Saturday, April 26, 2008

Stressed out? Turmoil takes a toll on diet, exercise routine

Thu Apr 24, 6:30 PM ET
Stressed workers often reach for calorie-rich foods, skip the gym after a taxing day or forego meals because of heavy workloads. Or they indulge in other bad-for-you behavior like smoking, drinking or staying out late.
As the credit and housing crises rattle Wall Street, pressures over bigger workloads, job security and shrinking nest eggs are upending diets and fueling unhealthy habits across the country.
Breakfast is diet Pepsi and two packets of M&M's. For lunch, macaroons and white chocolates filled with marzipan from the farmer's market near Wall Street.
After learning her job would be cut this summer, Kelly Daly started reaching more frequently for the soothing effects of sugar.
"It's a stress reliever. Especially now that a bunch of us are going to be laid off," said the 49-year-old Daly, whose job reviewing medical insurance records in Manhattan's financial district is being cut after 11 years.
But it is in times of duress, experts say, that minding your health is perhaps more critical than ever.
Eating right and getting exercise may seem burdensome and even frivolous under such circumstances, but it actually gives people a greater sense of control and calm, said registered dietitian Heather Bauer, author of "The Wall Street Diet."
"It's one less thing to stress you out," Bauer said. "If you're out of a job or in a financial slump, it can give you a sense of inspiration as well."
For Aleksandra Cogura, heftier workloads in recent months means skipping lunch. If she's lucky, she'll manage to grab breakfast on the go. Once a gym regular, she hasn't been in four months.
"I just feel like I need to complete my work," said Cogura, a 44-year-old sales analyst in publishing in Manhattan.
Stress can take more serious, physical tolls. People under great stress release hormones and nerve chemicals that weaken the immune system, rendering them more susceptible to illness, said Dr. Esther Sternberg, who studies the effects of stress at the National Institute of Mental Health. Stress can also slow the body's ability to heal wounds, she said.
That could all translate into higher worker absenteeism, and those who do show up are likely not as productive when under great stress, said David Ballard, who specializes in work stress issues at the American Psychological Association.
Some ingredients for happy, productive workers include a flexible work-life balance, employee recognition programs and an atmosphere that lets employees take part in decisions, he said.
"It's about looking at the big system, creating a work place that puts a variety of components in place," Ballard said.
For individuals, reducing stress means "controlling the things you can control" when works seems to get too chaotic, said Marlene Clark, a dietitian with Cedar Sinai Medical Center in Los Angeles.
Taking a brisk, 10-minute walk can do wonders for clearing the head, Clark said. She suggests penciling the breaks in and giving them as much priority as other meetings.
Laying off the caffeine — coffee, tea, soda or even chocolate — could also help calm nerves, she said. Getting enough sleep is critical, too, especially when faced with more demanding work and hours, Clark said.
Taking such measures to reduce stress will only become more critical as the economic forecast darkens.
The nation's unemployment rate, now at 5.1 percent, is expected to move higher in coming months. Gasoline and food prices are at record levels, too, with ground beef, milk, apples, coffee and orange juice costing more these days.
"The first thing people want to do when they get stressed is eat stuff that's bad for them," said Bauer, who counsels Wall Street executives. "But the end result is that they're more stressed out because they're eating something they shouldn't have."
On the Net:
Information on stress:
Andy Dick, an affiliate of The Institute for Medical Wellness has some helpful tips:

I think it is important that everyone acts selfishly to an extent. Take care of yourself first. By this, I mean to put your health, wellness, and happiness with your life before deadlines and perceived stresses by outside influences. If you take care of yourself, and feel better overall, every aspect of your life should be the better for it. If you are well rested, properly nourished, and enjoying your choices, then your personal life should be better, your family life should see benefits, and you should be a better, more efficient worker. I think it is important that I note I am not specifically talking about exercise. Although I feel that exercise is important to most, this should be a personal decision. If it does not make you feel better short, or long term, than you need to change what you do.

Rest, healthy living, nutrition, personal enjoyment, and anything else that you value should never be put on the back burner.

