Healthcare - always an issue during an election year - has even the New England Journal of Medicine presenting comments by presidential candidates Obama and Romney

Obama vs. Romney on Healthcare in NEJM

By Peggy Peck, Editor-in-Chief, MedPage Today

Published: September 26, 2012

 

Less than a week after they co-starred on TV's "60 Minutes," President Barack Obama and Governor Mitt Romney delivered another "showdown" with dueling commentaries on the Affordable Care Act, published online Wednesday by the New England Journal of Medicine.

The statements came in response to a request from NEJM editors asking the candidates to "describe their healthcare platforms and their visions for the future of American healthcare."

Not surprisingly, the statements were long on sound bites and light on details.

The president made a case for "Obamacare" -- and he, too, used that term in his statement, saying he doesn't mind the term because "I do care."

Romney pledged to repeal Obamacare and replace it with "common-sense, patient-centered reforms suited to the challenges we face."

If re-elected, Obama said his priorities will include:

• A permanent fix for "Medicare's flawed payment formula that threatens physicians' reimbursement"
• Medical malpractice reform that doesn't include "placing arbitrary caps that do nothing to lower the cost of care"
• Support of clinical research.

Moreover, he wrote, "I will keep Medicare and Medicaid strong, working to make the programs more efficient without undermining the fundamental guarantees."

Romney said he will control and reduce healthcare costs by offering incentives to do so to everyone, "providers, insurers, and patients." He did not, however, offer many specifics about those incentives, but he did call for changes in the tax code as well as strengthening and expanding "health savings accounts" and establishing "strong consumer protections."

A Romney-Ryan administration would not propose any changes to Medicare for current beneficiaries or for those who would be enrolling in the next 10 years, Romney wrote, but future beneficiaries would be covered through a means-tested premium support program.

Romney also pledged support of "those who cannot afford the care they need."

"We will provide support for low-income Americans and those uninsured persons whose preexisting conditions push the cost of coverage too high for them to pay themselves. But my experience as a governor and the lessons from the president's attempt at a one-size-fits-all national solution convince me that it is states -- not Washington -- that should lead this effort. I will convert Medicaid into a block grant that properly aligns each state's incentives around using resources efficiently. Each state will have the flexibility to craft programs that most effectively address its challenges -- as I did in Massachusetts, where we got 98% of our residents insured without raising taxes."

The health reform plan in Massachusetts, "Romneycare," has often been cited as a model for the Affordable Care Act, particularly in its implementation of an individual mandate.

Primary source: New England Journal of Medicine

Source reference:
Obama, B "Securing the future of American health care" This article was published on Sept. 26, 2012, at NEJM.org.

Additional source: New Enland Journal of Medicine
Source reference:
Romney, M "Replacing Obamacare with real health care reform" This article was published on Sept. 26, 2012, at NEJM.org.

Perhaps not so surprising, in a study funded by the makers of yogurt and cranberry juice, it was found that yogurt, cranberry juice and rice/bran oil all help to lower blood pressure.

Medscape Medical News from the:

• High Blood Pressure Research (AHABP) 2012 Scientific Sessions
  

This coverage is not sanctioned by, nor a part of, the American Heart Association.

From Heartwire > Conference News

Food Fighters: Yogurt, Cranberries, Rice/Bran Oil Lower BP

Lisa Nainggolan

September 20, 2012 (Washington, DC) — Including foods such as low-fat yogurt, sesame/rice-bran oils, and low-calorie cranberry juice in the diet can help keep blood pressure under control, according to three new studies presented as posters at the American Heart Association High Blood Pressure Research 2012 Scientific Sessions , this week [1,2,3]. And the rice/bran oil also helped lower LDL cholesterol and triglycerides and increased levels of HDL cholesterol, the meeting heard.

Asked to comment on the findings for heartwire , chair of the AHA's nutrition committee Dr Rachel Johnson (University of Vermont, Burlington) said: "These results, the three abstracts together, very much reinforce the DASH diet--which the AHA supports--as an effective dietary intervention to lower blood pressure and a heart-healthy way to eat."

DASH recommends two to three servings of fat-free or low-fat milk and milk products per day, four to five servings of fruit a day, and two to three servings of "healthy" fats and oils, "and certainly sesame/rice-bran oil, which contains polyunsaturated fatty acids and is rich in antioxidants, would be classified as a healthy fat," she observes.

