Many Don't Tell Their Doctor They Feel Depressed

September 13, 2011 — More than two-fifths of adults may not tell their doctor that they have been feeling depressed, according to a survey.

The reasons vary, but many are concerned that their doctor would prescribe an antidepressant that they don't want to take. Other reasons include the belief that it is not the job of a primary care doctor to address emotional issues and concerns about keeping medical records confidential.

Regardless of why people don't want to talk about depression, the result is the same: Depression falls under the radar.

The new findings are published in the Annals of Family Medicine.

"It is clear that left to their own devices, many patients will not report important symptoms spontaneously," conclude the study researchers, who were led by Robert A. Bell, PhD, of the University of California at Davis. "This finding underscores the need to develop and test office-based interventions that address these patient concerns and motivate disclosure of depression."

Bell and colleagues surveyed 1,054 California residents by telephone. The participants were asked why they wouldn't tell their primary care doctor about any symptoms of depression and about their beliefs about depression.

Of those surveyed, 43% gave at least one reason for not discussing depression with their primary care doctor.

Past history of depression played an important role in how people answered the survey questions. For example, people with a history of depression were more concerned about privacy and losing emotional control. 

People with no history of depression were more likely to think that depression falls outside of the scope of a primary care doctor. They were also more worried about being referred to a psychiatrist or being treated with medication, the study showed.

Symptoms of Depression

Getting people to discuss symptoms of depression with their doctor is the most direct way to recognize and treat depression, the researchers suggest.

Symptoms of depression may include:

• Difficulty concentrating
• Fatigue and low energy
• Feelings of guilt or helplessness
• Hopelessness
• Sleeping difficultly
• Irritability
• Loss of interest in activities or hobbies that were once pleasurable
• Overeating or appetite loss
• Persistent aches or pains
• Thoughts of suicide or suicide attempts

The news in the survey wasn't all negative. Seven of eight people said that primary care doctors were capable of identifying and treating depression. And few people said they were scared to broach the topic of depression for fear of embarrassment or losing face.

"We have come a long way, but this study reflects that fact that we need to continue to work at educating patients and primary care doctors," says Alan Manevitz, MD, a psychiatrist at New York' City's Lenox Hill Hospital.

Today, the majority of prescriptions for antidepressants are written by non-psychiatrists, he says. 

"Depression is ubiquitous," Manevitz says. "Fourteen million Americans are depressed." Of these, just half will get treatment, and only half of these will receive adequate treatment.

The availability of newer antidepressant drugs with fewer side effects and direct-to-consumer advertising campaigns have helped get more people to talk about and seek treatment for their depression.

But "there may be some backlash against medication and side effects because the commercials end up making people fearful," he says.

One thing is clear: "If you are not disclosing your emotional symptoms, you are actually handicapping the primary care physician from being able to properly diagnose and treat you," Manevitz says.

SOURCES:

Alan Manevitz, MD, psychiatrist Lenox Hill Hospital, New York City.

Bell, R.A. Annals of Family Medicine, 2011.

Read More

NSAID Use in Chronic Kidney Disease Sparks Debate

September 14, 2011 — The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is just as common among patients with chronic kidney disease (CKD) as it is among the general public, despite concerns about the nephrotoxicity of these drugs, according to astudy published in the September/October issue of the Annals of Family Medicine.

"Our findings suggest there may be large numbers of individuals with CKD, many of whom unaware of their disease, who may be at risk for further kidney injury through use of NSAIDs," write Laura Plantinga, ScM, from the University of California, San Francisco, and other members of the Centers for Disease Control and Prevention CKD Surveillance Team.

"CKD screening in those who use NSAIDs daily, and effective communication of the risks of NSAID use among those with CKD may be warranted to prevent further kidney damage and progression of disease," the investigators add.

The study used data from the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2004 to examine the use of over-the-counter and prescription NSAIDs in relation to CKD.

Better Risk Communication Needed

The authors suggested that the nephrotoxicity of and potential interactions with NSAIDs may need to be more clearly communicated to primary care physicians and other prescribers.

