When Doctors Act as Gods My Unpleasant Experiences as the Harbinger of Bad News: “You are going to die”

“Dad, may mga nakita sa MRI ng utak nyo na mga kumalat na puti puting bilog ( showing him the Cranial MRI with gadolinium contrast scan plates). Hinala po namin ito yong mga cancer cells sa lungs nyo, umabot na po sya dito. Kaya pala nanghihina talaga ang katawan nyo”. About a prolonged silence, my dad asked me, “Gaano pa ako tatagal? Aabot pa ba kaya ako sa birthday ko?” . “Hindi ko po masagot yan dad, baka with radiotherapy….” Then I just stopped….

I am the youngest in a brood of three, my eldest brother being a surgeon and me, an internist. But during the last few months of my dad’s life ( who was diagnosed with stage 3b lung cancer 2 years before his death and who underwent a series of chemotherapy sessions), I was the one living close to our parents’ home and constantly supervising their immediate needs. I could still feel the awkward and sad feeling of breaking the bad news of the disease recurrence to dad and mom. When the recurrence was discovered, it was already in his brain after two years of remission. And yes as the internist and private physician of our dad, I was the one who pronounced him dead a few months after this revelation.

The problem with being an internist (as compared to surgeons, OB gynecologists, pediatricians, and  more so dermatologists and radiologists) is that most of the morbidities and mortalities fall under the group of patients that we handle. So after a decade or so of private practice, we had our share of patients who die while under our care and the list gets long, we become more or less used to telling bad news to patients and their relatives. From someone who gets really so down with your first dying private patient, the regularity of the experience make our soul callous (to put it bluntly) that when another of patients dies next time, we just formally seek scientific reasons why he or she suffered that fate and we keep our emotions out of the picture. We could call this our way of physician self preservation.

There are several situations when we take on a controversial and uncomfortable stance when dealing with our ailing patients. Among the things I could think of are the following:

A. Telling your patient’s relatives that he/she has a terminal illness.

B. Telling this thing to the patient.

C. Bringing in options to the relatives (difficult choices which include DNR), when the certainty of the patient improving and getting well is very slim.

D. Stopping any resuscitative or life prolonging efforts and pronouncing the patient dead.

Based on what we know as physicians, those diagnosed with stage 4 (disseminated cancer), end stage renal disease, NYHA class 4 heart failure, non resectable brain space occupying tumors, huge cerebellar or cerebral bleed with herniation, among many other conditions are patients who most likely will perish within the next 6 months. 

I recall about more than 10 instances wherein I would suspect a patient with a malignancy after examining the patient (mostly elderly ones) for the first time and I would request an imaging study. In about a day or two, it would be the loved one of the patient alone who would be showing the results to me. When I did confirm my suspicion and discussed the not so good result to them, they would strongly request me ahead not to tell the patient about the bad news before they bring the patient to me the following day. The main reason they give me is that they believe he/ she will be very depressed and will die earlier just knowing about the bad news.

I strongly believe in the maxim “the patient has the absolute right to know the truth.. It is his/ her body after all. I believe it to be strongly unfair not letting him/ her know what is actually happening to his/ her body.”

But there were indeed some instances wherein the patient’s spouse or son/ daughter know much more about the patient’s mental state and emotional capacity to handle the truth. I once told an elderly patient about his lung mass even after having been forewarned by his spouse not to tell him the truth. I broke it up slowly to him by even showing him the plates and offering the option for referral to an oncologist.  The patient suddenly exploded in curses in front of me and walked out with his loved ones following suit. I felt so bad then though I pressed on the thought that the patient is certainly just in a state of denial. Two month after, I heard from his neighbor patient of mine that their family went home to their province and consulted their local herbalists. From what this neighbor knows, the patient already died not seeking professional medical help. I should have asked this patient if he or she wants to know the truth in the first place even if it was not good.

I recall one situation wherein I had a COPD patient with cardiogenic shock on inotropics who eventually got pneumonia on the 3rd day in the ICU and had to be put on a ventilator. Despite all efforts to improve his cardiac and pulmonary status, the patient could not be weaned from both the inotropics and the ventilator even after two weeks, and he remained drowsy. It was pretty obvious that his relatives are having a hard time financially securing the medicines on time (patient was already on cash basis with the hospital), they could not give a go for the advice to do tracheostomy. One time, I had to call them and discuss with them the patient’s status, all the efforts we had been doing and his lack of progress, his prognosis (given an EF on 2d echo of only 21%), and how uncertainly long he would have to stay in the ICU with the present aggressive stance and the absence of assurance of his recovery. Seeing his relatives almost succumb everyday trying to secure very medications and their hopeless facial expressions, I reiterated that he has a poor prognosis and opened up the possibility of having the patient out to a private room (so he could be with his loved ones in his final hours and to help allay expenses). But they will have to sign a DNR form as the very decision means they relinquish their aggressive stance on the management. Before they signed, they asked me how many days the patient will last outside especially if it comes to a point when they had to discontinue all his medications. I discouraged them of the action but nonetheless told them, he might expire within 24 hours of doing so. Eventually the relatives signed the DNR, had the patient transferred to a private room with them, and owing to their financial constraints, even discontinued his meds 3 days after he was in the private room.

Two months after this event, this very same patient was following up with me in my clinic alive and kicking! Of course, he has activity precautions and an escort relative on the side always but this tells us that miracles do happen. If it is not yet the time for someone to go, it will not be.

Another phase of this God action of a doctor ruling over a patient’s life is when he/ she is called upon to handle an ongoing cardiopulmonary resuscitation case. On this alone there is a wide spectrum for us to decide what a patient’s chances of surviving would be and how aggressive we should become in handling the ACLS process. On one hand, there would be these patients who are very sick to start with, had been in and out of the hospital, and those who really could go into an arrest anytime. Let us call this Spectrum A. On the other end of the spectrum, there may be this very active young person who suddenly falls and goes into an arrest. Let this set of patients be called Spectrum Z.

I remember having read in the Washington Manual of Medical Therapeutics that if one does the ACLS sequence and protocols, he / she is advised to call off the resuscitation efforts after 15 minutes if the patient remains in asystole. The rationale for such is beyond 15 minutes of no brain circulation, the patient is assumed to have sustained irreversible brain damage.