Yogurt: Keep It Low in Fat and Sugar 
 
The yogurt research was presented by Dr Huifen Wang (Tufts University, Boston, MA), who together with colleagues examined the effects of consuming low-fat yogurt in just over 2000 adults participating in the Framingham Heart Study Offspring Cohort. Participants, who did not have hypertension at baseline, were said to be "consumers" if they ate one or more servings of yogurt per month, as noted by a food frequency questionnaire. Of those in the study, 44% were yogurt consumers at the beginning, and this increased over the 14 years of follow-up. There were 913 people who developed incident hypertension over the course of the study.

Yogurt can be an effective way to add milk or dairy products to your diet.

 

Those who ate >2% of total calories from yogurt (the high-intake group, representing one six-ounce cup of low-fat yogurt every three days) had about a 30% lower risk of incident hypertension than nonconsumers (OR 0.69, after adjustment for demographic and lifestyle factors and cholesterol medication use). The high-intake group also had 0.19-mm-Hg smaller annualized elevation of systolic BP than nonconsumers (p=0.04).

Johnson says: "Yogurt can be an effective way to add milk or dairy products to your diet, because many people do not come close to meeting those recommendations for two to three servings per day. The yogurt study reinforces what we already know about the role of dairy products." However, she cautions that care must be taken regarding the amount of sugar in yogurt: "We know that added sugars have the opposite effect on BP, so you need to watch the amount of sugar, and some yogurts are high in sugar."

Cranberry Juice an Option for a Fruit or Vegetable Portion 
 
In a second study, researchers from the US Department of Agriculture, led by Dr Janet A Novotny, gave low-calorie cranberry juice or a color/flavor/calorie-matched placebo beverage to 56 adult volunteers, incorporated into a controlled diet for eight weeks. At the end of the study, when BP values were compared with baseline, cranberry juice was associated with a significant decrease in diastolic BP (p=0.049) and a trend toward decreased systolic BP, while the placebo was associated with no change from baseline.

You can use cranberry juice or cranberries, which are rich in potassium and antioxidants, to meet that recommendation to eat plenty of fruits and vegetables.

 

Johnson observes that this was "a small study" and some key details are missing, such as the amount of cranberry juice consumed. Nevertheless, "It does show that you can use cranberry juice or cranberries, which are rich in potassium and antioxidants, to meet that recommendation to eat plenty of fruits and vegetables," she says. She notes also that low-calorie cranberry juice was employed in this study, "which I would certainly recommend. Cranberries are quite sour tasting, so they really do need to be sweetened to make them palatable, and full-calorie cranberry juice can be quite high in added sugars."

Blend of Sesame/Rice-Bran Oil Drops BP and Improve Lipids
 
Finally, Dr Devarajan Sankar (Fukuoka University Hospital, Fukuoka, Japan) and colleagues conducted a prospective, randomized open-label dietary-intervention study in 300 hypertensive patients in New Delhi, India, randomizing them to one of three groups: the calcium-channel blocker (CCB) nifedipine 30 mg/day; 35 g/day of a blend of sesame and rice-bran oil (trademark Vivo); or nifedipine plus sesame-oil blend for 60 days.

The CCB, sesame oil, and combination of the two induced significant falls in systolic BP (-16.2 mm Hg, -14 mm Hg, and -36 mm Hg, respectively) and in diastolic BP (-12 mm Hg, -10.8 mm Hg, and -23.8 mm Hg), respectively, over the course of the study. The combination resulted in such a remarkable drop in BP that the dose of nifedipine had to be reduced. And those using the oil saw a 26% fall in LDL and a 9.5% increase in HDL cholesterol.

"We have demonstrated, for the first time, that dietary interventions with blends of sesame and rice-bran oils lower BP and lipids in hypertensive individuals," say Sankar et al. However, they note that further studies of the oil--which was made specifically for this study and is not marketed commercially--are needed.

The yogurt study was funded by a research grant from Dannon and the cranberry study by Ocean Spray Cranberries. Sankar et al report no conflicts of interest.

