This week I had the occasion to be at UCLA for a very interesting meeting (more on that in a future post).  As I arrived at LAX to return my rental car, I drove past a huge billboard at the corner of 96^th Avenue and Airport Blvd (just across from the Renaissance Hotel)  that made me do a double take.  The billboard, said in gigantic white letters on a red background:  “This year thousands of men will die from stubbornness.”

Naturally, my first thought was this:  Why thousands? If men can die from stubbornness, aren’t they all doomed?  If stubbornness is the proximate cause of death, we are looking at a wipe-out of society on a pretty imminent basis.  The bad news:  no more future generations.  The good news:  no one will hassle us women about buying too many shoes and all the top-paying private equity jobs will soon be available.

So figuring that I had misread this billboard, I actually made a U-turn and drove past it again (not sure what made me do it:  alarm or wishful thinking). What I noticed on my second pass was the very fine print, which said, “Learn the preventative medical tests you need. AHRQ.gov.”

The billboard is apparently part of an U.S. Government Agency for Healthcare Research and Quality Department ad campaign targeted to get men to stop avoiding the doctor and to go and get the medical screening tests recommended each year, such as those for cholesterol, diabetes, high blood pressure, cancer and other illnesses.

According to AHRQ, the ads are targeted at middle-aged men who, according to their research, are 24 percent less likely than women to have visited the doctor within the past year and 30 percent more likely than women to be hospitalized for preventable conditions such as congestive heart failure and complications from diabetes.  The ad campaign consists of billboards and public service announcements that will run through Men’s Health Week (June 13-19) and Father’s Day (June 20).

When you go to the website that is associated with the billboard you can view several videos that are designed to be funny, scary and compelling.  One shows a realtor welcoming a family (obligatory middle-aged white guy included) to their new home.  She says, “You will have many happy years here, except you (pointing to dad); you will die in 3 years from the same thing your dad died of, which could have been detected with a simple test.”  Have a nice day.

In another of the videos that really gets men where they live, a dad and his son are buying a new TV at an electronics store and the young clerk tells the guy not to bother with the 5-year warranty since he won’t be around to take advantage of it.  Now that’s harsh.  Never get between a man and his electronics purchase.

It’s a very interesting approach.  The whole concept of using the mass media to promote health is certainly not new, but it seems to be very much on the rise.  There are companies and organizations now trying this from almost every angle, including gaming (I have heard companies say, “I’m going to be the Zynga for health!”), advertising, and social media.  We already have at least one TV show focused on wellness: The Biggest Loser.  Believe it or not, that is not a documentary about the new Charlie Sheen, but one that pits people against each other in a competition to lose the most weight.

For every ad promoting McDonalds or Marlboros we are seeing more and more ads that promote better health by preventing illness, stopping smoking, and eating better.  Yesterday I had a company present to me in my office that has the creation of entertaining health-oriented videos as a core part of its business model (if you click on this link, click on the blue link that says “entertain” to see their promo video…you will never look at french fries the same way again).

Another company I saw this week is focused on building an entire social media company around health.  This is not a new idea but no one has yet managed to create THE destination site–a true Facebook kind of experience–for those who come to learn and share about health, wellness and illness.  While I’m sure someone will crack that code, when I think about a central place for random people to communicate about their health, all I can see in my mind is the communal dinner table at a Jewish assisted living facility in downtown Fort Lauderdale.  Instead of a “Like” button, they are going to have to have an “Oy, I have that too and mine is worse” button.  Maybe instead of “friending” someone you will “infect” them!

But I digress.  As the AHRQ so aptly says on its Healthy Men website, “The single most important way you can take care of yourself and those you love is to actively take part in your health care.”  When AHRQ says that, they mean that people should be proactive in finding out if they are sick by getting preventative tests as recommended.  That is essential to ensuring that illnesses are found early, before they become chronic, difficult to treat and/or deadly.

However, to take a different twist on it, it is becoming more commonly known that somewhere between 50-80% of all chronic illness can be avoided by making good health and lifestyle choices.  This needs to become an even more familiar refrain for consumers as they become more and more responsible for paying for their own healthcare insurance and related services, an experience that is most certainly in the future of every American given the changes underfoot in our healthcare insurance landscape.