The reality is this principle may be applicable if your arrested patient is within spectrum A. But for those within spectrum Z? I recall an ACLS done on a husband of a middle aged colleague of mine who was suddenly rushed to a hospital after losing consciousness while jogging. The patient was fond of joining marathons before. It took the attending MD an hour and 30 minutes of active resuscitation and ACLS before he pronounced the patient dead.

As for me, there was an instance wherein I was handling a comatose patient with a huge inoperable intracranial bleed who had been status quo for 4 days in the ICU. I had divulged the poor prognosis to her relatives and opened up DNR as an option. However, they refused as I was told the patient still has a daughter coming home from the US en route. The patient even went into arrest the day after, ACLS still conducted with strict instructions from the relatives to be aggressive ( rhythm achieved after 20 minutes). The patient’s daughter arrived the evening of the arrest and visited her mother. Two hours after, the decision for DNR was made. The patient expired 30 minutes after the relatives signed. She was 78 years old.

This goes to say that it is not just the age and medical condition of the patient that dictates how aggressive you should be in conducting a resuscitation but also the family’s values. I even recall an ER resident physician telling me how he was roughly chided by a patient’s relative when he pronounced someone dead (DOA) after about 30 minutes of ACLS. “Hindi mo man ginawa lahat. Hindi mo sya binigyan ng electric shock!”. Apparently, the patient has asystole and at best, an unsustained idioventricular rhythm in between, so there is clearly no indication to do a cardioversion nor defibrillation. However, this is pretty hard to explain to a desperate angry and frustrated relative.

It is my routine to call on the deciding and responsible relatives when their patient’s prognosis is not good. When asked what his / her chances of surviving are, I now always add the phrase “Based on medical statistics and my limited experience, going on with our management there is about only this ____ % of survival and if ever he would survive, this will be our expectations…” One of my consultant mentors told me this on my first years of practice. He told me to speak with conviction whenever divulging unpleasant news. Back it all up with all the medical interventions you did to help the patient and the rationale of each intervention. Your endpoint is  to impress upon your patient and his / her relatives  that you (or your team) did your very best.

Yes, we may be God’s instruments of healing but we are not Him. God is the Author of life, never should we use our knowledge to actively end it. While we may be regarded as His stewards for promoting health and prolonging life, it will still be God’s will in the end that will prevail. Somehow, I believe part of our role is to help our patient and their relatives believe in this too.

-  Raymundo Marquez Jr. MD

Your Heart Health: 13 Numbers Everyone Should Know

1. Alcohol intake

Those fond of tipple may be dismayed, but the science on alcohol as an agent to promote heart health is just not definitive. "If you have heart disease, alcohol plays no role in your medicine cabinet; if [you do] not, alcohol is not the right way to reduce your risk," says Jonathan Whiteson, director of the Cardiovascular Rehabilitation Program at New York University Langone Medical Center. Some research has suggested that drinking red wine may increase one's HDL, or "good" cholesterol, but Whiteson notes that the boost is minimal. "Exercise [offers] a better increase in HDL," he says.

While he's not against a drink in a social setting, it's certainly not something folks—especially those with heart disease—should engage in with the idea that it will offer a heart benefit, says Whiteson. In fact, medications' effectiveness can be either hampered or heightened by alcohol, sometimes to a dangerous extent. (Common herbal supplements can interact with heart drugs, too). And drinking too much can lead to high blood pressure or increased blood levels of triglycerides, a type of fat.

Bottom line: The American Heart Association suggests that otherwise healthy individuals who drink should do so in moderation. That is defined as one to two drinks per day for men and one drink per day for women. And be careful with that pour: The AHA defines a drink as one 12-ounce beer, a 4 ounce glass of wine, 1.5 ounce of 80-proof spirits, or 1 ounce of 100-proof spirits.

2. Salt intake

Some experts say that the pervasive use of sodium in the America diet is wreaking havoc on our cardiovascular systems. "Sodium causes retention of fluid within the circulation, and if you're sodium-sensitive, it expands your blood volume and can contribute to high blood pressure, stroke, and other heart disease," explains Clyde Yancy, medical director of the Baylor Heart and Vascular Institute at Baylor University Medical Center in Dallas and spokesman for the American Heart Association.

A report in the New England Journal of Medicine suggested that if Americans reduced daily salt intake by 3 grams, we could significantly lower the annual number of new cases of coronary heart disease (by between 60,000 and 120,000), stroke (by 32,000 to 66,000), heart attack (by 54,000 to 99,000), and even the number of deaths from any cause (by 44,000 to 92,000). The paper's authors noted previous research that showed the average American man consumes 10.4 grams of salt daily, while the average American woman gets 7.3 grams.

Bottom line: The AHA recommends Americans limit salt intake to 1.5 grams daily. Be wary: Sodium creeps in via unexpected sources, and it's not so much the salt shaker on our table that's to blame. Research suggests we get as much as 80 percent of our daily salt intake from processed foods.

3. Sugar intake

It's not just the savory flavors that'll get you; sweets, too, can ultimately become a cause for concern, says the American Heart Association. Like salt, sugar creeps into the processed foods that make up much of the American diet, and sweetened beverages—soda, juices, and sports drinks—are especially loaded with the stuff. Here's some disturbing math for you: A 12-ounce can of soda has about 8 teaspoons (or 33 grams) of added sugars, totaling about 130 calories. (A gram of sugar translates into 4 calories.)

A can of Coke or Pepsi, then, basically takes you to the AHA's new upper limit on the recommended amount of added sugar Americans should ingest on a daily basis. The association's primary concern is the number of excess calories that added sugars sneak into our diets and pile onto our waistlines, which can contribute to metabolic changes that increase the chances of developing a host of diseases.

Bottom line: According to the AHA, women should get no more than 100 calories per day of added sugars and men should stop at 150 calories per day.

4. Resting heart rate

How hard does your heart have to work—and how fast does it have to pump—to get oxygen-rich blood throughout your body? A lower number suggests your cardiovascular system is more efficient at doing this. Thus, a highly trained athlete can have a resting heart rate in the 40s, says Whiteson.