Though its difficult learning how to get your baby to fall asleep on its own, a new study demonstrates that there is little harm in your child crying him/herself to sleep.

'Crying' to Sleep Safe for Babies

By Crystal Phend, Senior Staff Writer, MedPage Today

Published: September 10, 2012

 

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

 

Behavioral techniques for getting babies to sleep by themselves, such as camping out in the child's room initially, can be effective without any long-term downside for parents or children, clinical trial follow-up showed.

 

Sleep problems at age 6 weren't significantly more common among kids trained to go to bed with such methods as infants (9% versus 7% among controls, P=0.2), reported Anna M.H. Price, PhD, of the Royal Children's Hospital in Parkville, Australia, and colleagues.

The training didn't leave kids more distant from their parents or emotionally damaged, the group stated in the October issue of Pediatrics.

"Parents and health professionals can confidently use these techniques," they suggested.

The trial originally showed that "camping out" to get kids to fall asleep and "controlled comforting" to teach them to settle down on their own by gradually lengthening intervals at which parents respond to crying did improve infants' sleep and cut maternal depression by 60%.

Because of worries about long-term harm if parents don't consistently respond to their child -- as noted by the distress caused by an older technique that called for parents to let children "cry it out" without responding at all -- the researchers followed children into the school years.

Of the 328 families randomized to behavioral training or usual care for infant sleep problems reported at well-child visits by parents when the child was 7-months-old, 225 participated in the study for assessment around the child's sixth birthday.

For the primary outcomes, the intervention group didn't show poorer scores on children's emotional or conduct behavior (P=0.8 and P=0.6, respectively).

Likewise, the population-based study showed no differences between groups at age 6 for the following outcomes:

• Sleep habits (P=0.4)
• Parent-reported psychosocial functioning (P=0.7)
• Child-reported psychosocial functioning (P=0.8)
• Chronic stress as measured by saliva cortisol levels on a non-school day (29% versus 22%, P=0.4)
• Child-parent closeness (P=0.1)
• Conflict between parent and child (P=0.4)
• Overall quality of the relationship between parent and child (P=0.9)
• Disinhibited attachment (P=0.3)
• Depression, anxiety, and stress scores in the mother (P=0.9)
• Authoritative parenting, viewed as the optimal parenting style with warmth and control (63% versus 59%, P=0.5)

Although there weren't lasting benefits, the lack of harm suggested the techniques are safe, the researchers concluded.

They cautioned that loss to follow-up of about a third of families meant the study couldn't rule out small harms or benefits long term.

"Nonetheless, the precision of the confidence intervals make clinically meaningful group differences unlikely," they wrote.

The inclusion of only English speakers in largely more advantaged families might limit generalizability to other settings, they noted.

"Along with trials like ours demonstrating that sleep problems can be effectively treated in older infants, recent efficacy trials for children younger than 6 months suggest that parent education programs that teach parents about normal infant sleep and the use of positive bedtime routines could effectively prevent later sleep problems," they wrote.

The Infant Sleep Study was funded by the Australian National Health & Medical Research Council Project and the Pratt Foundation. The follow-up Kids Sleep Study was funded by the Foundation for Children and the Victorian Government's Operational Infrastructure Support Program.
The researchers all reported financial support from the Foundation for Children.

Primary source: Pediatrics
Source reference:
Price AMH, et al "Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial" Pediatrics 2012; 130: DOI: 10.1542/peds.2011-3467.

Once again another clinical trial demonstrates that the supplement ginkgo biloba is ineffective in preventing Alzheimer's Disease.

Forget About Ginkgo to Ward Off Alzheimer's

By Kristina Fiore, Staff Writer, MedPage Today

Published: September 05, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

 

 

Yet another large trial has failed to find long-term ginkgo biloba supplements effective at preventing Alzheimer's disease.

 

In a randomized, controlled trial of elderly patients who had complaints about their memory -- but no overt dementia -- there were no significant differences in the number of patients who progressed to dementia over 5 years whether they were taking ginkgo or placebo, Bruno Vellas, MD, of Hopital Casselardit in Toulouse, France, and colleagues reported in The Lancet Neurology.

Ginkgo has been used in some countries by patients with cognitive disorders, and its plausible mechanisms of action for brain benefits include antioxidant effects and potential inhibition of caspase-3 activation and amyloid-beta aggregation, the researchers wrote.