I hope AHRQ’s next media campaign focuses on tangible ways to prevent the onset of illness in kids and teens before it ever starts, which will make a great follow up topic for them.  As I have said elsewhere, telling people to shut up and eat their vegetables doesn’t seem to be working.  It’s going to take some very creative and long-term marketing to make a dent in this issue and we know it can work:  witness the approximately 50% decline in U.S. smoking since the advent of aggressive communication campaigns to attack the smoking epidemic.  It may be too late for some adults, but if we can affect young people’s lifestyle choices and customs, our healthcare system has a chance of financial survival, even if it is after all the men over 40 have died from stubbornness.

Unfortunately, it’s an all-out war out there in mass media land.  For every marketing thrust towards good health, there is a corresponding parry from tobacco-, sugar- and fat-purveyors to lure us to the dark side.

For the good health warriors to win on the teen media front, they are going to need the big guns–Rihanna, Arcade Fire, those annoying kids from Twilight, Justin Bieber, the cast of Glee– to get out there and make good health choices seem cool.  As for companies, I am searching for the one that that has figured out how to make texting into an activity that lowers blood sugar and prevents cancer.  Now that’s a business.

Lisa Suennen is a managing member of Psilos Group, co-headquartered in the Bay Area and New York City, The firm has funded and developed more than 38 innovative companies, including ActiveHealth, AngioScore, Click4Care, Definity Health, ExtendHealth and OmniGuide. Lisa blogs at Venture Valkyrie.

Marijuana is the most common drug that people will try to cover up in a drug test, and due to the fact that THC attaches itself to fat cells, it is virtually impossible to disguise the presence of THC in a urine sample. A common myth is that drinking an excessive amount of water will help flush the THC out of a person’s system. In reality however, all that drinking a lot of water will do is dilute the test and allude to the fact that the person is trying to cheat the system. Vinegar and pickle juice yield the same result as water while dehydrating the person’s body in the process.

An extremely dangerous method of passing pre screening recently is to take an overdose of aspirin. Overdosing on aspirin will not help anyone pass a drug test and it can actually cause kidney and liver failure if the overdose is severe. Other myths have circulated that taking ibuprofen will result in a positive drug test result. The moral of the story is that over the counter pain medications don’t influence urine or saliva drug test in any way.

Finally, be very wary of the cleansing systems that are advertised on the internet. These systems are advertised to flush all of the toxins out of a person’s system and, as a result, clear the urine of all traces of drugs. However, THC metabolite stays in our fat cells and will continue to come out in our urine for anywhere between days to months. Cleansing systems may be very good for cleaning out our digestive tracts, but they are no way to pass a drug test.

Lastly, urine and saliva drug tests will pick up any trace of drug metabolite in a person’s system. However, to test positive for drugs, an individual must exceed a cutoff point that eliminates the possibility of having contact with a drug through a friend or family member. For this reason, common fears that coming in contact with marijuana smoke will cause a positive drug test result are unfounded.

If you have any more questions about the accuracy of drug testing or to find out more about CMM Technology’s drug testing products, please contact us at +618-9204-2500 or email us at  info@cmm.com.au .

alcohol testing australia

It has become a truism almost to state that workplace safety is an important issue for the employee, employer and the community. And yet, despite the best of intentions, many workplaces still fall far short of implementing quality risk management systems. Even in workplaces that have a dedicated OHS department and head, the commitment required to sustain quality OHS programs within a changing and demanding business environment can prove ineffective without proper protocols and external checking mechanisms that ensure an OHS system’s maintained integrity, cohesion and currency. In addition to these concerns, the complexity of OHS law and evolving legislation ensure that OHS managers and business owners (across a spectrum of  industries), have laid before them a daunting task of deciphering OHS law and Standards as well as a great legal responsibility with regard to implementing them in the most practical, economical and streamlined way.

It is for these reasons that OHS related training and professional development should be viewed as the cornerstone to ensuring quality deployment of OHS systems. Properly managed with adequate and ongoing professional support, workplace OHS policy and protocols can certainly make a great difference with regard to: minimising tragic and costly safety risks and accidents, improving employee wellbeing, safeguarding the community, elevating individual workplace performance and boosting profits. In this way, as an OHS professional, HR Manager and business owner, regular training and guidance on industry best practices and OHS legislation is your key to exercising ethical and sound business acumen.