Andy Dick
Owner, Optimum Results
(609) 304-7598
One of my favorite movies growing up was “The Karate Kid”. Mr. Miyagi (The karate instructor) taught Daniel (the Karate Kid) the meaning of the word Balance and how it relates to ones own life. There are many things that are important in life, and we need to balance out the good with the not so good, the stressful with the calming. We always look for things that make us happy, but sometimes the quick burst of happiness can cause further problems down the line. I try to tell my daughter, when she needs to make a decision, think of safety, health and happiness in that order.
First what you want must be safe, then it must be healthy for you, and then it should make you happy. Choosing happiness over safety or health will just make you end up in my office sooner rather than later!

Steven Horvitz, D.O.
Founder of The Institute for Medical Wellness
For past issues of the Newsletter please click here.
More information on Dr. Horvitz can be found at his website at

Tuesday, April 22, 2008

Heart exam, EKG recommended before children get ADHD drugs

By STEPHANIE NANO, Associated Press Writer

Children should be screened for heart problems with an electrocardiogram before getting drugs like Ritalin to treat hyperactivity and attention-deficit disorder, the American Heart Association recommended Monday.

Stimulant drugs can increase blood pressure and heart rate. For most children, that isn't a problem. But in those with heart conditions, it could make them more vulnerable to sudden cardiac arrest — an erratic heartbeat that causes the heart to stop pumping blood through the body — and other heart problems.

About 2.5 million American children and 1.5 million adults take medication for attention-deficit hyperactivity disorder, or ADHD, according to government estimates. Stimulant drugs, like Ritalin, Adderall and Concerta, help children with ADHD stay focused and control their behavior.

The medications already carry warnings of possible heart risks in those with heart defects or other heart problems, which some critics said were driven more by concerns of overuse of the drugs than their safety.

The heart group is now recommending a thorough exam, including a family history and an EKG, before children are put on the drugs to make sure that they don't have any undiagnosed heart issues.

"We don't want to keep children who have this from being treated. We want to do it as safely as possible," said Dr. Victoria Vetter, a pediatric cardiologist at the University of Pennsylvania School of Medicine and head of the committee making the recommendation.

The label warnings were added after a review by the Food and Drug Administration of its databases found reports of 19 sudden deaths in children treated with ADHD drugs and 26 reports of other problems including strokes and fast heart rates between 1999 and 2003. There were also reports of heart problems in adults; the committee didn't look at adults.

An EKG can detect abnormal heart rhythms that can lead to sudden cardiac arrest. Children who are already on ADHD drugs should also be tested, Vetter said. If problems are found, the child should be sent to a pediatric cardiologist. With careful monitoring, Vetter said, children with heart problems can take the medicines if needed.

The cost of an EKG varies depending on who does it and the location. For example, the amount that Aetna Inc. pays for an EKG in a doctor's office ranges from $24 to $50; Medicare's payment rate is about $23. Vetter said Children's Hospital of Philadelphia, where she works, has been doing EKG screening for three years and it has been covered by insurance.

She said a screening of about 1,100 healthy children found that about 2 percent of them had some kind of heart problem.

"We thought it was reasonable to include the electrocardiogram as a tool for the pediatrician, the psychiatrist so that this would help identify additional children who have heart disease," Vetter said.

But Dr. Steven Pliszka, a child psychiatrist at the University of Texas in San Antonio, said he was baffled by the EKG recommendation. He said there's no evidence that sudden death is a bigger problem for children taking stimulants than for children who aren't taking the drugs.

Pliszka said an EKG might deter people from seeking treatment because it's an added expense and hassle. Psychiatrists aren't likely to have an EKG machine, and pediatricians might not either, making patients go elsewhere to get the test, he said.

The American Academy of Child and Adolescent Psychiatry recently updated its treatment guidelines for ADHD, and did not recommend routine EKGs, said Pliszka, who was the lead author. He has received research support or served as a consultant for makers of ADHD drugs.

"We definitely did not feel we needed to screen everyone," Pliszka said.

He noted that the heart association doesn't recommended EKG screening for young athletes to prevent sudden death. The group has said it wasn't feasible or cost-effective to screen all student athletes.

Representatives for Shire PLC, which makes Adderall and two other ADHD treatments, and Norvartis Pharmaceuticals Corp., which makes Ritalin, said the labeling already suggests patients be evaluated for heart problems and an EKG done if needed.

"There's no new information here. And frankly, we're a little perplexed as to the purpose of the American Heart Assocation coming out with this statement at this time," said Shire spokesman Matt Cabrey.

