Book Review: 'Stay Healthy at Every Age' by Shantanu Nundy

You've been told you have high cholesterol and need to get the numbers down. But how bad are your levels, really, and what might happen if they don't improve? What's the best way to get them in line? 

Or maybe you have a history of breast cancer in your family and wonder what kinds of screenings you should be getting and when. Should you consider genetic testing?

Dr. Shantanu Nundy addresses these and other preventive healthcare questions in his new book, "Stay Healthy at Every Age: What Your Doctor Wants You to Know." 

Nundy's book was born out of conversations he had with his mother when he was in medical school. She was in her early 50s and had Type 2 diabetes. He was surprised at how little she knew about preventive health measures, despite seeing a doctor regularly and having medical insurance. 

He talked to her about getting screened for colon cancer, taking aspirin every day to reduce the risk of coronary heart disease and getting an annual flu shot. Eventually, at her request, he put together a preventive healthcare checklist with additional reading material to help her understand each of the services on the list. 

This became the foundation of Nundy's book, which aims to help readers take charge of their preventive healthcare to improve their chances of living a longer, healthier life. Nundy says he includes only recommendations that have been proved to prevent disease and save lives. "Nothing discussed in this volume is experimental or controversial," he writes. 

The book, published by Johns Hopkins University Press, indeed takes a straightforward, conservative approach both in its presentation and advice. Many of the recommendations come from the U.S. Preventive Services Task Force, a government-sponsored panel of independent experts in prevention and primary care, Nundy says. Information on immunizations comes from the Centers for Disease Control and Prevention.

Readers may want to go first to the checklist section of the book, which outlines the screenings, vaccines, counseling and preventive services recommended for children, women, men and at-risk people at eight stages of their lives, starting at birth.

Later chapters discuss these things in greater depth. Topics covered in a Q&A format include screenings and preventive services for alcohol misuse, blood pressure, various cancers, cholesterol, depression, diabetes, obesity, osteoporosis, sexually transmitted diseases and tobacco use. The book describes the conditions and outlines causes, prevention, risks, tests, screening risks, results and recommended next steps. It has short chapters on early childhood and pregnancy preventive health. A section on vaccines talks about how they work, who should get them and when, and their risks. 

"Stay Healthy" is not comprehensive -- breast, cervical and colon cancer screenings each have a chapter, but prostate and skin cancer do not, for example. And some discussions are fairly brief. Nevertheless, those who want to better understand common health conditions and determine whether they're getting the recommended preventive care for their age may find it a helpful, trustworthy resource. 

-- Anne Colby

Photo: "Stay Healthy at Every Age: What Your Doctor Wants You to Know," Dr. Shantanu Nundy, Johns Hopkins University Press, $45 hardcover, $18.95 paperback

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Leukemia drug Mylotarg taken off the market over safety, effectiveness concerns

For patients with a diagnosis of the blood cancer acute myeloid leukemia, or AML, the search for a drug that can effectively treat a recurrence of leukemia has been elusive. So the withdrawal from the market Monday of the AML drug gemtuzumab ozogamicin, marketed as Mylotarg, comes as another disappointment to those hoping for a cure.

Pfizer, which makes Mylotarg, withdrew the drug after a clinical trial raised concerns about its safety and effectiveness. Early trials had spurred hopes that Mylotarg would induce remission -- meaning the absence of leukemia in the bone marrow -- in almost a third of patients who took it. But the drug, which promised reduced side effects because it appeared to home in only on cancerous cells, has been associated with a serious and sometimes fatal liver condition call veno-occlusive disease.

Although Mylotarg received accelerated FDA approval in 2000, the agency required an additional clinical trial to demonstrate its safety and effectiveness. That trial, which began in 2004, has shown higher levels of liver toxicity in patients than seen in early trials, with no benefits to patients. In fact, compared with AML patients on standard chemotherapy alone, those on Mylotarg were more likely to die.

The FDA said that patients who have begun treatment with Mylotarg may complete their therapy, but that patients with new recurrences of AML will not be permitted to start on the medication.

Remember that some patients with AML can be treated -- and cured -- with a bone marrow transplant, but they need an excellent match for a good outcome. Joining the bone marrow registry is easy and painless, and you could be the match that saves someone's life. Find out why and how to register as a prospective bone marrow donor here.