And while the research is still emerging on what one's resting heart rate predicts about heart disease risk, a picture is beginning to take shape. "There is certain evidence to support [the idea that] a higher resting heart rate is associated with heart disease," especially ischemic heart disease, he says, which involves reduced blood flow (and oxygen) getting to heart arteries and the heart muscle. This effect seems to be more pronounced in women than in men, but a study in the Journal of Epidemiology and Community Health suggested that in women up to the age of 70, every 10-beats-per-minute increase in resting heart rate boosted the risk of dying from ischemic heart disease by 18 percent. In men, the risk was increased by 10 percent for every extra 10 beats per minute, and age didn't have an impact. The study also found that women who got high levels of physical activity were able to reduce their risk of death considerably, compared with those who did little or no activity. The same effect was not found in men, but the researchers suggest the results may have been skewed because men tend to overestimate how much exercise they get.

Bottom line: A normal resting heart rate is between 60 and 100 beats per minute. Check yours by finding your wrist's pulse, counting the beats in a 15-second period, then multiplying by four.

5. Hours of sleep per night

An overcaffeinated America seems to perpetually crave more shut-eye. And evidence is cropping up to suggest that a poor night's sleep is not only felt the next day but could have implications for one's heart over the long term. It is well established that sleep apnea, which results in numerous interruptions to breathing while asleep, is associated with stroke and coronary artery disease.

The reason is not clear, says Whiteson, but it's been hypothesized that people with disrupted sleep breathing have higher blood pressure overall because they don't get the restorative sleep that normally allows blood pressure to go down and gives the cardiovascular system a break during slumber. And a study in the Journal of the American Medical Association showed that middle-aged people who got five hours of shut-eye or less a night had a greater risk of developing coronary artery disease than those who got eight hours. The clue was the beginnings of calcium buildup in their arteries, found by CT scanning long before the disease process would normally be picked up.

Bottom line: Get eight hours of sleep per night. Making it happen isn't easy, we know.

6. Exercise

You've heard it a thousand times over, and the message stays the same: Regular, heart-thumping exercise offers a multitude of health benefits, particularly for cardiovascular fitness. Perhaps clinicians (and health writers) keep bashing us over the head with that fact because of the eye-popping number of American adults who reported getting zero vigorous activity in a 2008 Centers of Disease Control and Prevention survey: 59 percent.

Bottom line: For a clean bill of health, the major health associations (including the AHA and the American College of Sports Medicine) suggest a minimum of 150 minutes of moderate-intensity physical activity each week—say, brisk walking that boosts your heart rate. This translates into 30 minutes of exercise on five days of the week. Twice-weekly strength training of eight to 10 exercises, up to 12 reps each, is also on their to-do list.

Whiteson at NYU Langone Medical Center suggests that those who don't have heart disease should bump that recommendation up to 60 minutes a day, five days a week of vigorous activity, where you're breathing pretty heavily and sweating. But he offers a concession: "You can break it up" into, say, three 20-minute sessions per day, since "the effect of aerobic exercise is cumulative." He also thinks those without heart disease should do strength training thrice weekly. Individuals with heart disease should always discuss a new exercise regimen with a doctor first, he says.

7. Cigarettes

A 2009 study of Norwegians found that heavy smokers—those who puff at least 20 cigarettes per day—were 2.5 times more likely to die over a 30-year period than nonsmokers. But the cardiovascular risks associated with smoking aren't just seen in chain smokers.

The more nuanced message that doesn't always get across is the risk that the occasional smoker is exposed to. Even 10 minutes of secondhand smoke exposure may affect cardiovascular function. Just because you might not smoke a pack a day or even a week doesn't mean you're in the clear. "There is no safe level of exposure" to tobacco smoke, says Yancy.

Bottom line To protect against heart disease (not to mention cancer, stroke, and reproductive problems), the goal is to smoke exactly zero cigarettes.

8. Blood sugar

Over time, high blood sugar levels associated with diabetes can damage nerves and blood vessels. This can spur the buildup of fat on blood vessel walls, which can impede blood flow and promote atherosclerosis. Having diabetes increases one's risk of cardiovascular disease considerably. Three quarters of those with diabetes die of heart or blood vessel disease.

Your body's ability to use glucose (blood sugar) properly can be tested by getting a fasting blood glucose test, which is a snapshot of your blood sugar at the time, or by getting a hemoglobin A1C test, which measures overall blood glucose over the previous three months. Both can be insightful. "There is data to suggest that there is a significant decrease in the risk of heart and vascular disease with every 1 percent reduction in hemoglobin A1C," says Whiteson.

Bottom line: The more controlled, the better. The normal range for a fasting blood glucose test is typically less than 100 milligrams per deciliter; prediabetes is indicated by a level between 100 and 125 mg/dL and diabetes by a reading of 126 mg/dL or above. A normal hemoglobin A1C level is below 6 percent, and those with diabetes should aim to keep it under 7 percent.

9. C-reactive protein

Inflammation is a process our body uses to fight off an assault, like a cold or injury, in order to heal. But over the long term, chronic inflammation plays a detrimental role to health because the nasty byproducts—inflammatory molecules like cytokines—are believed to be part of several disease processes, including atherosclerosis, obesity, and Alzheimer's disease. In the realm of heart disease, much ado has been made of c-reactive protein, a marker for one's level of inflammation that can be picked up through a blood test called hs-CRP, for high-sensitivity c-reactive protein.

Who should get the test, and what are doctors to do with the results? Those are matters of considerable debate. "We can't treat high [c-reactive protein]," says Whiteson. It's an indicator of potential heart trouble, but medicine doesn't have the tools, via medications or procedures, to bring an elevated c-reactive protein down to normal. It is possible, however, to directly treat other critical risk factors like high blood pressure and high cholesterol. Doing so can bring down the risk of future cardiac events and death. A landmark study from late 2008 found that subjects who did not have heart disease and had normal cholesterol and who took statins had a lower risk of heart attack and stroke and also had fewer angioplasties and bypass surgeries over the course of the study, compared with the group who took a placebo. But too many questions remain about the study to make a blanket statement that folks should be taking statins more liberally.