Along with VETAB accredited training, there are many complementary organisations and peak bodies that convene regularly with members and offer professional advice to help guide and design practical ways of implementing OHS legislation, including: Workplace Safety Australia, The National Workplace Safety Summit and CMM technology. Through active participation in OHS training and professional organisations (such as those offered by the aforementioned), businesses can more effectively integrate comprehensive OHS planning into their core business strategy, business systems and processes. Overall, the benefits associated with continuing professional development in OHS include:

• Understanding what currently constitutes quality and ongoing risk assessment management and response in your industry (to safeguard employee health and safety in the drug free workplace).

• Being informed of and actioning your legal responsibilities and duty of care.

• Proactively promoting a culture of compliance.

• Proactively promoting a positive organisational culture and fostering EAP programs that support employee wellbeing.

• Gaining understanding into how effective OHS strategies can enable improved productivity and the reduction of claims.

• Designing strategies that offer real solutions to minimise areas of high occupational safety risks, including: falls and hits by moving objects, fatigue and stress management, workplace drug and alcohol breaches, manual handling, working at heights and occupational diseases.

With the right OHS training and professional guidance, Australian businesses can be far better equipped to face the modern challenges of the new global and competitive business environment. Talk to our team of experts today to see how CMM Technology can help you navigate your business.

So what preventive care should people get and when should they get it?

I’m glad I asked!

The list below is based on the most up-to-date recommendations from the U.S. Preventive Services Task Force.  For any particular preventive screening, they have established its usefulness and graded each on the following scale, which I will be referencing.  The web site (link at the bottom of the blog) has graded out preventive care procedures for, literally, hundreds, of possible interventions.  I am going to talk about the most important ones for the general person.  For people who are at high risk for certain other medical problems, it may well be that it behooves you to get preventive screening for that problem, while the general population would not benefit from it.

So why don’t we screen for everything?  I mean, if we can, shouldn’t we?  What is the harm of testing everyone for every conceivable medical problem?

Well, my friends, there are many many reasons why this is not done.

1.  Cost – We would bankrupt the system if we screened every single person for every disease, including diseases they are highly unlikely to ever even hear about!  Sure, there are people who absolutely need to be screened for Sickle Cell Anemia, but if we screened every person regardless of their risk, it would cost us hundreds of millions of dollars.

2. Outright harm – yes indeed.  Screening can hurt you!  How, you ask, incredulously?  If you screen a low risk population, then most of the positive test results will be false positives.  if you get a false positive, you will probably need follow-up testing to see if the screening test was real or not.  This can lead to dangerous outcomes.  I will give you 2 examples.  In the past, we used to give “The Executive Physical” which was titled after high-power male executives at large corporations.  This overly-complete exam usually included a stress test looking for heart disease.  When you do stress tests on people who are neither having symptoms of heart disease, nor have many risk factors, the majority of your positive stress tests end up being false positives.  Unfortunately, you cannot ignore a positive stress test (or only ignore it if you want to be sued to the moon when they have their heart attack!), so these people end up being referred for angiograms to see if they have real cardiac blockages.  Unfortunately, about 1 in every 200 people who get angiograms have some kind of substantial complication during the exam (i.e.  heart rhythm problems, puncture of the arteries or even death).  So….we were taking young and healthy executives and we were killing them!  Not so good, eh?  Another fine example is when the state of Illinois demanded that all people asking for a marriage license get tested for HIV.  You can tell that an illinois bureaucrat made that decision, and not a doctor!  Again, when you take a low risk population and screen them for a fairly rare disease, most of the positive results are false positives.  So what we had was thousands of people coming up with false positive HIV tests; all which required expensive follow-up testing to determine if the original test was accurate.  The costs alone were catastrophic, but worse still were the thousands of people who were literally freaking out, waiting for the results of their follow up testing, right before they were supposed to get married.  A few suicides later, the state of Illinois stopped the program!  As you can see, screening for everything in everyone can end badly!

3. Failure to help – in most cases, screening programs for rare or unusual diseases does not improve the mortality rate from the disease.  If it doesn’t grant some sort of survival benefit, there is rarely a reason to screen!  This argument is the one that makes the general population angry and upset, since it is hard to understand.  It makes “sense” to screen all smokers with a Chest X-ray, looking for early lung cancer, but every study ever done on this program has shown that once we find a cancer on Chest X-ray, it is usually too far advanced to save them, or even help them to live longer.