-- Melissa Healy

The Father's Day gift that keeps on giving

Without further ado, here's a Booster Shots tribute to dads and their families, courtesy of Dr. Marc Siegel, a practicing internist who writes the Unreal World column for the Health section, and Dr. David Samadi, a practicing urologist and the chief of robotics at Mt. Sinai Medical Center in New York.
 
* * *

Guys out there, give yourselves a present for Father’s Day -- go to the doctor. Do you want to be around to receive another godawful tie from your kids next year? Go to your doctor now to make sure you have the chance. Are you having problems peeing or difficulty getting aroused? Don’t argue, see your urologist. It could save your life.
 
Unfortunately, statistics show that you guys are just not doing it. The Agency for Healthcare Research and Quality has just released the results of a sobering survey showing that just 57% of American men see a doctor, nurse practitioner or physician’s assistant for routine care on a yearly basis. The number is much higher for women -- 74%.
 
Further, it appears that the men who need care the most are often the ones less likely to seek it. Three-quarters of men who said they were in excellent health sought routine care versus only half of men who reported being in fair to poor health. What better time than Father’s Day to make a resolution to change your ways? If not for yourself, do it for your family.
 
If you come to see your internist or family practitioner, we won’t attack you; we will simply check your blood pressure, your weight, your cholesterol, your glucose and your PSA (if you’re over 40). These are all crucial measurements to make sure you aren’t at risk for a heart attack, diabetes, stroke or prostate cancer.

High blood pressure is the most common chronic disease and the second-leading cause of death in the U.S., affecting one out of three adults, or 65 million people. More than 102 million adults have elevated cholesterol levels. You can learn to change your lifestyle, or if needed, we can give you medicine that will help you. 

Prostate cancer will be diagnosed in one in six men in the U.S., and it kills 30,000 men every year, the second-biggest cancer killer of men after skin cancer. We can screen you for prostate cancer and for colon cancer over age 50, which, when we catch it early, can be cured. We want you to be around next year.
 
What exactly is your prostate? It lives right below your bladder, and although it is just the size of a plum, it causes big problems. The prostate can grow and block the urinary stream, or it can develop a lethal form of cancer. Although recent studies have provided conflicting results regarding the PSA blood test, we continue to value its usefulness. We don’t believe in over-treatment, or that everyone with prostate cancer should be treated. But we do believe that knowledge is power, and a simple blood test can help us gain that knowledge.
 
Make yourself a Father’s Day resolution: Go to see your doctor so that your kids have a holiday to celebrate next year at this time.

And now for some helpful health links ...

- The risk factors for high blood pressure.

- The risk factors for a heart attack.

- How to manage cholesterol.

... and some statistics for U.S. men and cholesterol by age, from the National Center for Health Statistics:

- 11% of men age 20-34 have high cholesterol.

- 21.1% of men age 35-44 have high cholesterol.

- 22.9% of men age 45-54 have high cholesterol.

- 16.5% of men age 55-64 have high cholesterol.

As for information about prostate health, the Centers for Disease Control and Prevention offers a primer on informed decision-making, the National Cancer Institute explains cancer screening, and the Prostate Cancer Foundation offers a look at physiology. 

 -- Drs. Marc Siegel and David Samadi

Become a fan: We've set up a page dedicated to fitness, medical and health news at facebook.com/latimeshealth.

Photo: What better time than Father’s Day to make a resolution to change your ways? Credit: Al Schaben / Los Angeles Times

New Benadryl recall adds to consumers' headaches

The Food and Drug Administration and the maker of a wide range of over-the-counter medicines have announced a new addition to a wide-ranging recall of popular medicines that started in December. The latest recall urges consumers who may have purchased certain 100-count packages of Benadryl Allergy UltraTab tablets and 50-count packages of Extra-Strength Tylenol Rapid Release Gels to stop using these products and contact the manufacturer (either by logging on here or by calling 1-888-222-6036), about refund or replacement.

McNeil Consumer Products says these medications should have been included in the recalls issued in January, which were prompted by reports of a musty, moldy odor emanating from several of the company's products. 