Bottom line: According to the American Heart Association, a hs-CRP measure of 1 mg/L means you are at low risk of developing cardiovascular disease, a measure between 1 and 3 mg/L means you are at average risk, and levels above 3 mg/L means your risk is high. Getting the test may be helpful, says Yancy, if you are at intermediate risk for heart disease based on other risk factors and your doctors would like another data point to determine treatment. But "there is no need to check CRP if a person already has high risk or truly is in the healthy bracket," he says.

10. Waist circumference

While not a direct measure of heart disease, a high waist circumference tracks with increased risk for high blood pressure, high cholesterol, and diabetes—all of which have a direct impact on heart health. And the bigger the belly, the heavier one tends to be. Obesity, of course, is a well-known risk factor for a range of diseases, including heart disease.

Importantly, a higher waist circumference indicates distribution of fat around the abdomen and packing fat around vital organs, which research has indicated is more dangerous than carrying weight in the thighs or buttocks. Be sure you're measuring properly. The correct waist circumference measurement is taken by wrapping a measuring tape around the natural waist at the belly button, not around the hips.

Bottom line: Men should have a waist circumference of less than 40 inches. The figure for women is less than 35 inches.

11. Body mass index

Your weight matters, but it has to be considered in the context of how tall you are. Body mass index takes the two numbers into account. Like waist circumference, BMI is an indirect measure of risk, but a higher measure correlates with greater risk. The catch, however, is that it is not always entirely accurate. A person in excellent condition who has a lot of muscle mass may have a high BMI.

Too much excess weight is associated with diabetes, heart disease and stroke, some cancers, sleep apnea, osteoarthritis, fatty liver disease, and complications in pregnancy.

Bottom line: People with BMIs less than 18.5 are underweight. Target BMI range is between 18.5 and 24.9. Overweight is considered between 25 and 30, and a BMI above 30 puts you in the obese category.

12. Blood pressure

This one is critical to heart health. According to the National Heart Lung and Blood Institute, 1 in 3 Americans have high blood pressure. When a nurse wraps the cuff around your arm, she's taking a reading of the force on the walls of your arteries, which is subject to fluctuating pressure as the heart beats to push blood through your body. The trouble is, high blood pressure doesn't have any telltale symptoms, so a person might be living with hypertension unknowingly. Over the long haul, elevated blood pressure can damage organs and fuel a cascade of problems.

Action to lower blood pressure can include medications, but diet and exercise can really beat those numbers back into submission. The DASH diet (Dietary Approaches to Stop Hypertension)—high in veggies, fruit, fish, and whole grains but low in red meat fat and sugar—has been shown to lower blood pressure significantly. And research has suggested that the DASH diet packs an especially powerful wallop when people simultaneously work to reduce salt intake, a known blood pressure booster.

Bottom line: "The only number that really matters is 120 over 80," which is the cutoff for a normal blood pressure reading, says Yancy. The more one's blood pressure surpasses that level, the more damage to the vascular system, heart, and kidneys. The top number is called systolic blood pressure and is the measure of pressure while the heart beats. The bottom number is called diastolic and is the measure of pressure between heart beats. A reading above 120/80 but below 140/90 is considered prehypertension; anything above that is high blood pressure. Both require attention and steps to bring the blood pressure back under control.

13. Cholesterol

Your cholesterol level is a measure of the fats circulating in your bloodstream. With out-of-whack cholesterol levels comes greater risk for coronary artery disease and stroke. Reducing saturated fat, trans fat, cholesterol, and total fat can help bring down your cholesterol level. And exercise, says Whiteson, "is one pill that treats all ills. It can touch all risk factors for heart disease," including reducing weight, reducing stress, improving blood sugar profiles, bringing down high blood pressure, and lowering total cholesterol, lowering LDL (the "bad" cholesterol), increasing HDL (the "good" cholesterol), and lowering triglycerides, a type of fat in the blood.

Bottom line: You're aiming for total cholesterol below 200 mg/DL; above 240 mg/DL puts you at twice the risk of coronary artery disease as a person within the normal range. HDL should be above 40 mg/DL for men and above 50 mg/DL for women (women tend to have higher HDL before menopause); above 60 mg/DL is categorized as protective to your heart. LDL ideally should be below 100 mg/DL, though up to 129 mg/DL is near optimal. High LDL is considered 160 mg/DL or above. Triglycerides should be below 150 mg/DL; a measure above 200 mg/DL is considered high.


Article from Sarah Baldauf, USNews.com

2010 AHA Guidelines: The ABCs of CPR Rearranged to "CAB"

October 20, 2010 — Chest compressions should be the first step in addressing cardiac arrest. Therefore, the American Heart Association (AHA) now recommends that the A-B-Cs (Airway-Breathing-Compressions) of cardiorespiratory resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing). 

The changes were documented in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in the November 2 supplemental issue of Circulation: Journal of the American Heart Association, and represent an update to previous guidelines issued in 2005.

"The 2010 AHA Guidelines for CPR and ECC [Emergency Cardiovascular Care] are based on the most current and comprehensive review of resuscitation literature ever published," note the authors in the executive summary. The new research includes information from "356 resuscitation experts from 29 countries who reviewed, analyzed, evaluated, debated, and discussed research and hypotheses through in-person meetings, teleconferences, and online sessions ('webinars') during the 36-month period before the 2010 Consensus Conference."

According to the AHA, chest compressions should be started immediately on anyone who is unresponsive and is not breathing normally. Oxygen will be present in the lungs and bloodstream within the first few minutes, so initiating chest compressions first will facilitate distribution of that oxygen into the brain and heart sooner; starting with "A" rather than "C" adds another 30 critical seconds.

"For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim's airway by tilting their head back, pinching the nose and breathing into the victim's mouth, and only then giving chest compressions," noted Michael R. Sayre, MD, coauthor and chairman of the AHA's Emergency Cardiovascular Care Committee, in an AHA written release. "This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body," he added.