"Primary care physicians, who are likely to manage both early-stage CKD and indications for NSAID use, should be aware of NSAID (both prescribed and over-the-counter) use, assess the risk of NSAID use in each patient, and, most importantly, engage each patient in informed decision making about the risks and benefits of NSAID use," they recommend.

The study included a total of 12,065 adult survey participants (mean age, 51 years) who answered questions about both demographics and medication use and provided samples for the measurement of serum creatinine and urine albumin and creatinine.

CKD status was defined by using estimated glomerular rate (eGFR) and albumin-to-creatinine ratio (ACR) as follows:

• No CKD: eGFR ≤ 60 mL/ min per 1.73 m², and ACR ≤ 30 mg/g
• Mild CKD (stages 1 and 2): eGFR ≥ 60 mL/min per 1.73 m², and ACR ≥ 30 mg/g
• Moderate to severe CKD (stages 3 and 4): eGFR 15 to 59 mL/min per 1.73 m²

In total, 80% of the study participants were classified as having no CKD (mean age, 47 years), 9% as having mild CKD (mean age, 57.5 years), and 11% as having moderate to severe CKD (mean age, 73 years).

Awareness of CKD Very Low

Awareness of having CKD, defined as a yes or no answer to "Have you ever been told by a doctor or other health professional that you have weak or failing kidneys?" was very low among study participants, with 95.6% of those with mild disease and 90% of those with moderate to severe disease being unaware of their illness.

NSAID use was defined by self-reported use of ibuprofen, naproxen, sulindac, piroxicam, indomethacin, tolmetin, or diclofenac (with brand names and combination formulas identi?ed) daily or nearly every day for the past 30 days.

Long-term use was de?ned as use for 1 year or longer.

Self-reported cardiovascular disease, hypertension, obesity, cancer, arthritis, and use of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers were also recorded.

Overall, current use of NSAIDs was "not uncommon" (3.5%) in the general US population and "low but not rare" among those with both mild and moderate to severe CKD (4.3% and 5.7%, respectively), report the authors.

"At a population level, this percentage reflects up to 870,000 persons in the United States with advanced CKD who are using NSAIDs," they write.

"Among those with CKD, current NSAID use was similar among those [who] were aware and those who were unaware of their CKD status (5.7% vs 5.0%, P = .80)," they note.

In addition, long-term use of NSAIDs was reported by two thirds of users (66%) and did not differ between those with and those without CKD.

Among patients with CKD who reported NSAID use, 10% of those with moderate to severe disease and 11% of those with mild disease reported having an NSAID prescription, "possibly reflecting the lack of both clinician awareness of CKD status and possible adverse effects of NSAIDs in patients with CKD who have additional competing indications for NSAID use," the authors suggest.

Although arthritis was reported by 28% of the overall cohort, it was more common in patients with CKD (35% of those with mild CKD and 44% of those with moderate to severe CKD) than in those without CKD (23%).

Patients with CKD who used NSAIDs also reported other prescription drug use. Specifically, 16% of NSAID users with stage 3 CKD and 20% with stage 4 CKD also had prescriptions for angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and loop diuretics.

Contradictory Evidence

 While describing the "general consensus" that NSAIDs should be avoided in CKD, the authors also acknowledge that there is contradictory evidence for this risk, a factor that might contribute to the continuing use of NSAIDs in this population. Additionally, they suggest that in considering patients’ overall quality of life, the benefits of NSAID use may be considered to outweigh the risks.

Asked to comment on the findings, Jeffrey Berns, MD, professor of medicine and pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, said they did not ring any alarm bells.

"The number of people taking significant amounts of NSAIDs was actually not that high," he told Medscape Medical News. "Among those who had some impairment of kidney function…a small percentage of them were taking NSAIDs on a long-term basis, and of that relatively small number of patients some may have had an impact on their kidney function because of the NSAID use."

But it’s still an open question as to how much NSAID use contributes to kidney problems, he added.

