VA Hospital Counter

[2] Community Update

 1. Is living alone hurting your heart?

Living without a roommate or spouse may sometimes feel like complete freedom. However, a new study suggests that living by yourself may double your risk of serious heart disease.

Researchers from the University of Aarhus, Denmark, have found that women over the age of 60, and men over the age of 50, who lived alone were twice as likely to have acute coronary syndrome, a condition that may include severe angina, heart attack or sudden cardiac death.

"High age and single living are the strongest predictors of acute coronary syndrome," write the researchers in the Journal of Epidemiology and Community Health.

For this study, researchers tracked the health status of over 138,000 men and women between the ages of 30 and 69 for two years. During this time-period, 646 people were diagnosed with at least one symptom of acute coronary syndrome.

After looking at the factors that seemed to be tied to these heart conditions low education levels and living on a pension were seen as somewhat linked to an increased risk. However, living alone and age were most strongly linked to this risk. In fact, while women who lived alone comprised only 5 percent of the female study population, they accounted for one-third of all deaths from acute coronary syndrome within 30 days of diagnosis.

The lone men, who were only 8 percent of the male population in the study, accounted for two-thirds of all male deaths. But, while living alone does not seem to be heart-healthy, women divorcees seemed to enjoy a lower risk of this syndrome, along with those who worked and had a high level of education.

The authors speculate that living alone tends to promote certain unhealthy traits, like obesity, high cholesterol and fewer doctors' visits, making their heart disease risk that much higher. Additionally, social support may be less available to persons living by themselves.

Source: http://www.healthology.com

2. Sacrifices in a relationship mean more if made for the right reason

If you do something positive for your mate, does it matter why? The answer is "Yes".

Assistant research professor Heather Patrick (University of Rochester) unveiled the results of a study at The Third International Self-Determination Theory (SDT) conference held at the University of Toronto, Canada, 24-27 May 2007.

The research shows that both small sacrifices, like doing the dishes for your partner, and big ones, like moving across the country for a new job he or she really wants, mean more if you do them because you genuinely want to.

Patrick was one of more than 300 researchers from 25 countries who attended the Toronto conference and shared their work within Self-Determination Theory (SDT) developed by Edward Deci (Gowen Professor in Social Sciences) and Richard Ryan (Professor of Psychology, Psychiatry and Education) of the University of Rochester.

The conference featured theoretical overviews by SDT founders, Edward Deci and Richard Ryan, as well as other senior invited keynote speakers discussing this ground breaking psychological theory of human motivation.

In the SDT program, students are viewed as essential to the growth and development of this theory. Besides presenting work, the conference is a unique opportunity for students to interact with established researchers and develop their skills in an optimally supportive environment. Thus, faculty and students have ample opportunities to present their work and make important pathways into future work together.

To answer one of the most common conundrums of romantic relationships, Patrick asked 266 men and women in relationships to document their own, or their partner's, pro-relationship behaviours (PRB) for two weeks. Pro-relationship behaviour was classified as "any sacrifice or accommodation made out of consideration for one's partner or one's relationship".

In this connection, Patrick found that partners who engaged in PRB because they wanted to--not because they felt pressured or obligated to--were more satisfied in their relationships, more committed to them, and felt closer to their mates following PRB experiences.

Patrick says her research has practical applications. She sees it being used for individual and couples therapy. She says this new information gives couples and psychology professionals an insight into why some relationships are not fulfilling even when everything looks okay on the surface. "It is important to understand what makes positive relationships positive and what might undermine positive experiences," says Patrick.

In addition, along with Patrick, Richard Ryan Edward Deci and a fourth researcher Geoffrey Williams (Associate Professor of Medicine from the University of Rochester School of Medicine and Dentistry), presented other findings. These new findings demonstrate that patient involvement in a quit plan leads to smokers who are more motivated to quit because they genuinely want to, not because they are being nagged or bullied into kicking the habit. Williams said that this method has also proved successful for patients managing diabetes, weight loss, and dental care.

Both Patrick's and Williams' research illustrates the crux of the Self-Determination Theory: A self-motivated person derives more satisfaction in completing a given task, and is more likely to do it well. The research presented at the conference also explored motivation in human development, education, work, relationships, sports, health, medicine, virtual environments, psychotherapy, and cross-cultural applications.

Source: http://www.medicalnewstoday.com/medicalnews.php?newsid=72126

 

Book Review

Better: A surgeon's notes on performance
Atul Gawande, Metropolitan Books: New York, New York, USA.2007. 288p. ISBN: 978-0-8050-8211-1

In Better: a surgeon's notes on performance, author Atul Gawande investigates human performance in medicine.