Yet several studies -- including the Ginkgo Evaluation of Memory trial reported in 2008 -- haven't been able to demonstrate that the plant extract can prevent dementia. Indeed, the entire field of prevention of Alzheimer's disease is lacking, with little effects seen for various therapies including hormone replacement therapy, NSAIDs, vitamins, and cholinesterase inhibitors, the researchers noted.

To further assess ginkgo's effects, Vellas and colleagues conducted the GuidAge trial of adults, ages 70 and up, who were free of dementia but reported memory complaints to their primary care doctors in France.

A total of 2,854 patients were enrolled between March 2002 and November 2004 and randomized to placebo or to 120 mg of ginkgo biloba extract twice a day.

Patients were followed for a median of 5 years, with 2,487 completing the trial.

Overall, the researchers found no significant difference in the proportion of patients who developed dementia over those 5 years: 61 in the ginkgo arm and 73 in the placebo group (HR 0.84, 95% CI 0.60 to 1.18, P=0.306).

That translated to a similar incidence of probable Alzheimer's disease: 1.2 per 100 person-years in the ginkgo group compared with 1.4 per 100 person-years in the placebo group.

Nor were there significant differences in diagnoses of pure Alzheimer's or mixed dementia: 70 among those on ginkgo and 84 among those on placebo, for a rate of 1.4 per 100 person-years and 1.6 per 100, respectively (P=0.267).

Also, the incidence of adverse events was similar between groups:

• Death: 76 for ginkgo, 82 in placebo (HR 0.94, 95% CI 0.69 to 1.28, P=0.68)
• Stroke: 65 for ginkgo, 60 in placebo (RR 1.12, 95% CI 0.77 to 1.63, P=0.57)

There were no differences in the incidence of other hemorrhagic or cardiovascular events, either, they added.

The study was limited because the number of dementia events was much lower than expected, leading to a lack of statistical power to detect effects, the researchers noted. There was also some evidence of selection bias, as those who chose to participate had a higher level of education than the general elderly population.

In an accompanying editorial, Lon Schneider, MD, of the University of Southern California in Los Angeles, wrote that more than 10,000 patients have now been involved in clinical trials of ginkgo biloba with no reported benefits.

"The GuidAge trial adds to the substantial evidence from the Ginkgo Evaluation of Memory trial ... that ginkgo biloba does not prevent dementia in elderly individuals with or without memory complaints or cognitive impairment and is not effective for prevention of Alzheimer's disease," Schneider wrote.

"It would be unfortunate if users of ginkgo biloba, nevertheless, are led to believe that the extract prevents the dementia. Some users will rationalize that, in the absence of effective treatments, ginkgo biloba could still possibly help, and appearing safe, will not harm them," he added.

But other users, he wrote, "might now consider letting it go."

Nikos Scarmeas, MD, from Columbia University Medical Center in New York City, said in an email to MedPage Today that the trial was "very well designed and executed" with a "long enough follow-up to see conversion."

When asked about the dearth of preventive strategies for Alzheimer's, Scarmeas acknowledged that there's little advice for Alzheimer's prevention. But "with an increasing number of scientists and researchers in the field and commitment and investment from society, we can be hopeful it will change in the future," he said.

The study was supported by Ipsen, producer of ginkgo biloba extract.
Two researchers are employees of Ipsen.
Scheider reported relationships with Ipsen and Schwabe, both makers of ginkgo extract. He also reported relationships with Baxter, Genentech, Johnson & Johnson, Eli Lilly, Novartis, Pfizer, Abbott Laboratories, AC Immune, Allon, AstraZeneca, Bristol-Myers Squibb, Elan, Exonhit, GlaxoSmithKline, Lundbeck, MedAvante, Merck, Roche, Sanofi, Servier, Takeda, Toyama, and Zinfandel.

Primary source: The Lancet Neurology
Source reference:
Vellas B, et al "Long-term use of standardized ginkgo biloba extract for the prevention of Alzheimer's disease (GuidAge): A randomized placebo-controlled trial" Lancet Neurol 2012; DOI: 10.1016/S1474-4422(12)70206-5.

