31 mg, highest = 11.15 mg). The range of monacolin K (a.k.a lovastatin) varied even more, by a remarkable 100 fold (lowest = 0.10, highest = 10.09 mg).

Four of the 12 products contained citrinin, in levels ranging from 24 parts per million to 189 parts per million.
 
Of interest, the average dose of lovastatin contained in the 12 red yeast rice formulations was 6 mg/day. The maximum dose was 14.5 mg/day. The normal dose of FDA-approved lovastatin is 10-80 mg/day.

“Our findings suggest the need for improved standardization of red yeast rice (RYR) products and product labeling. Until this occurs, physicians should be cautious in recommending RYR to their patients for the treatment of hyperlipidemia and primary and secondary prevention of cardiovascular disease,” the authors wrote.

The Affordable Care Act is the most important piece of federal health care legislation since the Social Security Act of 1965 established the Medicare program. It assures that 32 million Americans will have access to health insurance for the first time. But who will care for these people?

Our health care system was plagued by a severe and worsening physician shortage even before the new law took effect. In fact, a 2008 study by the Health Resources and Services Administration projected shortages of 35,000 surgeons and 27,000 medical specialists within 10 years, and that’s not even counting expected shortfalls among primary care practitioners like those in Family Practice and Obstetrics.

Those 32 million newly insured people will create an unprecedented surge in demand for physician services, exacerbating this shortfall by at least 50%, according to a new report by the Association of American Medical Colleges.

The report estimates that by 2015—which is one year after the major provisions of the Affordable Care Act take effect—the US will be short a whopping 63,000 physicians—including both PCPs and specialists. Previous analyses had pegged the shortage at 39,600 physicians.

Nearly half the shortfall, 33,100 to be exact, involves specialists like cardiologists, oncologists and emergency medicine experts. For certain specialties like urology and thoracic surgery, the number of physicians is actually expected to decrease.

The report adds that the shortage will get worse in the following 10 years. For example, by 2020, our nation will be short by 45,000 primary care physicians, and 46,000 few specialists.

The physician shortfall will be exacerbated by demographic trends. The number of Americans who are at least 65 years old (a group known to require more medical care than younger folks) will increase by 36% during the upcoming decade, according to the Census Bureau. The graying of the US population is also expected to mean that nearly a third of today’s practicing physicians will retire within the next 10 years, according to the AAMC report.

The physician shortfall will hurt everyone, but the AAMC projects that the impact will be particularly severe on medically underserved populations where finding a doctor is already quite difficult. The population in question includes nearly 20% of Americans living in inner-city and rural areas where shortages of health professionals are already acute.

Offsetting this trend to some degree is the fact that (provisions in the Affordable Care Act aside) the number of medical school students will increase by about 7,000 graduates per year during the next decade. Unfortunately, according to the AAMC this increase doesn’t keep up with the projected surge in demand for physician services.

What Should We Do?
While team-based approaches like “medical homes” can ameliorate the looming crisis to some degree, few believe they will eliminate it.

Recognizing this, the AAMC recommends that Congress should mandate at least a 15% increase in residency training slots which would add 4,000 physicians per year to the pipeline. This surge is not contemplated by the Affordable Care Act, which in the most optimistic of projections will add approximately 350 physicians per year for the next decade via small primary care grants and the reshuffling of residency programs.

The only way to reach the AAMC’s proposed target of 4,000 new physicians per year, it seems, would be for Congress to overturn a 1997 law that froze Medicare-funded residency positions and increase by at least 15% the number of GME positions funded by Medicare. However with Congress mired in partisan gridlock and public opinion now pretty entrenched against new spending programs, this seems like a long shot at best.

Beyond this, the options are relatively slim and controversial. We either agree to increase the numbers of foreign medical graduates or expand the scope of practice for nurse practitioners so they can help shoulder the burden of an accelerating demand for medical services.

To those who would disagree with these latter solutions, which can work, I ask, “What alternatives do you propose?”

Teenagers with otherwise healthy lifestyles consume large amounts of sports drinks and high-calorie fruit drinks, probably because they believe the products are “healthy,” according to scientists from the University of Texas.

To reach these conclusions, Nalini Ranjit and colleagues surveyed 15,000 students attending grades 8-11 during academic year 2004-2005. The survey asked about dietary and exercise habits, as well as time spent watching TV, playing video games and using computers.