[Atul Gawande is best-selling author of Complications: a surgeon's notes on an imperfect science, and general and endocrine surgeon at Brigham and Women's Hospital and assistant professor at Harvard Medical School and Harvard School of Public Health]

Gawande takes the reader to courtrooms, clinics, war zones, and execution chambers to demonstrate the incredible environments in which doctors care for and treat patients. While drawing on a vast array of sources, including his own personal experience, Gawande interweaves into nearly every chapter fascinating vignettes about the most important person in his view of medicine: the patient. By ensuring that every message is personalized in this manner he brings a warm, humane touch to this superb book.

Gawande defines "three core requirements" for successful performance in medicine -- diligence, doing right, and ingenuity -- and in turn considers specific problem areas in each. He cites three distinct examples in which diligence is essential to the successful execution of medical therapy: (i) the WHO's mop-up of a polio outbreak in rural India; (ii) the efforts of the US military's medical staff to save the lives of servicemen seriously injured in Iraq; and (iii) the work of infection-control specialists to ensure hand washing to prevent the spread of hospital-acquired infections. The numbers cited in each example are impressive and daunting: 4.2 million Indian children vaccinated by 37,000 vaccinators over three days; 60 to 70 surgeons supporting the 130,000 troops fighting in Iraq (where injuries are horrific); 2 million Americans contracting hospital-acquired infections per annum. All of these efforts are demonstrably linked by the almost obsessive diligence of the clinicians responsible and their need to "make a science out of performance."

When considering doing right, the author tackles a number of compelling issues, including the litigious nature of American society toward health care providers. We are introduced to two interesting individuals, a physician colleague of Gawande's whose son was harmed by medical error and an ex-clinician now practicing as a medical malpractice lawyer, and thus gain novel insight into the difficulties associated with rectifying the occasional harm that may inevitably result from health care.

Gawande's approach is novel and intelligent and allows all parties to consider this taxing area from enlightened viewpoints. As he declares, litigation is a "singularly unsatisfactory solution," bringing out the worst in everyone and often failing to help those injured by medical error. The search continues for more productive ways of recompensing victims, but creative potential solutions are offered and are worthy of consideration.

Gawande moves on to consider what may be the most controversial topic in the book: the role of physicians in state-sanctioned executions. "Doctor D" is an anti--capital punishment activist who has supervised the executions of six of his "patients" and who donates his entire fee for this service to a children's shelter. He considers those on death row to be "legally" terminally ill and thus feels a responsibility to ensure their final minutes are as pain free as possible. The paradox is intriguing, and Gawande is not judgmental. His moral indignation at the very thought of colleagues participating in this process rescinds to a realization that the ethical issues are perhaps more complex than first thought, a realization we share as readers.

Finally, ingenuity is addressed as a matter "more about character and less about superior intelligence". The near-obsessive nature required not only to attain excellence but to then perpetually evolve to stay ahead is illustrated by the fascinating tale of LeRoy Matthews and Warren Warwick, pediatricians who led the development of centers of expertise for cystic fibrosis. As fellow clinicians, we find these stories describing phenomenal improvements in patients' results through the targeted efforts of a few doctors to be inspirational and to serve as examples of what can be achieved if a culture of intellectually rigorous self-improvement is adopted within a unit. However, the next logical step is to question why we are not all this way. Gawande does not shrink from considering this bell curve of clinician performance and how it applies to his surgical practice and medicine as a whole. We are in an uncomfortable period for clinicians, as more and more of our work is subject to public scrutiny and objective assessment, a situation that meets with significant opposition from many colleagues. How, when, and by whom should this grading occur? Will being in the below-average group be used against us? Will those at the bottom be remunerated less than those at the top? Answers are not offered to all these questions, but as fellow surgeons, we share the author's only definitive conclusion -- that there is no shame in being average, but settling for average is unacceptable.

Better opens a door to the oft-closed world of medical performance for careful scrutiny, explores variations in standards of clinical practice, and challenges all involved in health care to adopt the role of "positive deviant." By refusing to flinch when faced with controversy, Gawande has created an essential text for both patients and their doctors, to the betterment of us all.

And so, with this book, Gawande inspires all of us, doctor or not, to be better.

References

Ara Darzi and Oliver Warren (Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Imperial College London),

J Clin Invest. 2007 June 1; 117(6): 1454. 2007, American Society for Clinical Investigation, http://www.pubmedcentral.nih.gov/

 

News

Proper Pill-Taking: Reading Drug Labels

The Australian Therapeutic Goods (ARTG) Act 1989 came into operation in February 1991. The TGA carries out a range of assessment and monitoring activities to ensure therapeutic goods available in Australia are of an acceptable standard with the aim of ensuring that the Australian community has access, within a reasonable time, to therapeutic advances.

