Transradial in the Spotlight

As some of you know, the transradial approach to cardiac cathterization is a specialty of CCNM's Dr. Jordan Safirstein. The use of the wrist to access the heart, instead of the groin, has now moved beyond niche procedure and is growing in frequency every year. The lack of associated bleeding complications and improved patient comfort have begun to wear down even the most staunch femoral supporters. While Europe and Asia have zoomed ahead of us in their utilization of the radial artery for cath, the U.S. has begun to catch on. The NJ Star-Ledger recently published a great article along with an online pictoral display of the entire procedure from beginning to end. Check it out here:

• Pictures of transradial cardiac catheterization
• NJ Star-Ledger's A second opinion on unclogging arteries: Catheters through wrist, not groin

Should Your Doctor Be Forbidden to Ask You Certain Questions?

A new law in Florida restricting physicians' ability to interview their patients has the local medical community up in arms.

In early June,  Governor Rick Scott signed a law prohibiting any written or verbal questioning regarding owndership of a firearm.

As a physician, I feel it is my job to look out for the safety of my patients and the thousands of family practitioners and pediatricians in Florida I'm sure feel similarly. Preventing a child's doctor from attempting to educate a parent or teenager about gun safety seems not much different from asking and etaching patients about safe sexual practices or drug use or eating habits. Why would gun owners want to hide this information? And it amazes me that an ostensiblyu intelligent man and accomplished politician would try to prevent physicians from asking this question. Well, some local doctors and medical societies agree with me and have filed suit in Miami Federal COurt to overturn this law.

Please read more below from TheHeart.org...

Miami, FL - A group of physicians and several medical societies have sued Florida Gov Rick Scott and other state officials in a Miami federal court to overturn a new Florida law forbidding clinicians from asking patients if they own a gun.

The physicians argue that this "gag law" will prevent them from counseling patients about keeping guns unloaded and locked up, which can spare children and adults from shooting deaths, accidental and otherwise. Supporters of the law such as the National Rifle Association (NRA) counter that it will protect the privacy of gun owners and "keep politics out of the examination room."

The lawsuit seeks a temporary injunction against the new law and a declaration that it violates the plaintiffs' constitutional right to free speech as well as due process. The outcome of the case could have a bearing on a "don't-ask" bill pending in North Carolina and future legislation in other states.

"If the court upholds our law, it's free rein everywhere," said Dr Louis St Petery, a pediatric cardiologist in Tallahassee, FL and executive vice president of the Florida chapter of the American Academy of Pediatrics (AAP), one of the plaintiffs in the suit.

The cause of safe gun storage became dear to him, he said, after he and his wife Dr Julia St Petery, also a pediatrician, attended the funeral early in their careers of a two-year-old child who was shot by a five-year-old sibling with a handgun plucked from their parents' bedside drawer.

"It impressed me for life," St Petery said about the shooting. "I thought to myself, 'This is an issue I have to pay attention to.' "

No questions, no trust

The suit, filed on June 6, comes four days after Scott signed the law. The measure prohibits written as well as oral inquiries regarding firearms ownership, entering such information into a medical record, "unnecessarily harassing" gun owners, or turning away patients who refuse to answer gun questions.

That last provision speaks to what supposedly prompted the Florida law. In 2007, a pediatrician in Ocala, FL, told a young mother to find a new physician after she refused to say whether she had a gun in the house, according to a local newspaper. The pediatrician was quoted as saying that his question was merely one part of a general discussion about household safety and that physicians have a right to drop patients who do not trust them.

An early version of the legislation stipulated that a violation would amount to a third-degree felony punishable by up to five years in prison, in addition to a fine as high as $5 million. An amendment scaled down the consequences to possible disciplinary action by the state health department.

Many patients lack knowledge about gun safety, says suit

Three physicians, along with the Florida chapters of the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), and the AAP, filed the suit, with national organizations also going on record opposing the law.

"Every year, thousands of Americans are seriously injured or killed when a child finds a gun and accidentally pulls the trigger, an argument between acquaintances or family members spins out of control, or a depressed teenager or adult becomes suicidal," the suit states.

The risk of those tragedies increases when guns are too handy, according to the suit, which asserts that one-third of US homes with children younger than age 18 have a firearm, and of these, more than 40% store them unlocked. Of this last subset, one-fourth store their guns loaded.

One of the physicians filing the suit, Dr Bernd Wollschlaeger (Ventura Family Health Center, North Miami Beach, FL), himself a gun owner and a concealed-weapon permit holder, noted that "many patients and parents are unaware of how to use child safety mechanisms and lockboxes and the importance of separately storing guns and ammunition."