4.  Low Yield – this is another common problem with screening tests that infuriates the public.  For example, recently, they determined that Mammographic Screening for women between the ages of 40 and 49 did not make sense.  The reason is that Breast Cancer is rare enough in women this age, that you have to do mammograms on tens of thousands of women in order to find enough early cancers to save the life of one woman.  The cost was $56,000 per year of life saved, in this age group.  For a 5-year survival (i.e. “cured”), this is $255,000 per life saved.  Despite the high costs, the public wants mammographic screening to be available to all women of these age groups; partly because Breast Cancer is very exposed in the press and it is the 2nd most common cancer killer in women.

Ok, so let’s talk about the screening that makes most sense, with some basic discussion!

Blood Pressure Screening

I wrote an entire blog on Hypertension, and I welcome you to go back into the archives and read it.  The short and snappy answer from the USPSTF (United States Preventive Services Task Force) is that all adults should be screened for high blood pressure at least every other year (if your blood pressure is “normal” on the first screening) or every year if it is borderline.  It grants blood pressure screening a GRADE A on the scale noted above.  It’s cheap, has no known complications and is saves lives in bucketloads.  The screening and treatment of hypertension is amongst the most cost effective preventive measures you can take!  Do it.  Do it now.

Pap Smears

Men, you can skip this one!

Pap Smears are done in order to screen women for Cervical Cancer.  It is amongst the best screening programs we have.  By this, we mean that it is cheap, saves lives and is relatively safe!  The recommendation is that all women have their first Pap Smear done within 3 years of becoming sexually active, or age 21, whichever one comes first.  Continued testing should be at least every 3 years as long as the results are negative, until age 65 (Grade A recommendation).  Continuing Pap Smears in low risk individuals after age 65 is a GRADE D recommendation.  Understand, that the recommendations of the USPSTF are not the same ones as your gynecologist will probably recommend.  They are absolute minimum recommendations based on cost/benefit analysis.  Most women, especially those who are not in continuing monogamous relationships, should probably get them yearly.  There will also always be a change as soon as you have a borderline or positive test; then you are no longer under the auspices of these guidelines!

Prostate Cancer Screening

This is much more controversial.  We do screening with the PSA (Prostate Specific Antigen) blood test every year beginning at age 40, and the rectal examination of the Prostate Gland yearly after age 50.  However, the data regarding the PSA test is murky at best (Class I) and the Rectal Examination has actually never been proven to save lives at all (Grade C).  The problem with the PSA test is that the false positive AND false negative rates are pretty high.  Thus, you can have a positive test and probably not have the disease, or you can have a negative test and still have prostate cancer!  Positive tests usually end up with prostate biopsies…a very unpleasant test with a small complication rate.  The rectal examination is still offered, as there were some studies showing that a combination of PSA testing plus rectal examination seemed to slightly increase the chance of survival.  It has also been a part of the exam of all men over the age of 50 for a long time, such that most men expect it and feel that doctors who do not do the test are shirking their duty!  I personally suggest getting the PSA test, with the full knowledge that it is imperfect, and allowing the doctor-patient relationship to do the rest when discussing what to do with the results.  The Task Force specifically states that patients over the age of 75, or men with a likely lifespan of less than 10 years, should not be screened.  In these populations, it is far more likely that they will die of something other than prostate cancer, even if it was discovered, since it is usually a slow growing cancer and many never spread.