The new guidelines also recommend that during CPR, rescuers increase the speed of chest compressions to a rate of at least 100 times a minute. In addition, compressions should be made more deeply into the chest, to a depth of at least 2 inches in adults and children and 1.5 inches in infants.

Persons performing CPR should also avoid leaning on the chest so that it can return to its starting position, and compression should be continued as long as possible without the use of excessive ventilation.

9-1-1 centers are now directed to deliver instructions assertively so that chest compressions can be started when cardiac arrest is suspected.

The new guidelines also recommend more strongly that dispatchers instruct untrained lay rescuers to provide Hands-Only CPR (chest compression only) for adults who are unresponsive, with no breathing or no normal breathing.

Other Key Recommendations

Other key recommendations for healthcare professionals performing CPR include the following:

    * Effective teamwork techniques should be learned and practiced regularly.
    * Quantitative waveform capnography, used to measure carbon dioxide output, should be used to confirm intubation and monitor CPR quality.
    * Therapeutic hypothermia should be part of an overall interdisciplinary system of care after resuscitation from cardiac arrest.
    * Atropine is no longer recommended for routine use in managing and treating pulseless electrical activity or asystole.

Pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of continuous CPR. The new guidelines also discuss resuscitation of infants and children with various congenital heart diseases and pulmonary hypertension.

Toothbrushing Less Than Twice a Day Linked to Increased Cardiovascular Risk

June 7, 2010 — Individuals who do not brush their teeth twice a day have an increased risk of heart disease, a new study shows.

The study was published online May 27, 2010 in BMJ; corresponding author is Prof Richard Watt (University College London, UK).

The researchers note that while it has been established that inflammation in the body (including mouth and gums) plays an important role in the buildup of atherosclerosis, this is the first study to investigate whether the number of times individuals brush their teeth has any bearing on the risk of developing heart disease.

They analyzed data from more than 11 000 adults who took part in the Scottish Health Survey, in which individuals were asked about lifestyle behaviors such as smoking, physical activity, and oral health routines. Questions asked included how often they visited the dentist and how often they brushed their teeth (twice a day, once a day, or less than once a day). Information was also collated on medical history and family history of heart disease and blood pressure. Blood samples were taken from a subgroup of participants and tested for C-reactive protein (CRP) and fibrinogen levels. The data gathered from the interviews were linked to hospital admissions and deaths.

Results showed generally good oral hygiene practices, with 62% of participants saying they visited the dentist every six months and 71% reporting that they brushed their teeth twice a day. After adjustment for established risk factors, it was found that participants who reported less frequent toothbrushing had an increased risk of heart disease compared with people who brushed their teeth twice a day. Participants who had poor oral hygiene also had increased levels of CRP and fibrinogen.

Hazard Ratio for Cardiovascular Events (Fatal and Nonfatal) Relative to How Often Teeth Are Brushed Each Day
Frequency of toothbrushing HR* (95% CI)
Twice a day 1.0
Once a day 1.3 (1.0–1.5)
Less than once a day 1.7 (1.3–2.3)
p for trend 0.001

*Adjusted for age, sex, socioeconomic group, smoking, physical activity, visits to dentist, body-mass index, family history of cardiovascular disease, hypertension, and diabetes

The researchers say: "To the best of our knowledge, this is the first study to show an association between a single-item self-reported measure of toothbrushing and incident cardiovascular disease in a large representative sample of adults without overt cardiovascular disease."

They add: "Our study suggests a possible role of poor oral hygiene in the risk of cardiovascular disease via systemic inflammation. Raised inflammatory and homoeostatic responses as well as lipid metabolism disturbance caused by periodontal infection might be possible pathways underlying the observed association between periodontal disease and the increased risk for cardiovascular disease."

But they note that further studies are needed to confirm whether the observed association between oral health behavior and cardiovascular disease is in fact causal or merely a risk marker.

References

1. de Oliveira C, Watt R, and Hamer M. Toothbrushing, inflammation, and risk of cardiovascular disease: Results from Scottish Health Survey. BMJ 2010; DOI:10.1136/bmj.c2451. Available at: http://www.bmj.com.

Additional Information

Information about oral hygiene and cardiovascular risk is available online on the National Institute of Dental and Craniofacial Research Web site
Clinical Context

Systemic inflammation plays a role in cardiovascular events, and a previous study by Danesh and colleagues, which was published in the July 22, 2000, issue of the BMJ, found that certain serum markers of inflammation were independent predictors of the risk for coronary heart disease events. Specifically, CRP and serum amyloid A protein were significantly associated with the risk for nonfatal myocardial infarction or coronary heart disease death, even after a multivariate analysis. The serum white blood cell count and albumin levels were not significantly associated with coronary heart disease risk.

Periodontal disease is associated with a moderate systemic inflammatory response. The current study explores the relationship between oral hygiene behavior and inflammatory response as well as the risk for cardiovascular disease.
Study Highlights

* Data were drawn from the Scottish Health Survey administered in 1995, 1998, and 2003. The survey is a broad questionnaire of health behaviors and outcomes among adults 35 years and older.
* Participants who were edentulous (no natural teeth) or had existing cardiovascular disease were excluded from the current analysis.
* Researchers of the current study specifically examined oral hygiene behaviors and their relationship to a composite of cardiovascular diagnoses, which were derived from hospital discharge and death certificate databases. These diagnoses included myocardial infarction, coronary artery bypass surgery, percutaneous coronary angioplasty, stroke, and heart failure.
* The main study outcome was adjusted to account for other cardiovascular risk factors.
* Researchers also examined the relationship between oral hygiene and 2 serum markers of systemic inflammation: CRP and fibrinogen.
* 11,869 individuals provided study data. The mean age was 50 years old, and 46.1% of participants were men.
* 62% of participants reported visiting a dentist at least every 6 months, and 71% said they brushed their teeth twice a day.
* Participants who brushed their teeth less than twice a day were more likely to be older and have a higher number of cardiovascular risk factors.
* There were 555 cardiovascular events during an average of 8.1 years of follow-up.
* Compared with participants who brushed their teeth twice daily, individuals who brushed less often than once a day experienced a significant multivariate hazard ratio of 1.7 for cardiovascular events. The adjusted hazard ratio among patients who brushed once a day was 1.3, a result of borderline significance.
* The risk for cardiovascular disease related to poor oral hygiene was similar among men and women, and it also did not differ by age or smoking status.
* Mean levels of CRP among participants who brushed twice daily, once daily, and less than once daily were 3.07, 3.51, and 4.18 mg/L, respectively. The respective fibrinogen levels were 2.86, 2.95, and 2.98 mg/L.
* Further analyses indicated that these markers of systemic inflammation at least partly mediated the risk for cardiovascular events associated with poor oral hygiene.