The scientists found that teens who preferred flavored and sports beverages (FSBs) over soda tended to exercise harder and more frequently, and to consume truly healthy foods more often.

“The most likely explanation for these findings is that FSBs have been successfully marketed as beverages consistent with a healthy lifestyle, to set them apart from sodas,” Ranjit’s team concluded in their write-up, which appears in Pediatrics.

FSBs contain miniscule amounts of fruit juice and about the same amount of sugar as carbonated soda.

The link between FSB intake and a healthy diet turned out to be stronger in girls. Girls who consumed 3 or more FSBs per day were more likely to consume more milk, fruit and vegetables.

The link between FDB intake and exercise was more apparent in boys. Boys who consumed 3 or more FSBs per day engaged in more vigorous exercise and participated more regularly in gym class and organized sports.

Commenting on the team’s findings for MedPage Today, Vanderbilt University sports medicine expert Alex Diamond said that, “marketing has a great deal to do with the perception that sports drinks are generally healthy. They have a role when it comes to prolonged activity or exercise, but on a regular basis, it’s not something kids should be drinking just to get hydration.”

Levels of cancer-causing nitrosamines are higher in US-made cigarettes than those from other countries, according to scientists at the Center for Disease Control.  That means they can potentially cause more cases of lung cancer.

To reach these conclusions, David Ashley and colleagues group measured mouth levels of a highly carcinogenic substance known as NNK, and urinary levels of its major metabolite, NNAL in 126 smokers from New York, Minnesota, Australia, Canada and England. The US smokers used several popular brands including Camel Light, Marlboro, Newport and Newport Light. The scientists counted butts to assure smokers from each location consumed the same numbers of cigarettes.

It turned out that 24 hour mouth levels of NNK (in nanograms) were 1,490 in New York, 1,150 in Minnesota, 1,010 in England, 449 in Canada and 350 in Australia. There was a direct correlation between mouth levels of NNK and urinary levels of NNAL.

Of note, 2 recent studies have shown a direct relation between urinary NNAL levels and lung cancer risk.

Together, these findings suggest that “higher levels of tobacco-related nitrosamines in the smoke of US cigarette varieties lead to higher mouth-level exposure to NNK and increased NNAL, which may be associated with excess lung cancer burden,” wrote the scientists.

The scientists also hypothesized that high levels of NNK in US tobacco products result from domestic curing processes and the blends of tobacco used during production.

Unfortunately, lowering nitrosamine levels in US cigarettes might not make them safer because that may increase the amounts of other carcinogenic substances.

As well, the scientists “did not look at the two dozen other cancer-causing toxins,” according to John Spangler of Wake Forest University. “And it did not examine chemicals that might affect heart disease, stroke, emphysema, and other diseases caused by tobacco use,” he added.

The findings appear in Cancer Epidemiology, Biomarkers & Prevention.

Camel Orbs, a flavored Tic Tac-like tobacco-containing pellet introduced last year by R.J. Reynolds,  poses a threat to children, according to a new study published in Pediatrics.

The smokeless tobacco product is supposed to be used by smokers when they can’t light up. It contains 1 mg of nicotine, about half that received by smoking one cigarette.

This amount can cause nausea and vomiting in a small child (a lethal dose of nicotine for an infant is about 1.0 mg/kg body weight). The problem is made worse by the fact that the Orb contains a highly bio-available form of nicotine.

To reach these conclusions, Hillel Alpert and colleagues from the Harvard School of Public Health  reviewed 13,705 tobacco product ingestion cases by children under 6 years of age that were reported to 61 regional poison control centers between 2006 and 2008.

The scientists counted 13,705 cases of tobacco product ingestion, more than 70% of which involved infants less than 1 year of age. Orbs came in second only to cigarettes themselves as the substance ingested by the kids. There was one death.

In an accompanying editorial, Marisa Cruz and Lawrence Deyton of the FDA Center for Tobacco Products said their agency has requested information from RJR and will be seeking “research around the impact of marketing for dissolvable tobacco products on young people, how adolescents and young adults perceive such products, and whether dissolvable tobacco products may lead to initiation or persistence of tobacco use in this population.”

An RJR spokesperson said the company hadn’t known of any pediatric adverse events caused by Orbs ingestion before the article was published. He added that Orbs taste like tobacco despite the candy-like flavorings and that the packaging meets government standards for child resistance.