Therapeutic goods are divided into groups of "medicines" and "medical devices". Some medicines are limited to prescription-only while others are available without a prescription. Non-prescription medicines are sometimes termed as "complementary medicines" (OCM) or "over-the-counter" (OTC) medicines and may be listed or registered in the ARTG. These guidelines are solely concerned with OTC medicines. Some OTC medicines (eg. sunscreens) are normally list-able but the majority is registrable. Information on registration and listing is available on the TGA website at http://www.tga.gov.au/

The Australian Regulatory Guidelines for OTC medicines came into effect in July 2003. Medicines are evaluated by one of three regulatory units: OTC Medicines Section (OTC); Office of Complementary Medicines (OCM); and Drug Safety and Evaluation Branch (DSEB). The criteria for deciding which of these units evaluates a particular medicine are set out in Schedule 10 to the Therapeutic Goods Regulations.

The TGA has proposed placing strong warning labels on many over-the-counter painkillers, cautioning patients about the risks of possible liver failure from taking them too often.However, some Australians take these drugs in combination, and overdoses can lead to deaths every year from complications such as liver failure. The risks of liver failure are particularly high in people over the age of 60 with a history of ulcers or stomach bleeding.

A warning label is proposed in all bottles of aspirin, ibuprofen, naproxen and ketoprofen, drugs known to cause stomach bleeding from overuse, which can lead to liver failure. Whether the placement of a warning label on these drugs will deter everyone from overusing the drugs remains to be seen. However, this move highlights the importance of reading and understanding drug labels on both over-the-counter and prescription medications.

Over-the-Counter Drug Safety
Consumers often get their information from media and the Internet. They can be misled especially when they misinterpret the results of clinical trials making exaggerated claims of health benefits. Those who rely on such popular, but simplistic, information can reach false and sometimes dangerous conclusions.

In this connection, Michael S. Wolf, professor of medicine at Northwestern University Feinberg School of Medicine, says, "Over-the-counter drugs are held to a higher bar, because there is no physician intermediary."

For a medication to become available over-the-counter, it has to be proven to be safe and effective. However, just because a drug is safe when taken by itself, does not mean it is safe in combination with other drugs. So, every time an over-the-counter drug is purchased, we need to read its label. Here is what we should look for and what it means.

• Active Ingredient The active ingredient is the chemical in the medicine that interacts with the body to improve symptoms. It is always the first thing listed on an over-the-counter drug label.

• Uses Sometimes called "indications," this section lists only the symptoms the drug is approved to treat.

• Warnings This section tells what other medications, foods or situations (like driving) may be needed to avoid when using this medication. If a medication is listed in this section, its "active ingredient" will be named, not its brand name.

• Directions This section tells the amount to take and how often. Follow this section carefully to avoid overdose.
• Other Information This section is about any special storage requirements for the medication. For example, many drugs should be kept out of direct sunlight or away from heat to prevent them from becoming inactive.

Prescription Label Problems
Reading prescription labels can be even trickier than reading OTC medication labels.

In a study, Wolf surveyed 395 English-speaking patients in doctors' waiting rooms about various prescription labels. The results of the study published in the Annals of Internal Medicine, indicate that only 34 percent of those surveyed (who were determined to have a low degree of literacy) were able to correctly demonstrate what was meant by the directions "take two tablets by mouth twice daily."  Worse, more than one-third of patients who were judged to have average literacy (at grade level) could not understand at least one of the medication directions given to them.

Wolf adds "... This is cause for concern, because patient misunderstanding could be a potential source of medication error. Often, the cause for misunderstanding prescription labels is that patients do not take enough time to read the directions carefully and think about what they mean before they start popping the pills. The potential for a patient to take one drug incorrectly is troubling, but many patients take a variety of drugs, and juggling various prescription schedules can lead to this misunderstanding having an even greater impact.

"It is possible that as patients take more prescription medications, the complexity and possible confusion of managing multiple instructions may be greater." Therefore, Wolf recommends that pharmacists and doctors be more explicit when explaining how a drug should be taken, and also ask patients to repeat the instructions given to them.

Wolf adds "... "More important, that patients themselves take responsibility and take the time to ask their doctor about the drug they are taking and its side effects, and also ask the same questions at the pharmacy."

References

Australian Regulatory Guidelines for Over-the-Counter (OTC) Medicines, July 2003, http://www.tga.gov.au/docs/pdf/argom.pdf

Michael S Wolf & Terry C Davis, 2006. Prescription Label Problems, Annalsof Internal Medicine, 29 November 2006.

Prescription drug labels often misunderstood. In: Ed Edelson,HealthDay News, 1 December 2006, HealthonNet Foundation, http://www.hon.ch/,

Terry C Davis, Michael S Wolf et al, 2006. Literacy and Misunderstanding Prescription Drug Labels, Annalsof Internal Medicine, Volume 145: Issue 12, 19 December 2006.

Monika Bhatia
Editor, Health and Ageing

20 June 2007