Clinical Implications

* A previous study found that serum levels of CRP and amyloid A protein, but not the white blood cell count or albumin level, were positively and independently associated with the risk for coronary heart disease events.
* The current study suggests that toothbrushing less than twice daily might independently increase serum markers of systemic inflammation as well as the risk for cardiovascular disease.


From Heartwire CME © 2010 Medscape, LLC

Super Foods for Men and Women

Guess what? You have different nutritional needs than the opposite sex. Discover the best foods for you both.

One in five women have a history of painful urinary tract infections. "I had three in one year," says Patty Buxton*, a Colorado middle-school teacher. Reading that cranberry juice may help prevent these infections, Buxton went on a regimen a year ago, and since then she's been infection-free. She thinks cranberry juice did the trick.


Cranberry juice isn't the only food that offers protection from specific illnesses. Here's a list of disease-fighting foods for men and women.

Foods for Men

1. Tomato Sauce.
Men who eat a lot of tomatoes, tomato sauce, or pizza smothered with the stuff may be giving themselves a hedge against prostate cancer. So say researchers at Harvard, who studied the eating habits of more than 47,000 male health professionals. They found that men who ate tomato sauce two to four times per week had a 35 percent lower risk of developing prostate cancer than men who ate none. A carotenoid called lycopene, which tomatoes contain in abundance, appeared to be responsible. But scientists were puzzled: tomato juice didn't seem to have a protective effect. Other research showed why. For best absorption, lycopene should be cooked with some kind of fat. So pizza may be just what the doctor ordered.

2. Oysters.
Myth has it that oysters are the food of love. Science may agree. Just two to three oysters deliver a full day's supply of zinc, a mineral critical for normal functioning of the male reproductive system. Scientists are divided over reports that sperm counts have declined over the last 50 years and that environmental factors are to blame. Nutritional deficiencies do seem to be the cause of certain cases of low testosterone. Getting adequate zinc is sometimes the answer (11 mg per day is recommended for men; more than 40 mg can pose risks). In one trial, 22 men with low testosterone levels and sperm counts were given zinc every day for 45 to 50 days. Testosterone levels and sperm counts rose.


3. Broccoli.
A recent Harvard study finds that cruciferous vegetables, like broccoli, may protect against bladder cancer. It's one of the most common cancers in this country, and affects two to three times as many men as women. Scientists analyzed the diets of nearly 50,000 men and discovered that those who ate five servings or more per week of cruciferous veggies were half as likely to develop bladder cancer over a ten-year period as men who rarely ate them. And broccoli and cabbage were singled out as the most protective foods.

4. Peanut Butter.
If you want a healthy heart, spread your morning toast with peanut butter. Heart disease is the leading killer of men and women, but men fall victim at an earlier age. Researchers from Pennsylvania State University compared the cholesterol-lowering effect of the American Heart Association's Step II Diet with a higher-fat diet based on peanuts. The AHA plan included more carbohydrates. The peanut regimen was 36 percent fat. After 24 days both diets lowered "bad" LDL cholesterol. But the peanut plan also caused a drop in blood fats called triglycerides and did not decrease HDL, the "good" cholesterol. The AHA diet raised levels of triglycerides and lowered levels of HDL.

"Peanut butter is a little higher in fat," says Penny Kris-Etherton, Ph.D., the lead author of the Penn State study. "But it's the type that's good for you -- monounsaturated fat." Researchers have predicted that the peanut diet could reduce heart-disease risk even more than could the AHA diet. Just don't go nutty plastering on the tasty spread, since it is high in calories.


5. Watermelon.
Until the age of 55, more men suffer from high blood pressure than do women. Research suggests that foods rich in potassium can reduce the risk of high blood pressure and stroke. The evidence is so convincing that the Food and Drug Administration recently allowed food labels to bear a health claim about the connection between potassium-rich foods and blood pressure. "There isn't a dietary requirement for potassium," says Kathleen Cappellano, nutrition-information manager at Tufts University in Boston. "But a good goal is about 2000 milligrams or more a day." Watermelon, a rich source of this mineral, has more potassium -- 664 mg -- in one large slice than the amount found in a banana or a cup of orange juice. So cut yourself another slice and enjoy the taste of summer.

Foods for Women

1. Papaya.
This tropical fruit packs about twice the vitamin C of an orange. Add it to your arsenal against gallbladder disease, which afflicts twice as many women as men.

After analyzing the blood of over 13,000 people, scientists from the University of California, San Francisco, found that women who had lower levels of vitamin C were more likely to have gallbladder illnesses. One medium papaya (about ten ounces), with its 188 mg of vitamin C and a mere 119 calories, is a refreshing source of the vitamin. The once exotic fruit now can be found in most supermarkets.

2. Flaxseed.
Bakers use this nutty-flavored seed mainly to add flavor and fiber. But scientists see the tiny reddish-brown seed, rich in estrogenlike compounds called lignans, as a potential weapon against breast cancer. An exciting report at last year's San Antonio Breast Cancer Symposium showed that adding flaxseed to the diet of women with breast cancer effectively slowed tumor growth. You can flavor your muffins with flaxseed, but the easiest way to get the beneficial lignans is to sprinkle a few tablespoons of ground flaxseed on your morning cereal. Look for the seeds in health food stores or in supermarkets on the flour aisle. They're easy to grind in a blender or coffee grinder. But get seeds -- there are no lignans in the oil.