Screening for Colon Cancer

This is the one I have a hard time selling to patients, even though it is a slam-dunk!  Colon Cancer screening can be done in several ways, but the highest grade is for Colonoscopy (a procedure where a fiber-optic camera is inserted through the rectum and pictures are taken of the entire colon.  Yes, you are sedated for the procedure!).  The best thing about colonoscopy is that if they find a pre-cancerous “polyp”, they can remove it right there on the spot!  It’s both screening and cure, in one fell swoop!  Screening colonoscopy for people age 50-75 is Grade A, ages 76-85 is Grade C and older than 85 is Grade D.  The first test should be at age 50, and the interval determined by what they find (usually anywhere from 2-10 years depending on the kinds of polyps they might find, or if they find nothing at all!).  Colonoscopy is an invasive procedure, so complications occur in 25 people out of every 10,000 (less than 1/3rd of 1%).  In the 15 years I have been a practicing, I have seen 1 complication from a screening colonoscopy.  Screening should occur at a younger age for people with colon cancer in their family.  There are alternatives to colonoscopy, but they are not as good.  Hemoccult Testing of the stool (looking for microscopic blood in the stool) has not been shown to improve mortality (i.e.  once a cancer is bleeding into your colon, it is usually too late) and is Class I.  CT Colonography has fewer risks (6 complications per 10,000 procedures) but you have to have follow up colonoscopy anyway if they find something!  And, they find “something” in 16% of all tests!  There is also radiation exposure from CT scans; enough to cause an one additional cancer of some type per 1000 people tested.  People can also screen themselves with a Barium Enema combined with a Flexible Sigmoidoscopy (a scope passed into the first 60cm of the colon from the rectum).  Doesn’t work as well, has a 3.4 in 10,000 complication rate…and you have to proceed to a full colonoscopy if they see something!  All in all, you are best off with the colonoscopy.  They are working on “Capsule Endoscopy” where you swallow the camera and they take pictures, but the data is not yet sufficient to make a recommendation.  However, again, if they see something you will need a colonoscopy anyway!

Screening for Osteoporosis

Screening for low bone density, or “osteoporosis” is done by performing a very low radiation test called a Dexascan.  There are ultrasound methods which look at your feet or fingers, but they do not work very well and are probably only good for screening high risk patients.  Current guidelines suggest that screening women over the age of 65 is a Grade B recommendation, as finding and treating asymptomatic osteoporosis does save lives (the average lifespan of a woman after her first hip fracture from a fall declines dramatically and is less than 1 year if they can’t fix it due to high surgical risk).  The real controversy is whether or not we should scan post-menopausal woman (age 50-ish to 60).  Screening in this age group is a Class C recommendation.  I recommend screening this lower age group in women who are at high risk (i.e. family history of osteoporosis or if they fit the “profile” for a woman who will get it:  Small, Caucasean/Asian, female.) or if they have other risk factors (steroid use, chemotherapy, malnutrition, vitamin D deficiency, alcoholism, drug abusers).  When to do follow-up screening is based on the findings at the first test.  Men over the age of 75 also can be considered for screening.

Breast Cancer Screening

Screening women, ages 50-74, for breast cancer is a Class B recommendation.  Screening before the age of 50 is a Class C recommendation.  Over the age of 75 is Class I.  The controversy about screening women age < 50 has been discussed earlier.  Interestingly, the Task Force recommends against (Grade D) teaching Breast Self Examination.  The data show that women who examine their own breasts are much more likely to find benign findings which require follow up testing (i.e.  mammograms, ultrasounds or biopsies) than findings of a malignancy.  Thus, the cost and suffering for these women is much higher, as well as exposure to interventions which might have complications.  Although I think it would be a hard sell to encourage doctors not to teach breast self-exam because of all the publicity it has been given, it may well be that it does more harm than good for most women.

Screening for High Cholesterol

Another slam dunk!

Testing people over the age of 35 is a Grade A recommendation.  No risk and tons of benefit.  We can prevent strokes and heart attacks and save lives by finding high cholesterol early and treating it.  I did an entire blog on high cholesterol, so please feel free to go back into the Archives and read more about it.  Testing people age 20-35 is a Grade B recommendation (Grade A if they have any other risk factors, such as a family history of high cholesterol or heart disease).  The task force actually did break down their recommendations into many sub-groups, dependent on risk, but it is far more complex than most people need to know.  That’s why you pay your doctor!

Vaccines

I did a huge blog about the benefit of vaccines so please read it (and there are several follow ups, but the original blog was one of my first ones), and the Task Force bows to the superior data and knowledge of the CDC when it comes to determining the benefit of vaccines (and even provide a link to the CDC page).

Summary:  Get your vaccines.  Get them all.  They extend lives and save lives more than every intervention listed in this blog, put together! Vaccinate yourself.  Vaccinate your family.  Vaccinate your children.  Listening to any other advice about this is a critical misrepresentation of the facts and medical knowledge.