"We don’t have great evidence to indicate the regular, low-dose NSAID use is deleterious in terms of kidney disease progression or even short-term GFR in the vast majority of patients."

A more contemporary cohort of patients might look quite different, he added, given that current awareness of CKD is much higher than it was at the time of the survey.

"There were a lot of patients who were unaware that they had CKD. I’m not sure that is the case any longer. I think [today] their doctors would be more likely to be aware of CKD, and more attentive to their patient’s NSAID use."

"Patients don’t always report over-the-counter medication use, so one of the messages out of this paper is to emphasize to physicians that they ought to be asking about this."

The study was supported under a cooperative agreement from the Centers for Disease Control and Prevention through the Association of American Medical Colleges. One of the study authors (Dr. Robinson) received grants in the last 3 years from Abbott Laboratories, Amgen, Genzyme Corporation, and Kyowa Hakko Kirin. Another study author (Dr. Powe) is partially supported by the National Institute of Diabetes and Digestive and Kidney Diseases. No other study authors have disclosed relevant financial relationships. Dr. Berns is editor-in-chief of Medscape Nephrology and has served as an advisor or consultant for Amgen Inc.

Ann Fam Med. 2011;9:423-430. Abstract

Read More

Slim Is Not Necessarily Always Healthy in Heart Failure Risk

September 12, 2011 (Athens, Greece) — Greek researchers have demonstrated, for the first time, that normal-weight individuals with metabolic syndrome had an increased risk of developing heart failure compared with obese people who were metabolically healthy [1]. They report their findings in the September 20, 2011 issue of theJournal of the American College of Cardiology.

Lead author Dr Christine Voulgari (Athens University Medical School, Greece) told heartwire : "A lot has been written about the 'obesity paradox.' What makes our study unique is that we have shown the clinical translation of this in our prospective, but observational, study." But she adds that "a lot of work still needs to be done in order to explain what makes this phenotype--obese but metabolically healthy--unique."

In an accompanying editorial [2], Dr Eileen Hsich (Cleveland Clinic, OH) says, "The paper by Voulgari et al nicely demonstrates that metabolic syndrome better correlates with the development of heart failure than body-mass index [BMI]."

Presence of Metabolic Syndrome Ups HF Risk by More Than Twofold

Voulgari said she was inspired to conduct her study because normal-weight patients with heart failure would ask her why they were suffering with heart problems despite being a healthy size, when some obese people did not have any cardiac concerns.

She and her colleagues studied 550 individuals without diabetes or baseline macrovascular complications for a median of six years. Participants were classified by the presence (n=271) or absence (n=279) of metabolic syndrome and by BMI. A BMI of 25 kg/m² or less was classified as normal weight (n=177), a BMI of 25 to 29 kg/m² was overweight (n=234), and a BMI of >30 kg/m² was categorized as obese (n=139).

The researchers showed that, after adjustment for other well-known cardiovascular risk factors, BMI was not associated with increased heart-failure risk. The presence of metabolic syndrome did confer around a 2-to 2.5-fold higher HF risk, however.

Compared with normal-weight individuals without metabolic syndrome, overweight and obese individuals without metabolic syndrome had the lowest six-year risk of HF (hazard ratio 1.12 and 0.41, respectively) while normal-weight people with the metabolic syndrome had one of the highest risks of HF (HR 2.33; p<0.001).