3. Tofu.
Foods high in soy protein can lower cholesterol and may minimize menopausal hot flashes and strengthen bone. Isoflavones, plant chemicals in soybeans that have a structure similar to estrogen, may be the reason. Though animal studies form the bulk of the evidence, a human study found that 90 mg of isoflavones was beneficial to bone (specifically the spine). And two other studies suggest that 50 to 76 mg of isoflavones a day may offer some relief from hot flashes. A half-cup of tofu contains about 25 to 35 mg of isoflavones.

4. Buffalo Meat.
Due largely to menstruation, women tend to be anemic more than men. And low iron levels in blood can cause severe fatigue. To get a good dose of iron, try bison. Bison, or buffalo, meat is lean and has what diet-conscious women want -- lots of iron and less fat than most cuts of beef. "The iron content is about 3 milligrams in a 3 1/2-ounce uncooked portion," says Marty Marchello, Ph.D., at North Dakota State University. "That portion contains less than 3 grams of fat." Buffalo meat can help boost energy and lower weight. And you don't have to have a home on the range to get some bison anymore. You can pick it up at many supermarkets across the United States, or through mail order or on the Internet.


5. Collard Greens.
This humble vegetable may help fight osteoporosis, which afflicts many women late in life. In addition to getting adequate amounts of calcium and vitamin D, some studies suggest that vitamin K may have a bone-protective effect as well. Based on data from one of the largest studies of women, the Nurses' Health Study, researchers discovered that women who ate enough vitamin K-rich foods (at least 109 micrograms of the vitamin daily) were 30 percent less likely to suffer a hip fracture during ten years of follow-up than women who ate less. Researchers point out that dark-green leafy vegetables -- Brussels sprouts, spinach, broccoli -- are all good sources of the vitamin. But collard greens, with about 375 micrograms per half-cup, are among the best.

There you have it: five great foods for women and for men that can keep both of you well fed and healthy too.

By Maureen Callahan of Yahoo Shine

New Physicians at Increased Risk for Depression During Internship

From the Arch Gen Psychiatry. Published online April 5, 2010.

April 7, 2010 — The percentage of new clinicians who develop depressive symptoms increases significantly during medical internship, new research suggests.

A large prospective study showed a marked increase in depressive symptoms among new clinicians — from 3.9% at baseline to an average of 25.7% (P < .001) during internship — as reflected by increases in the 9-item Patient Health Questionnaire (PHQ-9).

Srijan Sen, MD, PhD, University of Michigan, Ann Arbor, and colleagues also found that 41.8% of participants met criteria for major depression at one or more quarterly assessments.

On stepwise linear regression analysis, neuroticism (P < .001), personal history of depression (P < .001), lower baseline depressive symptoms (P < .001), female sex (P = .03), US medical education (P = .005), and a difficult early family environment (P = .04) significantly correlated with a change in depressive symptoms.

"When myself and coinvestigator Constance Guille were interns 4 years ago, we noticed that people who were well adjusted and happy a few months before were having trouble sleeping and problems with their relationships and just struggling to adjust, so it struck us that these problems were very common during internship," Dr. Sen told Medscape Psychiatry.

"And while I think internship will always be a stressful time, there are things that we may be able to do to make it better for interns, including working fewer hours and using electronic records to reduce the risk of errors and making sure interns have some resources in place before they become depressed to reduce the effects of stress," he added.

The study was published online April 5 in the Archives of General Psychiatry.

No Link to Medical Specialty or Age

For the study, investigators recruited a total 1271 interns entering traditional and primary care internal medicine, general surgery, pediatrics, obstetrics-gynecology, and psychiatry residency programs during the 2007-2008 and 2008-2009 academic years. Depressive symptoms were measured using the depression module of the PHQ-9, where the total score ranges from 0 to 27. The PHQ-9 scores of 10 to 14 correspond to moderate depression, scores between 15 and 19 to moderately severe depression, and scores of 20 or greater to severe depression.

Mean PHQ-9 scores increased significantly from 2.38 at baseline to 6.70 at 3 months, 6.48 at 9 months, and 6.26 at 12 months (all P < .001 vs baseline). The percentage of subjects meeting criteria for moderately severe depression increased from 0.7% at baseline to 6.6%, 6.2%, 7.8%, and 7.6% at 3-, 6-, 9-, and 12-month points of the internship, respectively, the investigators add.

Similarly, the percentage of interns who met criteria for severe depression increased from 0% at baseline to 2.3%, 1.6%, 1.8%, and 0.8% at 3, 6, 9, and 12 months of internship, respectively. Investigators also assessed factors during internship that were associated with a change in depressive symptoms.

The 3 key variables that were associated with a significant increase in the risk for depressive symptoms were work hours (P < .001), reported medical errors (P < .001), and noninternship stressful life events (P < .001).

Interestingly, medical specialty and age were not associated with the development of depression.

5-HTTLPR Moderates Stress and Depression Response

Investigators also used internship as a model to explore the relationship between a serotonin transporter promoter polymorphism and stress in the development of depression.

"We found evidence that this variant moderates the response to stress in European American subjects, with subjects carrying at least one low-functioning 5-HTTLPR allele reporting a 43% greater increase in depressive symptoms than subjects with two low-functioning alleles," the study authors write.

European American participants with 2 high-functioning 5-HTTLPR alleles who met criteria for depression increased from 5.1% before internship to 36.2% at its highest during internship. Investigators also found that the association between 5-HTTLPR and the development of depressive symptoms under stress was moderated by neuroticism and work hours, although not with medical errors or stressful life events.

"Medical internship provided us with the unique situation where we know that a group of people currently under low stress will enter a period of high stress, and we showed that 5-HTTLPR had no effect on depression under the low stress conditions but was strongly associated with depression under high stress," Dr. Sen told Medscape Psychiatry. "So in my view, this provides strong evidence that 5-HTTLPR moderates the relationship between stress and depression, [although] the effect of this one genetic variant is relatively small compared with other factors, such as work hours, gender, and prior history of depression."

Stressful Experience

Gregory Dalack, MD, University of Michigan, Ann Arbor, agreed that internship is clearly a stressful experience, "as all of us who went through it know."

"Nevertheless," he said, "depressive symptoms detected in this cohort of interns were self-reported, which is different than detecting symptoms with a clinical diagnosis, because with a clinical diagnosis, physicians can rule out ongoing substance abuse problems or other medical conditions that may be contributing to symptoms such as sleep disturbances, which on self-reported questionnaires may be mistakenly attributed to depression."