The Yearly Physical

A lot of people do not get their yearly physical.  Again, they feel well, so they think it’s pointless!  The fact is that if you get your yearly physical, your doctor will do all of the preventive care we talked about in the paragraphs above!  There was a study that showed that people who got yearly physical exams from an Internist lived 7 years longer than people who did not.  There was some problem with this study, in that you could argue that people who get yearly physicals are more worried and involved with their healthcare in general!  All the same, the study did show a remarkable difference between people who saw their doctor yearly and those who did not.  Apart from cost, there can be no argument against it, so I certainly recommend a yearly physical for all patients 40 and older, and at least every other year for patients under the age of 40 who have no significant medical problems and take no medications on a regular basis.

Website for the United States Preventive Services Task Force:

http://www.uspreventiveservicestaskforce.org/recommendations.htm

Good Health!

Dr Mike

In one sense GP practices are small businesses.  They are not directly employed by anybody and must make as much money as they can.  But that money comes from government in doses which encourage the GPs to do as much screening as they can.  There is no evidence that it benefits anyone’s health.  Of course, stats are produced which purport to show that all sorts of diseases are “caught” early and lives are saved, but the stats are of very dubious value, since there are no valid comparisons.  What’s worse, the GPs do not have to regard their patients as customers of their small businesses, and can order them about disdainfully.  The GPs have become immensely well paid in the process.

I don’t know how this can be changed.  But I know it’s eating up money which could be better spent elsewhere.

The following is excerpted from Dr. Jennifer Ashton’s “The Early Show” report. Please see http://www.cbsnews.com/stories/2010/03/30/earlyshow/health/main6346394.shtml for the full article.

On “The Early Show,” CBS News Medical Correspondent Dr. Jennifer Ashton said screenings are traditionally recommended to begin for low-risk patients at age 45 and repeated every three years after. Low-risk, Ashton explained, means you are not overweight, obese or have a family history. But a new study in in The Lancet medical journal, may change things. The research, based on a sample of the U.S. population, says earlier screening for Type 2 diabetes, starting between 30 to 45 years, can reduce heart attacks, diabetes-related complications and even death. Researchers recommend that people have their screenings done along with cholesterol and blood pressure tests.

Ashton explained there are currently three tests available for diabetes. The two older tests, Fasting Plasma Glucose Test and Oral Glucose Tolerance Test for Diabetes, both require overnight fasting. A “newer” test called the A1C test is a simple blood test and does not require fasting and can diagnose a stage before Type 2 diabetes called pre-diabetes. The A1C provides an average of your blood sugar control for up to three months.  “These are all tests that can help catch the disease before it becomes too late and the harm is done to your body,” she said.

Nearly 18 million Americans are currently diagnosed with diabetes, according to the American Diabetes Association. However, an additional 5.7 million Americans have Type 2 diabetes — but don’t even know it. Type 2 diabetes can cause serious health complications. That’s why is very important to know how to spot type 2 diabetes symptoms. Even pre-diabetes can increase the chance of heart disease just like type 1 or type 2 diabetes. Talk to your doctor about preventive measures you can take now to reduce the chance of type 2 diabetes and heart disease.

According to WebMD’s Diabetes Guide, the symptoms of type 2 diabetes due to high blood sugar may include:

• Increased thirst
• Increased hunger (especially after eating)
• Dry mouth
• Frequent urination
• Unexplained weight loss (even though you are eating and feel hungry)
• Fatigue (weak, tired feeling)
• Blurred vision
• Headaches
• Loss of consciousness (rare)

Other symptoms of type 2 diabetes may include:

• Slow-healing sores or cuts
• Itching of the skin (usually around the vaginal or groin area)
• Frequent yeast infections
• Recent weight gain
• Velvety dark skin changes of the neck, armpit and groin, called acanthosis nigricans
• Numbness and tingling of the hands and feet
• Decreased vision
• Impotency

You should contact your health care provider if you have any type 2 diabetes symptoms or if you have further questions about type 2 diabetes. It’s important to get diabetes testing and start a treatment plan early to prevent serious diabetes complications.

If you are uninsured or have a high-deductible, don’t let concern over screening costs keep you from getting the tests you need to stay informed and healthy. The  A1C Test and the Fasting Plasma Glucose Test can be ordered online through SaveOnLabs . At just $18.50 and $17.50 respectively, SaveOnLabs offers the tests for a considerable savings over standard published rates. The tests are performed at your local LabCorp testing site. You will receive a copy of your results that you can then share with your doctor.