Besides objecting to what they consider to be infringement upon the physician-patient relationship, the plaintiffs criticize the new Florida law as vague. For example, the law makes an exception for questions about firearms if a clinician in good faith believes "that this information is relevant to the patient's medical care or safety or the safety of others." The plaintiffs complain that the law never defines the criteria for relevance—or for harassment, for that matter.

Two of the physician plaintiffs said they will continue to ask about guns in the home because they consider the subject always relevant but would refrain from posing follow-up questions when patients respond unfavorably. In contrast, Wollschlaeger said that as long as the law is on the books, he would never bring up guns for fear a patient will complain to the Florida Board of Medicine.

NRA sees gun-ban agenda

To physicians, talking with patients about gun safety has a noble goal—averting injury or death. The NRA, however, views these discussions in a more sinister light. Its website speaks of pediatricians and other physicians "prying into our personal lives." Patients receive an "arrogant berating" if they refuse to answer questions "that violate privacy rights and offend common decency." And "horrified parents" worry that the federal government or private insurers will tap into computerized medical records, discover that they own firearms, and consequently deny them healthcare coverage.

More than anything, a distrustful NRA sees a political agenda in questions about gun ownership.

"This is not about safety, but the gun-ban politics of the American Academy of Pediatrics," said NRA board member and former president Marion Hammer in a recent interview posted on the group's website. Hammer, also the executive director of a Florida gun-rights lobbying group, points to AAP statements of support for banning handguns and assault rifles as well as the academy's advice that "the best way to keep your children safe from injury or death from guns is to never have a gun in the home."

In an interview, St Petery said that the NRA takes those AAP pronouncements out of context. "The NRA says we're out to wipe guns from the face of the earth," he said. "That's not true."

While the scientific evidence points to children being safer when homes are gun-free, he said, pediatricians also accept the reality that many parents own pistols and rifles. "If you have a gun, let's talk about how to store it," said St Petery, a father of three and a shotgun owner. He added that he has never heard of a pediatrician attempting to convince parents to get rid of their firearms.

The NRA also acknowledges the need to teach people about storing and handling firearms but contends that this job belongs to parents and private groups like itself. It claims that "voluntary firearms safety training, not government intrusion," is responsible for a dramatic decrease in firearm accidents. According to the NRA, the rate of accidental deaths related to firearms has declined 94% since an all-time high in 1904, while the annual number of these accidents has decreased by 80% since 1930.

The new Florida law, Hammer said, does not completely silence physicians on the subject of gun ownership. The "relevance" exception could come into play when doctors fear, for example, that a depressed person may be a danger to himself or others. In addition, the law leaves physicians free to distribute brochures on gun safety and any other public-health issue to all their patients, without asking any questions.

The physicians who sued in federal court to overturn the law find little benefit in these prerogatives. Again, they argue that the relevance exception is too vague to give them any assurance that they are obeying the law. They also consider it bad medicine to give gun-safety advice to every patient without asking questions to personalize their care.

"Such counseling, to be effective, requires a back-and-forth between patient and practitioner," their suit states. "Healthcare practitioners are not effective when they simply lecture their patients or hand them a pamphlet."

High Cholsterol Surprises

Not all of the high cholesterol foods are as obvious as milk, ice cream and egg yolks. Staying heart healthy is all about being aware of the not-so-obvious things that put you at elevated risk for coronary artery disease. So here's a few more clandestine cholesterol-containing food items:

1. Lobster - If you listen to most of my patients, they will tell you that anything that tastes good, is probably not good for you. And sure enough, this most prized crustacean packs a walloping 61 mg of cholesterol in every 3 oz bite! Add the melted butter and you might as well schedule your stress test for the following week. If you're going to splurge, avoid the butter (or most any "dipping" sauce for that matter), steam that sucker and watch your portions! By the way, processed shrimp, crab cakes and anything fried also have super high levels of cholesterol as well.

2. Chicken - But you were told it's so healthy, right? Well, it all depends on how it's prepared. With the skin on, a drumstick has more cholesterol than a cup of ice cream or a burger. Also, the dark meat, which tends to contain more fat, is higher on cholesterol. When the chicken is breaded, egg-dipped, fried, sauteed in butter/oil it becomes no more healthy than any of the other offenders above. Bake or broil it, stick to the white, skinless meat and surround it with vegetables - not batter.

3. Liver - While most of the younger readers will cringe at the thought of eating liver there are still many out there who gladly smother it in onions, spread it on a cracker or choose it in a fine dining establishment where it gains the much prettier title of foie gras. But no matter what name it is give, this organ meat is like the motherload of cholesterol, amassing more than a single day's daily allowance in one 3 oz chunk. Yikes! If you need further discouragement, just picture it when it's raw and that should do the trick.