An ADHD advocacy group called CHADD said parents should monitor their child's reaction to all medications. EKG screening "will bring an even further measure of safety to what is already a safe clinical treatment approach," the group said.


On the Net:

ADHD drugs:

American Heart Association:

National Resource Center on ADHD:
This article shows another case of putting the fear into parents of "Should I get this test or not???"
Heart abnormalities in children, thankfully are extremely low. I do not understand the reasons for recommending EKG's for children before potential treatment with ADHD stimulant medication. A thorough history and physical should tell most doctors whether the child is at risk for side effects.
Could the American Heart Association be recommending this to drum up more business??
My job is to help my patients stay healthy, through good preventive care and guidance, hopefully with as little medication and unnecessary testing as possible.
How do I know whether to recommend testing? By spending extra time talking with my patients and really honing in on the problems that need to be dealt with. The more specific we get, the less testing and treatment necessary!!
Steven Horvitz, D.O.
For past issues of my newsletter please click here.
August 10, 2008
Addendum: Copied below is the AAP (American Academy of Pediatrics) opinion on the above topic which agrees with my opinion.
AAP and AHA Differ on ECG/ADHD Advice

Sue Hughes

Heartwire 2008. © 2008 Medscape

August 1, 2008 — The American Academy of Pediatrics (AAP) has issued a new policy statement emphasizing that routine ECGs for children receiving medications for attention-deficit/hyperactivity disorder (ADHD) are not warranted [1]. The statement comes after advice given by American Heart Association (AHA) earlier this year [2], that physicians consider ordering an ECG to aid them in deciding whether or not underlying heart disease is present before prescribing ADHD drugs.

A spokesperson for the AHA told heartwire that in May/June it "clarified" its original advice, issued in April, in a joint advisory from the AHA and the AAP [3], saying that an ECG should be at the physician's discretion and it is not mandatory to obtain one. The AHA also updated its original statement [4]. "Our recommendations have not changed since we issued them this spring. Rather, we issued a clarification as a result of confusion and concern among the public and healthcare professionals. Routine use of ECGs to assess these children has not ever been part of our recommendations," the spokesperson said.

The current statement from the AAP, published in the August 2008 issue of Pediatrics, formalizes its position on the issue, an AAP spokesperson told heartwire. However, the two organizations still seem somewhat out of kilter on the strength of the advice they are issuing, with the AHA still more strongly recommending the use of an ECG than the AAP.

AHA Recommendations

The AHA makes the following recommendations for children starting ADHD medications:

  • A thorough patient and family history should be obtained for assessment of these children. This is a class I recommendation (using the ACC/AHA classes of recommendations and levels of evidence).
  • Acquiring an ECG is a class IIa recommendation. This means it is reasonable for a physician to consider obtaining an ECG as part of the evaluation. It is not mandatory, but rather is left to the physician's discretion. Treatment of a patient with ADHD should not be withheld because an ECG is not done. The child's physician is the best person to assess whether there is a need for an ECG.
  • It is reasonable to use ADHD medications with caution in patients with known congenital heart disease and/or arrhythmias if these patients are stable and under the care of a pediatric cardiologist.

Latest AAP Statement

The latest AAP statement says that the AHA's recommendation to obtain an ECG before starting medications to treat ADHD "contradicts the carefully considered and evidence-based recommendations of the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics." It notes that these organizations have concluded that sudden cardiac death in people taking medications for ADHD is a very rare event, occurring at rates no higher than those in the general population of children and adolescents. It also notes that it has not been shown that screening ECGs before starting stimulants have an appropriate balance of benefit, risk, and cost-effectiveness for general use in identifying risk factors for sudden death. "Until these questions can be answered, a recommendation to obtain routine ECGs for children receiving ADHD medications is not warranted," the statement concludes.

The AAP statement adds that the authors of the AHA statement acknowledge the lack of evidence showing a benefit of routine ECG screening for these children, but still assigned their recommendation for screening a IIa classification (weight of evidence/opinion is in favor of usefulness/efficacy) and a category C level of evidence (only consensus opinion of experts, case studies, or standard of care). The AAP disagrees with both of these classifications. "Using AHA criteria, the AAP would, at most, classify this recommendation as IIb ('the level of evidence is less well established by evidence/opinion . . . . Additional studies with broad objectives needed'). In addition, using the AAP classification of recommendations, the AAP would assign the recommendation a category D level of evidence (on the basis of expert opinion without even observational studies)," the statement says, adding that the AAP avoids making guideline recommendations with a category D level of evidence.