Since the first and second rounds of recalls were announced in December and January -- affecting such products as Tylenol, Motrin, Benadryl and Rolaids -- McNeil Consumer Products says it has discovered the source of the unsettling odor: the breakdown of a product used on the wooden crates and pallets on which the products are transported and stored. "The risk of serious adverse medical events is remote," the company said in its notice of the latest addition to its recall list.

Do you want to be the first on your block to know when the FDA issues a product warning or recall? You can sign up for regular alerts, you know. (But better be ready to get a lot of e-mail!)

--Melissa Healy

The FDA cites rare risk of liver damage with weight-loss drugs Xenical and Alli

The Food and Drug Administration said Wednesday that it is ordering a revision of the labels of the weight-loss drugs Xenical and Alli to warn of the risk of very rare cases of severe liver damage associated with their use. The active ingredient in both drugs is orlistat, which blocks the absorption of fats in the intestines. Xenical is a prescription form of the drug. Alli is an-over-the-counter version which contains lower doses.

The agency said it had identified 13 cases of severe liver damage associated with the drugs, one in the United States and 12 abroad. Two of the patients died from liver failure and three others required liver transplants. The FDA said it could not positively say that the drug caused the damage because there is insufficient data in most of the cases. Some of the patients, for example, might have been taking other drugs or had other medical conditions that could have caused the injury. Worldwide, more than 40 million people have taken either Xenical or Alli, so the cases are very rare.

Patients taking the drugs should contact their physicians if they develop itching, yellow eyes or skin, dark urine, loss of appetite, or light-colored stools, all of which are signs of liver damage.

-- Thomas H. Maugh II

The FDA approves new drug for Pompe disease

The Food and Drug Administration on Tuesday approved a new drug called Lumizyme for the treatment of Pompe disease, a disabling genetic disorder that is often fatal. A drug called Myozyme is available to treat the disease, but supplies have been severely restricted and it is reserved for use in children and infants with the most severe form of the disorder. Approval of Lumizyme, which is closely related to Myozyme, will make treatment available to much larger numbers of people.

Pompe disease, which affects about one in 40,000 Americans, is caused by mutations in the gene that is the blueprint for an enzyme called acid alpha-glucosidase, which is used by tissues to convert a form of sugar called glycogen into energy. If the enzyme is not working properly, glycogen builds up in tissues, especially in the heart and muscles, weakening them severely. Many different mutations have been discovered, and they vary in severity. Some mutations produce only a partial impairment in activity and the disease does not become a problem until adolescence or adulthood. In other cases, however, the enzyme does not work at all, and the disorder can be fatal at a very young age unless treated. In infants, symptoms include respiratory problems that often lead to infections, feeding problems, poor weight gain, muscle weakness, floppiness, head lag and an enlarged heart. More than half of victims also suffer enlarged tongues. In the late onset form, the primary symptom is muscle weakness leading to respiratory problems that can be fatal. The heart is usually involved, but it does not become grossly enlarged.

Myozyme, produced by Genzyme Corp. of Cambridge, Mass., is a synthetic form of alfa-glucosidase that breaks down the glycogen, easing Pompe symptoms. The company originally produced the drug in 160-liter batches, which limited the available supply so that its use had to be restricted to infants and children who were most severely affected. The company applied to the FDA to manufacture the drug in 2,000-liter batches, but the agency determined that the synthetic enzyme produced in the larger batches was slightly different from the original product. Apparently, more sugar molecules are attached to its surface. The company was thus forced to conduct clinical trials of the new form, which it chose to call Lumizyme. The safety and efficacy of the drug was demonstrated in a trial on 90 late-onset patients ages 10 to 70, and the FDA granted approval. An estimated 200 adult patients in this country are already receiving the drug on a compassionate basis, and it has already been approved in several other countries.

Because it is a protein, the drug has to be administered by infusion. The primary side effects are allergic reactions to the drug, which include hives, diarrhea, vomiting, itchy skin, skin rash and chest discomfort. The drug will carry a so-called black box warning cautioning about the possibility of severe allergic reactions. The company will undertake a post-marketing surveillance program to monitor for side effects, and the drug will be available only through a restricted distribution system to ensure that it reaches the proper patients, the FDA said.

-- Thomas H. Maugh II

Diabetes drug trial unethical and dangerous, researcher charges

The Canadian physician whose research escalated safety concerns about the Type 2 diabetes drug rosiglitazone (marketed as Avandia) is urging the U.S. Food and Drug Administrationto call a halt to a major international trial designed to compare the safety of Avandia against another diabetes drug in the same class.