Dr. Dalack also noted that a number of organizations have already put forward suggestions that are intended to reduce stress among interns, including limitations of hours worked. Currently, interns are still allowed to work 80 hours per week.

"They are following these recommendations prospectively to make sure hospitals are putting systems in place so that residents are not overworked, and while there may be transgressions from the rules under some circumstances, there is a higher level of scrutiny now in place to make sure people stay within those limits so as to reduce interns’ fatigue and depression and maintain a high level of quality care for patients," he said.

The study was supported by a Donaghue Foundation Clinical and Community Grant, an American Psychiatric Association Substance Abuse and Mental Health Services Administration grant, a Veterans Administration Research Enhancement Award Program award, and an American Foundation for Suicide Prevention Young Investigator grant.

Soft Drink Consumption Linked to Pancreatic Cancer

February 16, 2010 — The regular consumption of sugar-laden soft drinks could boost a person's risk of developing pancreatic cancer. The results of a new study found that individuals who consumed 2 or more soft drinks per week had an 87% increased risk for pancreatic cancer, compared with those who did not.

Even after taking factors such as smoking, caloric intake, and type 2 diabetes mellitus into account, the authors found that consuming soft drinks might play an independent role in the development of pancreatic cancer.

The finding is reported in the February issue of Cancer Epidemiology, Biomarkers & Prevention.

Both soft drinks and fruit juices have a high glycemic load relative to other foods and drinks, and it has been hypothesized that both are risk factors for pancreatic cancer. The high levels of sugar can increase levels of insulin in the body, and this can contribute to pancreatic cancer cell growth, the researchers explain.

Association Not Seen With Fruit Juice

However, this study did not find an association between consumption of juice and an increased risk for pancreatic cancer.

"There are several plausible explanations why fruit juice was not significantly associated with pancreatic cancer," said first author Noel Mueller, MPH, a research associate at Georgetown University Medical Center in Washington, DC.

One reason is that the finding was based on a relatively small number of cases, so there might have been too few cases to detect an effect with fruit juice, he explained. Another is that there are differences between soft drinks and fruit juice — fruit juice is lower in sugar, includes many nutrients, and is typically served in smaller portion sizes.

A third explanation is that fruit juice intake is associated with healthier lifestyle characteristics than soft drink intake, he said.

The consumption of soft drinks coincided with a number of other unhealthy lifestyle characteristics, making it somewhat difficult to separate smoking, caloric intake, body weight, and type 2 diabetes mellitus from soft drink consumption. "But the findings from our study suggest that soft drinks may play an independent role in the development of pancreatic cancer," Mr. Mueller told Medscape Oncology.

"The influence of soft drink intake on the risk of pancreatic cancer remained virtually unchanged after adjustment for smoking status, energy intake, body weight, and type 2 diabetes mellitus," he added.

Results Statistically Significant for Soft Drinks

The current study examined the association between the consumption of soft drinks and juice and the risk for pancreatic cancer among Chinese people residing in Singapore. The data came from the Singapore Chinese Health Study (n = 60,524), and information regarding the consumption of soft drinks, juice, and other dietary items, along with lifestyle factors and environmental exposures, was collected at recruitment to the study. The participants were followed for up to 14 years.

At the start of the study, 9.7% of the participants consumed at least 2 soft drinks per week and 10.2% consumed at least 2 servings of juice per week. The authors note that, compared with those who did not consume soft drinks, those who consumed 2 or more soft drinks per week were younger, were more likely to be men, and were more likely to smoke cigarettes. They also had higher levels of education, alcohol consumption, and total energy intake; lower levels of physical activity; and consumed more total carbohydrates, fat, added sugar, and red meat.

Individuals who reported consuming 2 or more juice drinks a week had lifestyle and dietary habits that were similar to those who consumed soft drinks. However, there was no association between juice intake and cigarette smoking, and body mass index (BMI) was comparable across different categories of soft drink and juice consumption.

At 14 years and a cumulative 648,387 person-years of follow-up, 140 incident pancreatic cancers developed in people who were cancer free at baseline. After adjustment for confounders such as BMI, type 2 diabetes mellitus, and fruit juice intake, the authors found that those consuming 2 or more soft drinks per week experienced a statistically significant increased risk for pancreatic cancer (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.10 - 3.15).

Although people who consumed 2 or more juice drinks a week had an increased risk for pancreatic cancer of approximately 30%, elevated HR was not statistically significant after adjustment for variables.

However, in an age-adjusted analysis, smoking was also a risk factor. After excluding former smokers, the authors found that current smokers had a 49% increased risk for pancreatic cancer, compared with never smokers (HR, 1.49; 95% CI, 0.98 - 2.27). This risk factor remained unaffected after adjustment for diabetes and BMI.

Can Be Extrapolated to United States and Europe

Singapore is a highly industrialized nation with lifestyle and nutritional patterns reminiscent of many westernized countries. In that sense, these findings could be extrapolated to the United States and Europe, explained Mr. Mueller. Soft drinks are the leading source of added sugar in the American diet, the authors note.

"However, there are inherent differences between Singaporean Chinese and Caucasians, which is why one must be cautious when generalizing these results to the United States and Europe," he said. "But it is important to note that other studies in Caucasian populations have suggested that soft drink intake may increase risk for pancreatic cancer."

Because pancreatic cancer is a relatively rare disease, the number of cases in this study was relatively small, the authors point out. This limited the statistical power of the study. Another limitation was the inability to collect repeated dietary measurements during the course of the study; therefore, they could not account for changes in consumption of soft drinks and juices.

However, this study adds to the evidence that soft drink consumption plays a role in the development of pancreatic cancer, they conclude, and that "clinical studies examining biomarkers for glycemia and insulinemia and taking a mechanistic approach to the question of soft drink consumption and pancreatic cancer are warranted."

There is "still much to understand on the link between sugar-sweetened beverages and pancreatic cancer," the authors write.

The study was supported by a grant from the National Cancer Institute. The researchers have disclosed no relevant financial relationships.