It further claims that expert opinion suggests that the harm outweighs the benefit of recommending routine ECGs for healthy children who are starting stimulant medication for ADHD. "Accordingly, the AAP would recommend against such routine ECG screening," the statement concludes.

AAP Recommendations

The AAP makes the following recommendations:

  • Careful assessment of all children, including those starting stimulants, using a targeted cardiac history (eg, patient history of previously detected cardiac disease, palpitations, syncope, or seizures; a family history of sudden death in children or young adults; hypertrophic cardiomyopathy; long QT syndrome) and a physical examination, which includes a careful cardiac examination (evidence quality: C; strength: recommendation). If patient history, family history, or physical exam is suggestive of cardiac disease, further evaluation is advised, with input from a pediatric cardiologist.
  • Given current evidence, the AAP encourages primary care and subspecialty physicians to continue currently recommended treatment for ADHD, including stimulant medications, without obtaining routine ECGs or routine subspecialty cardiology evaluations for most children before starting therapy with these medications (evidence quality: D; strength: option).
  • More research is needed on risk factors for sudden cardiac death among all children and adolescents, including those with ADHD who are treated with stimulant medications. Better methods of detecting hidden cardiac disease in children should be another focus of such research efforts.

Nissen Disagrees with AAP

But cardiologist Dr Steven Nissen (Cleveland Clinic, OH) says the AAP statement is misguided. He commented to heartwire: "It suggests that as many as 8% of children should be treated with amphetamines or related stimulant drugs. These drugs increase blood pressure and have not been studied in long-term trials. The statement asserts that sudden death is not more common in children receiving these drugs. However, the FDA has issued a warning for all of the ADHD drugs that states that they can cause sudden death at usual doses. It is irresponsible for a professional medical society to recommend to its members that they ignore an FDA-mandated warning. This is the second time in a few weeks where the AAP has issued poorly thought out guidelines that promote inappropriate drug use in children. The previous statement promoted statin use in children as young as 8 years of age."

Wednesday, April 16, 2008

Ghostwriters for medical research criticized, reforms urged

By LINDSEY TANNER, AP Medical Writer 27 minutes ago

Two new reports involving the painkiller Vioxx raise fresh concerns about how drug companies influence the interpretation and publication of medical research.

The reports claim Merck & Co. frequently paid academic scientists to take credit for research articles prepared by company-hired medical writers, a practice called ghostwriting. They also contend Merck tried to minimize deaths in two studies that showed that the now withdrawn Vioxx didn't work at treating or preventing Alzheimer's disease.

Merck called the reports in Wednesday's Journal of the American Medical Association false and misleading. Five writers of the articles were paid consultants for people who sued Merck over Vioxx's heart and stroke risks; the sixth testified about Merck and Vioxx's heart risks before a Senate panel. Merck says those connections makes the reports themselves biased.

While Merck is singled out, the practices are not uncommon, according to JAMA's editors. In an editorial, they urge strict reforms, including a ghostwriting crackdown and requiring all authors to spell out their specific roles.

Dr. Catherine DeAngelis, JAMA's editor-in-chief, said those are already policies at JAMA but not at many other journals.

"The manipulation is disgusting. I just didn't realize the extent," she said.

The practices outlined in JAMA can lead editors to publish biased research that can result in doctors giving patients improper and even harmful treatment, she said.

DeAngelis said doctors, medical researchers and journal editors bear some responsibility for those harms.

"We're the ones who have allowed this to happen. Now we've got to make it stop," she said.

Drug studies involve several steps, including designing and performing the research, analyzing the results and writing them up for submission to a medical journal. Pharmaceutical companies sometimes pay for a study but have independent scientists perform all those steps. Sometimes companies and their own scientists are involved in some or all the steps, and those were the studies scrutinized in the JAMA reports.

The articles are based on reviews of company documents from court cases over Vioxx, which was pulled in 2004 because of its heart and stroke risks. Merck agreed to pay $4.85 billion last November to settle thousands of lawsuits.