Dr. David Juurlink, chief of clinical pharmacology and toxicology at Sunnybrook Health Sciences Center in Toronto, was the lead author of a 2009 study that found that compared to elderly diabetics taking a drug called pioglitazone (marketed as Actos), those taking Avandia were about 30% more likely to suffer heart failure or death. On Tuesday, Juurlink joined with Dr. Sidney Wolfe, director of health research for the consumer watchdog group Public Citizen, in calling a further clinical trial pitting the two diabetes drugs against each other "unethical" and "dangerous."

In 2007, the FDA issued two separate safety warningson Avandia and required the drug's maker, GlaxoSmithKline, to post "black box" warnings on the medicine's patient instruction sheet indicating the drug might put patients taking it at higher risk of ischemic heart attack or heart failure. The agency also ordered GSK to conduct a post-marketing safety trial of Avandia. That planned trial is expected to draw from sites in 14 countries, including a number of newly-added developing countries such as Pakistan, India, Latvia, Chile, and Mexico, and to enroll 16,000 subjects. Called the TIDE trial, or Thiazolidinedione Intervention in Vitamin D Evaluation, was the subject of Tuesday's appeal from Juurlink and Public Citizen.

In act, both drugs have been tagged with safety issues: In addition to raising rates of cardiovascular events, the class of Type 2 diabetes drugs known as thiazolidinediones (or TZDs) have been linked in studies to higher rates of edema, macular edema, bony fractures, anemia and acute liver injury. Older diabetes medicine such as metformin and sulfonylurea are widely believed to be safer alternatives. 

At the same time, the drugs are widely used and have many defenders in the care of Type 2 diabetes -- an obesity-related condition that has exploded in the U.S. population in recent decades. But extensive financial ties between the drug companies that make the medicines and many of the clinicians and researchers who have defended them have prompted some -- including leaders of the Senate Finance Committee -- to ask whether the safety debate has been tainted by industry influence. 

There is scant evidence that the proposed clinical trial will yield more reliable evidence of Avandia's relative safety profile than existing research has done, Juurlink and Wolfe wrote in a Tuesday letter to FDA Commissioner Margaret Hamburg. Nevertheless, it will expose "thousands of high-risk patients with diabetes to a drug with an unfavorable safety profile and clinical advantage over its comparator," they wrote. The "price of definitive proof" of the drug's safety hazards, they added, "will almost certainly be measured in the lives of study subjects who have been incompletely informed about the risks and benefits of participation" in the trial, they added.

--Melissa Healy

Parkinson's meds and compulsive behaviors: a strong link

Here's a perplexing medical irony: For Parkinson's disease patients, initiating certain voluntary movements such as walking and rising from a chair can be difficult. But the medications that help ease the challenging motor symptoms of Parkinson's seem to make it harder for some patients to halt certain behaviors that can be rewarding or pleasurable -- gambling, buying, eating, sexual stimulation.

While physicians have known about the link between Parkinson's medication and compulsive gambling since about 2005, little was known about how many patients are affected this way, whether the compulsive behavior went beyond gambling for some, and whether this is clearly a medication-induced problem. A study in the Archives of Neurology released Monday answers those questions.

Some 13.6% of Parkinson's Disease patients taking levodopa or one of the dopamine-agonist medications widely used for the movement disorder show clear signs of some impulse-control disorder. That rate was between 2 and 3.3 times higher among Parkinson's patients being treated with these medications than among patients who did not take them. About a quarter of those patients suffered from more than one type of compulsive behavior.

Compulsive buying was the most common manifestation of such impulse-control problems, affecting 5.9% of all medicated patients; 5% experienced problem or pathological gambling;  4.3% engaged in binge eating behaviors; and 3.5% engaged in compulsive sexual behavior.

Compulsive buying and binge eating were more common among women patients than among men; compulsive sexual behavior afflicted more men than women. The researchers also found some evidence that genetic inheritance might make some patients more vulnerable to these side effects of Parkinson's disease medicine: Patients were far more likely to develop compulsive buying, eating or gambling behaviors if they had a first-degree relative with a known gambling problem.