The Presence of Metabolic Syndrome, BMI, and HF Incidence During Six Years of Follow-Up

BMI group	Metabolic syndrome	n	Pre-incidence of HF (%)	Adjusted HR*	p
Normal	No	109	15.6	1.00	-
Normal	Yes	68	63.2	2.33	0.007
Overweight	No	127	14.2	1.12	0.36
Overweight	Yes	107	47.7	2.66	<0.001
Obese	No	43	9.3	0.41	0.49
Obese	Yes	96	54.2	2.13	0.002

*Adjusted for all factors associated with HF incidence: age, sex, impaired glucose tolerance, dyslipidemia, current cigarette smoking, physical inactivity, left ventricular hypertrophy and function on echo, high fasting glucose (>100 mg/dL), high BP (>130/85 mm Hg), waist circumference >102 cm in men or >88 cm in women, low HDL cholesterol (<40 mg/dL in men and <50 mg/dL in women), high triglyceride level (>150 mg/dL), and microalbuminuria

It's Not Okay to Be Fat, But Don't Be Complacent if You're Slim

Voulgari stressed to heartwire that she didn't want patients "to get the wrong impression. We showed that obese patients with metabolic syndrome also had an increased incidence of heart failure," and in fact those who were overweight with metabolic syndrome had the highest risk of developing HF.

Thus, it's only the "specific phenotype" of the obese individual without metabolic syndrome who appears to have a lower risk of HF. "These overweight or obese people without metabolic syndrome managed to exercise more and probably had better diet profiles [than the normal-weight people with metabolic syndrome], and they didn't have hypertension, dyslipidemia, or prediabetes," she observes.

In her editorial, Hsich questions how the information from this new study should be incorporated into daily medical practice. She wonders whether doctors should tell obese people that eating cheeseburgers and french fries is okay as long as they don't meet the criteria for metabolic syndrome, for example.

She thinks not, observing that while middle-aged obese people may often be comparatively healthy, this phenomenon does not appear to translate into old age, it being rare to see healthy elderly obese men and women.

Not that it's okay to be fat, but if you are slim, you should still take care of your health.

Voulgari says: "The important message here is not just to concentrate on losing weight but to see the whole picture. Our study addresses the contemporary question, 'You are slim, but is your heart fat?' Not that it's okay to be fat, but if you are slim, you should still take care of your health."

And the findings, she stresses, indicate the importance of the metabolic syndrome "as a highly prognostic marker of future HF risk, whereas obesity alone appears to confer little independent value in cardiovascular risk stratification."

"Appropriate medical treatment of hypertension, dyslipidemia, and hyperglycemia in those at risk of HF is an essential component of prevention," she and her colleagues conclude.

Neither the authors nor the editorialist have conflicts of interest.

Read More

Nonaspirin NSAID Use Linked to Risk for Renal Cell Cancer

September 12, 2011 — Long-term use of nonaspirin anti-inflammatory drugs (NSAIDs) is linked to a risk for renal cell cancer (RCC), according to an analysis of data from 2 prospective studies reported in the September 12 issue of the Archives of Internal Medicine.

"Epidemiologic data suggest that analgesic use increases the risk of ...RCC, but few prospective studies have been published," write Eunyoung Cho, ScD, from Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts, and colleagues. "We investigated the association between analgesic use and RCC in 2 large prospective studies."

Use of aspirin, other NSAIDs, and acetaminophen was determined in 1990 in the Nurses' Health Study and in 1986 in the Health Professionals Follow-up Study, as well as every 2 years subsequently. In the Nurses' Health Study, 77,525 women were followed up for 16 years, and in the Health Professionals Follow-up Study, 49,403 men were followed up for 20 years.

Although use of aspirin and acetaminophen was not associated with the risk for RCC, regular use of nonaspirin NSAIDs was associated with an increased risk for RCC. At baseline, the pooled multivariate relative risk (RR) was 1.51 (95% confidence interval [CI], 1.12 - 2.04). For users vs nonusers of nonaspirin NSAIDs, the absolute risk differences were 9.15 per 100,000 person-years in women and 10.92 per 100,000 person-years in men.

Duration of nonaspirin NSAID use was linked to RCC risk in a dose-response relationship (P < .001 for trend). Compared with nonregular use, the pooled multivariate RRs were 0.81 (95% CI, 0.59 - 1.11) for less than 4 years' use, 1.36 (95% CI, 0.98 - 1.89) for 4 to less than 10 years' use, and 2.92 (95% CI, 1.71 - 5.01) for at least 10 years' use.