Additional source: The Lancet Neurology
Source reference:
Schneider LS "Ginkgo and AD: Key negatives and lessons from GuidAge" Lancet Neurol 2012; DOI: 10.1016/S1474-4422(12)70212-0.

According to an article published in the Kaiser Health News, male healthcare does not fare as well as healthcare for women under the new ACA. So while political debates pop up regarding the ACA and who's more or less in support of womens healthcare, it seems important for men to inquire about getting all necessary healthcare for themselves.

Health Law Has Gaps in Services for Men

By Kaiser Health News

Published: September 02, 2012

 

 

The federal healthcare overhaul greatly expanded women's access to free preventive services, particularly for sexual and reproductive health. Men didn't fare nearly as well.

The Affordable Care Act guidelines' promise of free contraception may have generated the most controversy, but the law also provides many other services for women, including free screening for HIV, chlamydia and gonorrhea, and pregnancy-related benefits such as screening for gestational diabetes, and breastfeeding support, supplies, and counseling.

"Groups that were really focused on the health of women were identifying specific gaps that they wanted to make sure were covered," says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a research and advocacy organization.

Gaps in men's preventive health didn't receive the same focused attention by men's health groups, he says.

Under the law, new health plans or those whose benefits have changed substantially are required to provide four types of preventive care without any copayments or other forms of cost-sharing: services recommended by the U.S. Preventive Services Task Force (USPSTF), immunizations recommended by the CDC's Advisory Committee on Immunization Practices, and preventive services and screenings for women and for children that are recommended by the Health Resources and Services Administration (HRSA).

Sen. Barbara Mikulski (D-Md.) championed adding women's preventive services recommended by HRSA following an outcry over a USPSTF recommendation that regular mammography screening for most women begin at age 50 rather than age 40. In a separate amendment, she successfully pushed to reinstate the earlier recommendations that called for mammography screening starting at age 40. The new requirements substantially broadened the free preventive services available to women.

The new law requires most health plans to begin providing free contraceptives to women when their new plan year begins this fall or next year. It covers all FDA-approved methods, including permanent ones such as tubal ligation. But since its scope is limited to women's services, it does not offer free coverage for vasectomies.

Men's health specialists say both men and women could have benefited from such a requirement. Even though they're generally simpler and less expensive than female sterilization, cost can be a factor that deters men from getting vasectomies.

"Particularly for older men who are interested in playing a role in pregnancy prevention through sterilization, there are not many low-cost services available, even in a large city," says David Bell, MD, MPH, medical director of the Young Men's Clinic at New York-Presbyterian Hospital's Family Planning Clinic.

The health law also requires free coverage for screening for a number of sexually transmitted diseases in women but not men. For example, HIV screening is covered annually for all sexually active women. In men, free screening is recommended for those who are at higher risk, such as men who have sex with men or with multiple partners.

Similarly, the USPSTF, a federal panel of experts, recommends screening all sexually active women younger than 25 for chlamydia and screening at-risk women for gonorrhea. But the task force says there's not enough evidence to make such recommendations for men.

Some of the new preventive coverage requirements do address men's sexual health. For example, under CDC recommendations that become effective in December, new health plans must cover the three-shot human papillomavirus (HPV) vaccine for young men at no charge. Previously recommended for young women primarily to prevent cervical cancer, the vaccine is also associated with some cancers that affect men. It is recommended routinely for young men ages 11 or 12, and for those ages 13 to 21 who haven't been vaccinated.

It's no accident that most of the new preventive benefits are aimed at women, say experts. "Women bear a disproportionate burden when it comes to sexually transmitted diseases and preventing pregnancy," says Deborah Arrindell, vice president for health policy at the American Social Health Association, an advocacy group.

As women enter their reproductive years, they typically begin to see a primary-care practitioner, often a gynecologist, for regular checkups and to receive contraceptives. In 2009, 66% of women ages 18 to 44 visited a primary-care provider, compared with 52% of men in that age group, according to the CDC's National Center for Health Statistics.

Although men may visit the doctor to get a physical for work, sports, or school, it's not routine, say experts. "Many of the men who visit the family planning clinic are sent by their partners," says Bell. "Fifty percent came because of a female in their life."