4. Mashed potatoes - Surprise! They're not really much healthier than fries. The majority of recipes for this classic American side dish involve whole milk, lots of butter, and sour cream - the perfect storm. Throw some liver on top and you might break some kind of record.

5. Movie theatre popcorn - There seems to be a popular myth that popcorn is a healthy snack. This is very untrue unless you're popping those kernels in a pan by yourself, without oil. WebMD reports that Regal Cinema's medium-sized popcorn has a whopping 60 grams of saturated fat and 1,200 calories. Not healthy! Definitely do not add any of the liquid coronary-clogging butter and go for the small - we want you to have some enjoyment!

Stay tuned for the next installment where we discuss foods that may actually improve your cholesterol profile.

Red and Blue Berries Good for your Blood Pressure?

A recently published study has suggested that fruits and vegetables that are rich in anthocyanins--such as blueberries, strawberries, and blood oranges--may help prevent the development of high blood pressure, new research suggests.

It seems like every week we hear about a new food that is good, or bad, for your health and even the same foods have sometimes been linked with both good and bad data. What is most important is to see HOW the scientists performed the study and what their actual conclusions were. In other words, you must take these news snippets with a grain of salt (pun totally intended).

The media is very fond of stories like this because they are widely applicable to the general public and everyone can relate to eating berries, etc. However, just because a newspaper or Yahoo! publishes a study, it does not mean that it was well done or even clinically relevant. Sometimes, it's just interesting.

In this most recent food-for-therapy study, the subjects, who did not have high blood pressure at baseline, were asked to complete health questionnaires every two years, and their dietary intake was assessed every four years through a food frequency questionnaire. But this does not account for so many factors that also may have contributed to their blood pressure or health changes, e.g. drinking, smoking, social factors, other illnesses etc. In scientific lingo, these are known as confounding variables, ie factors that may impact the results of a study that cannot be controlled. There are ways, in a questionnaire-based study to try and make up for these variables but inevitably the study becomes less accurate because of it.

The most accurate studies are those that analyze 2 groups of patients, one which uses the treatment and one that does not - and neither group, nor the scientists are aware who is getting what. This is known as a randomized, double-blinded, control trial.

This is not to say that the results culled from thousands of questionnaires and analyzed by very smart people should be completely discounted but what we do with the results and how we interpret them and integrate them into recommendations for patients is very important. Here's what the author of the trial, Dr. Aedin Cassidy, stated - which often gets buried under a bold, sexy headline:

"Our findings are exciting and suggest that an achievable dietary intake of anthocyanins may contribute to the prevention of hypertension."

OK. That's a fair statement. Weekly intake of these blueberries, strawberries and foods high in anthocyanins MAY prevent development of high blood pressure.

"In terms of guidance to patients, I think this can help us give a little bit more targeted advice. Rather than just telling them to eat more fruit and vegetables--which they are tired of hearing--we can try to refine messages about which dietary components are beneficial in terms of cardioprotective effects," she says.

She cautions, however, that these findings come from an observational study and so will require confirmation in interventional trials.

Dr. Cassidy concludes by nothing that the next stage of the research will be to conduct randomized controlled trials with different dietary sources of anthocyanins to define the optimal dose and sources for hypertension prevention, enabling the development of targeted public-health recommendations on how to reduce blood pressure.

So are the red and blue berries good for high blood pressure? The take home message is that they might be, but more refined studies would need to be performed to say this with any certainty.

Quitting Smoking Great for Your Heart - And Wallet

According to a recent study by the University of Wisconsin's Center for Tobacco Research and Intervention, the cost of smoking cessation pales in comparison to the annual impact of cigarettes on your bank account. Oh yeah, and did we mention that smoking is horrible for you and causes lung cancer, coronary artery disease, impotence and peripheral artery disease?

The average cost of a pack of smokes is $5.51, which amounts to about $2,000 per year if you're anywhere close to a pack per day. If you're  living in one of the many places that has taxed cigarettes, then you are paying almost double that. A brief search on Expedia.com shows you that this is more than enough to take your spouse/friend/co-quitter with you on a Caribbean cruise on any major cruiseline. Hmmm, smell like smoke, increase my chance of multiple diseases or take a Caribbean cruise and improve my overall health substantially? It's a tough one.

Free Quitting Resources:

• Call the toll-free number (800) QUIT-NOW (1-800-784-8669)
• Smokefree.gov, a Department of Health and Human Services website.

More resources and the full body of the news article can be found by clicking here.