Healthy pregnancy is based in large part on maternal nutrition.  As a midwife, I want to work with all women, ideally before conception, and also early in pregnancy to identify and adopt healthy eating practices to sustain the woman and her fetus throughout pregnancy.  I will ask women in my care to complete a diet diary at the start of care and when any concerning symptoms arise. Because it is the standard of care, I will offer GTT to all of my clients, but what I care about the most is how a woman’s blood sugar is responding to the food she puts into her mouth every day, and unfortunately the GTT provides no information about a pregnant woman’s daily blood sugar levels. My strong preference as a clinician is to have a woman record fasting and postprandial blood sugars along with her intake and activity for several days around the time a GTT would typically be done.  Yes, this means more pokes, though overall less blood, as a home glucose monitor uses only a drop of blood from a finger for each glucose measurement.

I believe for most women the pokes are worth it; the daily log tells woman, midwife, and any consulting doctor who may have to be involved in care, what the woman’s blood sugar was at the point in her pregnancy where her body had the highest levels of blood-sugar-raising pregnancy hormones.  It also puts the woman at the center of her care; she performs the testing at home, while also reflecting on her food choices and their relationship to her blood sugar. In evaluating the results, she won’t need a midwife to explain to her what the numbers mean, rather she’ll see the foods that elevate her blood sugar to unsafe levels, and thus learn what foods to avoid.  If she records her daily physical activity as well, she will see how using her body can help keep her blood sugar under control. Rather than raising red flags and engendering fear, this practice can actually give a woman the information and the tools to control her own health, and that is what I want my midwifery to be about: education and empowerment.

The method I describe above will also detect those women for whom no amount of dietary diligence and physical activity can control their blood sugar, women with pathological metabolic disorders that require medical intervention, but it will not treat every pregnant woman as a pathological metabolic disorder waiting to happen.  I think of it as using the tools of science and medical technology to listen to the bodytides, the inner rhythms of the pregnant body.

In essence, these appear to be the significant features of these new guidelines: (1) physicians should better educate men about both the risks and benefits of using the PSA test for screening; (2) less use of a rectal exam for screening; and (3) a cutback in the use of “mass screening” for prostate cancer such as at community health fairs, community centers, and the like.  

Several recent studies have suggested that large numbers of tumors identified by PSA screening are inconsequential and that biopsies and treatment produce more harm than those tumors would.

The L.A. Times quotes Dr. Otis W. Brawley, chief medical officer of the American Cancer Society, who said the new guidelines were not that different from those issued in 1997 and 2001.  They are more a change in emphasis of informed consent to patients and direction to health care providers, who do such screening, to inform those patients of the relative risks and complications (of unnecessary treatment) associated with screening.

Now, Dr. Brawley added, “we have two clinical trials that very vividly illustrate the uncertainties associated with screening,” which makes it even more important for men contemplating the PSA tests to understand the risks. Those major trials showed that PSA screening does not lower the risk of death from prostate cancer and might actually increase it slightly, perhaps from unnecessary treatments.

The risks are not in the screening procedures themselves (PSA and/or rectal exam); they lie in what follows from screening – biopsies, radiation, prostactectomies and other forms of treatment.  The goal of the new guidelines – a better educated patient on the relative risks and complications  of screening and the resultant treatment that may follow (e.g. urinary incontinence and impotency) – is not embraced by all in the spheres of medicine and patient health.

Skip Lockwood, president of Zero — The Project to End Prostate Cancer, said that calls to end the digital rectal exam were “kind of nuts. . . . The whole concept that you would do anything to reduce the amount of information you have does not make sense to me.”

From the specialists in urology, there is also this admonition:

Dr. S. Adam Ramin, a urological oncology specialist at St. John’s Health Center in Santa Monica, said that the cancer society guidelines placed too much emphasis on whether the tests saved lives and not enough on whether they prevented complications from tumors, such as leaking of urine, incontinence, bone pain, anemia and weight loss.

“Although it is true that treatment will not necessarily save a lot of lives, it does prevent complications,” he said.

While the American Cancer Society is not advocating the termination of prostate cancer screening by any means, it is expressing a very worthwhile concern – are patients who are screened and advised of positive test results fully aware of the risks involved in treatment as well as the benefits (lessening of tumor complications, for example) when making potential life-altering decisions about treatment options?   The bottom line – have the test, get your results but understand in a meaningful way what your options are and what risks you run  - THEN decide.

Education should accompany prostate screening, new guidelines say – latimes.com.