Part of the problem in improving coverage of sexual and reproductive health for men is that research is scarce and comprehensive clinical guidelines have never been established, say experts. The USPSTF, in declining to recommend screening for chlamydia in men, for example, said there was a "critical gap" in research on the benefits of screening men for the disease.

Some women's health advocates note wryly that although there may be a relative dearth of data related to men's sexual and reproductive health, much of the broad medical research conducted to date has focused on men. Clinical trials for many drugs, for example, for many years excluded women.

Regardless, advocates agree that leveling the playing field for the sexes for sexual and reproductive health services only makes sense.

"It seems foolish to do it differently for women than for men," says Sonfield.

This article, which first appeared August 27, 2012, was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Have your teenage children not use Cheech & Chong as their role models...a New Zealand study demonstrates that adolescent pot smoking leads to having a lower IQ.

Heavy Pot Use Tied to IQ Drop

 

By John Gever, Senior Editor, MedPage Today

Published: August 27, 2012

 

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

 

 

Individuals repeatedly diagnosed with cannabis dependence during young adulthood had noticeable declines in IQ scores by age 38, especially when the heavy use started in their teens, researchers said.

 

A small to medium decline in mean IQ between tests taken on the eve of adolescence and again at age 38 was seen in those diagnosed at least three times with cannabis dependence, according to Madeline Meier, PhD, of Duke University, and colleagues, who reported on data from 1,037 participants in a New Zealand birth cohort.

In the small group of participants who became cannabis dependent before age 18 -- a total of 23 cohort members -- the decline translated to an average of about 8 IQ points, whereas 14 participants who also showed heavy cannabis use but only beginning in adulthood showed only a very small drop in full-scale scores (P=0.02), Meier and colleagues indicated online in Proceedings of the National Academy of Sciences.

The researchers also reported that the size of the mean decline increased with the number of cannabis dependence diagnoses that participants had received in five evaluations conducted from ages 18 to 38 (P<0.0001 for trend).

"Collectively, [the study's] findings are consistent with speculation that cannabis use in adolescence, when the brain is undergoing critical development, may have neurotoxic effects," Meier and colleagues wrote.

Study participants were members of the Dunedin Multidisciplinary Health and Development Study. It attempted to track all children born in Dunedin, New Zealand, from April 1972 to March 1973 starting at age 3. At age 38, the investigators had data on IQ testing and cannabis dependence diagnoses on 874 cohort members.

Besides assessing cannabis use, the five structured interviews in adulthood also elicited information on use of other illicit drugs and alcohol. IQ tests were conducted initially at ages 7 to 13 and again at age 38.

Among participants included in the current analysis, 242 never reported cannabis use in the structured interviews nor were they ever diagnosed with dependence; 479 indicated some use but never received a diagnosis; and 80, 35, and 38 had received one, two, or three or more dependence diagnoses in the adult evaluations.

Baseline mean IQ scores were similar and close to the standardized population average of 100 in these cannabis-use subgroups. However, at age 38, the mean scores had diverged considerably. The change from baseline was as follows (P values not reported):

• Never used, never diagnosed: +0.80
• Used, never diagnosed: -1.07
• One diagnosis: -1.62
• Two diagnoses: -2.47
• Three or more diagnoses: -5.75

Meier and colleagues reported other changes over time in "standard deviation units," in which changes of 0.20, 0.50, and 0.80 should be considered small, medium, or large, respectively.

For participants with three or more diagnoses, the change was -0.38 units.

The researchers also stratified participants into two groups according to whether, at a given interview, they reported using cannabis at least once a week on average ("regular user").

Individuals classed as regular users at least three times in the study also showed the largest declines in IQ between tests (mean -5.23 IQ points, -0.35 standard deviation units, P value not reported), whereas little change was seen in those never reporting regular use.

Similar patterns were seen in IQ subdomain scores.

These small to medium declines were also seen in this participant group in tests of memory, processing speed, and executive function.

Meier and colleagues sought to rule out potential confounding factors, taking educational attainment and use of alcohol and other drugs into account.

When they restricted their analysis to 278 participants who did not get beyond high school, again those with three or more dependence diagnoses showed medium-level declines in IQ (mean -0.48 standard deviation units) whereas those in the never-used, never-diagnosed category had essentially no change (mean -0.03 units, P=0.0009 for trend).