Finally, the study, which included 3,090 Parkinson's disease patients, found that those taking a combination of levodopa and one of the other dopamine-agonist medications (including pramipexole and ropinirole) were most likely to develop an impulse-control disorder; those on a dopamine agonist without levodopa were slightly less likely to develop such behavioral problems; and those on levodopa alone were about half as likely as the first two groups to develop impulse-control problems.

Researchers are gleaning insights into why and how some people become addicted to substances or behaviors from the experiences of Parkinson's patients. Here's a terrific overview of the curious link between Parkinson's medications and compulsion.

But you don't need to be a Parkinson's patient to have a compulsive behavior problem. Have a look here if gambling is your weakness; here if you compulsively seek out sexual stimulation; here if you buy or shop compulsively; and here if you think you might have a binge-eating problem.

-- Melissa Healy

Give home remedies a try, experts suggest, at least for kids' coughs and colds

We know that cough and cold medicines have not been proven effective in young children. We also know they can cause serious side effects. So the next time the little one gets sick, why not give the tried-and-true a new try? Add humidity to the air. Physically remove mucus from the nose. Spray a bit of nasal saline up there while you're at it. Such is the advice published in the May issue of the journal Otolaryngology -- Head and Neck Surgery.
In a commentary about children's cold medicines, the authors -- a pharmacy professor at Drake University in Des Moines and a pediatric otolaryngologist at Johns Hopkins University in Baltimore -- write of the harm that such seemingly benign over-the-counter drugs can pose. And they firmly endorse truly benign alternatives.

They conclude:

"Parents may administer these products to children with good intentions, as these medications are widely used to treat adults with upper respiratory infections. Data supporting their efficacy, however, do not exist. Evidence of the potential for significant harm from the use of these products in young children does exist."

The choice would seem clear.

The authors go on to tell otolaryngologists to get with the program and recommend such measures to parents and caregivers.

The Food and Drug Administration seems unlikely to argue. Here's the FDA recommendation on over-the-counter medications for children 2 and younger. In three words: Don't do it. The agency then offers (seemingly reluctantly) practical advice for those parents who think they simply must give such medications to older kids.

The Mayo Clinic offers this overview of cold remedies. Gargling with salt water, administering saline nasal drops and spray, using a humidifier -- all are on the might-help list. Antibiotics, obviously, are not. 

Adults themselves will probably remain committed to popping a pill at the first sign of a sniffle or scratchy throat, but perhaps they can learn from their kids' experiences. Maybe they'll give those home remedies a try themselves. (Except for the nasal suctioning.)

-- Tami Dennis

Photo credit: Bob Carey / Los Angeles Times

 

Nurses administering medications can't pardon the interruption

Nurses are busy, busy people. If you're a patient, you can help the nurse do his or her job by keeping mum when they are conducting important tasks. A study published Monday found that nurses make more medication errors when they are interrupted during the task.

Interruptions are known to increase on-the-job mistakes. But the researchers, from Australia, sought to understand the impact of interruptions on nurses. They observed 98 hospital-based nurses over 505 hours. The nurses administered a total of 4,271 medications during those hours. Only 19.8% of these administrations were free of two kinds of errors: procedural mistakes, such as failure to read labels or check patient identification; and clinical errors, such as administering the wrong drug, dose or formulation.

However, interruptions occurred in 53% of all administrations. When nurses were not interrupted, procedural failure rates were 69.6% and clinical error rates were 25.3%. When they were interrupted three times, the rates went up to 84.6% for procedural errors and 38.9% for clinical errors. The errors became more severe the more times the nurse was interrupted during the task.

Some interruptions, such as tending to a monitor alarm, are necessary. But the study found that only 11% of the interruptions were positive. "While it is clear that some interruptions are central to providing safe care, there is a need to better understand the reasons for such high interruption rates," the authors wrote.

"The frequency of interruptions during medication administration suggests a lack of understanding of the importance of this process and of the deleterious effects of interruptions on patient safety," Julie Kliger, of the Integrated Nurse Leadership Program at UC San Francisco, wrote in an editorial accompanying the study. "Perhaps more significantly, it alerts us to a widespread lack of respect for the medication administration process."

The study was released Monday in the Archives of Internal Medicine.

-- Shari Roan

Photo credit: Irfan Khan / Los Angeles Times