"Our prospective data suggest that longer duration of use of nonaspirin NSAIDs may increase the risk of RCC," the study authors write.

Limitations of this study include possible residual confounding, confounding by indication, confounding by past use of phenacetin, and incomplete information on NSAID dose.

"Risks and benefits should be considered in deciding whether to use analgesics; if our findings are confirmed, an increased risk of RCC should also be considered," the study authors conclude.

In an accompanying editor's note, Kirsten L. Johansen, MD, notes that approximately 60 million people in the United States use NSAIDs regularly.

"The study by Cho et al uses prospective data from 2 different cohorts to estimate the risk of renal cell carcinoma related to NSAID use and reports a pooled multivariate relative risk of 1.51 (95% confidence interval, 1.12-2.04) for nonaspirin NSAID use, with a dose-response relationship based on duration of use," Dr. Johansen writes. "Although the absolute risk differences between users and nonusers of NSAIDS were quite low, we find the results compelling in light of the widespread use of these drugs."

The National Institutes of Health, the Kidney Center Association, and the Dana-Farber/Harvard Cancer Center Kidney Cancer Specialized Programs of Research Excellence supported this study. The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2011;171:1487-1493, 1493.

Read More

Predicting How Diet and Exercise Affect Weight

Researchers have created a mathematical model—along with an accompanying online weight simulation tool—of what happens when people of varying weights, diets and exercise habits try to change their weight. The model challenges long-held assumptions about weight loss.

Organizations promoting weight loss often state that eating 3,500 fewer calories or burning them off exercising will result in a pound of weight loss. But the reality is more complicated. A growing body of evidence shows that the body’s metabolism can change as you lose weight and alter your exercise habits. These changes can significantly differ among people as well, depending on age and other factors.

A research team led by Dr. Kevin Hall of NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) set out to develop a computer simulation taking metabolic changes into account. They designed their model to accurately simulate physiological differences between people based on gender, age, height and weight, as well as body fat and resting metabolic rate. To test the model, the researchers compared predicted weight changes to actual changes in people. Their results appeared on August 26, 2011, in the Lancet.

The team found that people’s bodies adapt slowly to changes in dietary intake. The simulation highlights how long it takes for the body to reach a new steady weight after a dietary change. Heavier people can expect greater weight change with the same change in diet, but reaching a stable body weight will take them longer.

The model also revealed a potential simplified method to approximate weight loss in an average overweight adult. For every pound you wish to lose, permanently cut 10 calories from your current intake per day. At that rate, it will take about a year to achieve half of the weight loss, with 95% of the total weight change within about 3 years.

An online simulation tool based on the model will enable researchers to accurately predict how body weight will change and how long it will likely take to reach weight goals based on a starting weight and estimated physical activity. The tool, at http://bwsimulator.niddk.nih.gov/, also allows researchers to plan for a weight loss phase followed by a weight maintenance phase.

“This research helps us understand why one person may lose weight faster or slower than another, even when they eat the same diet and do the same exercise,” Hall says. “Our computer simulations can then be used to help design personalized weight management programs to address individual needs and goals.”

The researchers hope to continue refining the tool and using it to gain insights into what changes are required to achieve and maintain goal weight. For example, a comprehensive mathematical model of human metabolism was used recently to design an NIH clinical trial comparing the effects of reducing fats versus carbohydrates in obese adults.

The online tool isn’t meant as a weight-loss guide for the public. The program can run simulations for changes in calories or exercise that would never be recommended for healthy weight loss. People should consult with their physician prior to embarking on a diet plan.

Read More

Dengue Fever...

Use of Honey in hot water is useful to treat Dengue Fever

Read More

Antidote for Dengue Fever

Antidote for Dengue Fever

By Dr. Nadeem Ali
Microbiologist


Quaid-i-Azam University has proved; Mixing some drops of lemon in Apple Juice can cure from Dengue Fever. This will increase the amount of Platelets. This is a significant treatment for Dengue Fever.

Please forward this message as much as you can...

Read More