One JAMA report says internal company data showed in 2001 that Vioxx patients in two Alzheimer's studies had a higher death rate than patients on dummy pills. Merck didn't publicize that "in a timely fashion" and provided information to federal regulators that downplayed the deaths, the report said.

But Jim Fitzpatrick, a Merck attorney, said "it's completely not true" that Merck tried to minimize those deaths. He said a Merck analysis found the excess deaths were not related to Vioxx.

The other JAMA article says one Alzheimer study was designed and conducted mainly by Merck scientists. But when published, the lead authors listed were academic scientists not named in a study draft.

Peter Kim, head of Merck Research Laboratories, said those authors "were intimately involved in the studies." One was New York University Alzheimer's specialist Steven Ferris. He also disputed the implication that he had little to do with the study, and said Merck paid him for his work.

Fitzpatrick acknowledged that Merck has hired outside firms to write drafts of other studies that later list scientists as first authors. In those cases, the scientists are expected to review the manuscript and can suggest changes, he said.

The Alzheimer study was published in 2005 in the journal Neuropsychopharmacology. Its new editor, Dr. James Meador-Woodruff, said the journal's policies have been strengthened to ban ghostwriting.


On the Net:

If we did not trust the pharmaceutical industry before, how can we now?
Can we believe the hype and advertising that comes from this industry?
For those of you who know me well, I am not a big fan of medication. I prefer to use the least amount possible, and only after exhausting other options. I always prefer to find the cause of the problems and treat the cause with lifestyle adjustments first.
It sometimes take a little longer to come up with the solution, but it may save you both medication side effects and the cost of expensive medications.
If you think you are taking too much medication, please schedule an appointment so we can truly the assess their need, their benefits and their possible risks.
Always remember, that I work for you! Not for your insurance, not for the government!
You will get individualized and personal care and advice. That is what Family Practice is all about!!
Dr Steven Horvitz
For past issues of my newsletter please click here.
For more information on my office please visit my website at

Monday, April 07, 2008


Medicine mix-ups, accidental overdoses and bad drug reactions harm roughly one out of 15 hospitalized children, according to the first scientific test of a new detection method, according to a new study published in the medical journal Pediatrics.

Other findings:

  • Researchers found a rate of 11 drug-related harmful events for every 100 hospitalized children.
  • That compares with an earlier estimate of two per 100 hospitalized children, based on traditional detection methods.
  • The rate reflects the fact that some children experienced more than one drug treatment mistake.
  • The new estimate translates to 7.3 percent of hospitalized children, or about 540,000 kids each year, a calculation based on government data.
  • Simply relying on hospital staffers to report such problems had found less than 4 percent of the problems detected in the new study.

The new monitoring method developed for the study is a list of 15 "triggers" on young patients' charts that suggest possible drug-related harm. It includes use of specific antidotes for drug overdoses, suspicious side effects and certain lab tests. By contrast, traditional methods include non-specific patient chart reviews and voluntary error reporting.

The researchers said their findings highlight the need for "aggressive, evidence-based prevention strategies to decrease the substantial risk for medication-related harm to our pediatric inpatient population."

Patient safety experts said the problem is likely even bigger than the study suggests because it involved only a review of selected charts. Also, the study didn't include general community hospitals, where most U.S. children requiring hospitalization are treated.

Source: "Med Mix-Ups Hurt 1 In 15 Kids," USA Today, April 7, 2008.

For text:

Hospitals are dangerous places for children as well as adults.

The best way to prevent hospital errors is by avoiding hospitals. But to avoid hospitals you need to stay healthy.
Getting yearly wellness exams , learning about how your body works, learning about lifestyle modifications you can make to stay healthier will all help to achieve that goal.
How many of you are at an ideal body weight? If not do you know a healthy way to achieve it?
How many of you smoke and can't find a way to quit?
How many of you have had recent physical exams with proper laboratory testing to gauge your risks?
How many of you have sat with your doctor and talked about your families medical history and how it relates to you?
There are many things you can do to stay healthy. Truly knowing the status of your health and promoting continued well being is the foundation that gets you there.
If you have not done so already, set up a wellness physical. The time you spend will be well worth the good health you will enjoy!!
Steven Horvitz, D.O.
Founder Institute for Medical Wellness