The pattern also held up when the researchers excluded participants with persistent dependence on tobacco, alcohol, and "hard" drugs, and also those with diagnoses of schizophrenia.

However, the strongest relationships between persistent dependence and IQ decline applied to those who began heavy use in adolescence. Meier and colleagues suggested that, actually, the relationship between dependence and IQ decline may be entirely driven by this group.

The 23 participants with adolescent-onset dependence and at least three diagnoses overall showed a mean decline of about 0.53 standard deviation units, compared with a drop of about 0.13 among those with three diagnoses that all came during adulthood (P=0.02).

Nonsignificant trends toward greater declines in IQ were also seen in those teen-onset dependence but fewer total diagnoses of dependence.

"In fact, adult-onset cannabis users did not appear to experience IQ decline as a function of persistent cannabis use," Meier and colleagues wrote.

They cautioned that their data did not prove that heavy cannabis use actually caused the decline. "There may be some unknown 'third' variable that could account for the findings. The data also cannot reveal the mechanism underlying the association between persistent cannabis dependence and neuropsychological decline," they wrote.

They also acknowledged that their data relied on self-report of cannabis use, without confirmation from blood or urine testing.

But these caveats did not stop them from speculating on causal mechanisms and the implications of a causal relationship.

Meier and colleagues noted that animal studies as well as theories of neural development during adolescence support a neurotoxic effect of cannabis in the young adult brain.

Moreover, they argued, their findings should inform public health programs.

"Prevention and policy efforts should focus on delivering to the public the message that cannabis use during adolescence can have harmful effects on neuropsychological functioning, delaying the onset of cannabis use at least until adulthood, and encouraging cessation of cannabis use particularly for those who began using cannabis in adolescence," they wrote.

Duke University, in a press release, was even less circumspect in a press release headlined, "Adolescent pot use leaves lasting mental deficits."

Its first sentence claimed that "the persistent, dependent use of marijuana before age 18 has been shown to cause lasting harm to a person's intelligence, attention and memory" in the study.

The Dunedin cohort study was funded by the New Zealand Health Research Council. The current analysis was supported by the U.K. Medical Research Council, the U.S. National Institutes of Health, and the Jacobs Foundation.
No potential conflicts of interest were reported.

Primary source: Proceedings of the National Academy of Sciences
Source reference:
Meier M, et al "Persistent cannabis users show neuropsychological decline from childhood to midlife" Proc Natl Acad Sci USA 2012; DOI: 10.1073/pnas.1206820109.

Do you like to believe that there is sufficient research and evidence for every procedure performed in healthcare? Think again. ....and ask yourself if you'd follow through with a procedure if you learned there was no evidence to support it. Or worse, how would you feel learning that fact after you've already had the procedure?

Op-Ed Contributor

Testing What We Think We Know

By H. GILBERT WELCH

Published: August 19, 2012 Hanover, N.H.

Leigh Guldig

BY 1990, many doctors were recommending hormone replacement therapy to healthy middle-aged women and P.S.A. screening for prostate cancer to older men. Both interventions had become standard medical practice. 

But in 2002, a randomized trial showed that preventive hormone replacement caused more problems (more heart disease and breast cancer) than it solved (fewer hip fractures and colon cancer). Then, in 2009, trials showed that P.S.A. screening led to many unnecessary surgeries and had a dubious effect on prostate cancer deaths. 

How would you have felt — after over a decade of following your doctor’s advice — to learn that high-quality randomized trials of these standard practices had only just been completed? And that they showed that both did more harm than good? Justifiably furious, I’d say. Because these practices affected millions of Americans, they are locked in a tight competition for the greatest medical error on record. 

The problem goes far beyond these two. The truth is that for a large part of medical practice, we don’t know what works. But we pay for it anyway. Our annual per capita health care expenditure is now over $8,000. Many countries pay half that — and enjoy similar, often better, outcomes. Isn’t it time to learn which practices, in fact, improve our health, and which ones don’t? 

To find out, we need more medical research. But not just any kind of medical research. Medical research is dominated by research on the new: new tests, new treatments, new disorders and new fads. But above all, it’s about new markets. 

We don’t need to find more things to spend money on; we need to figure out what’s being done now that is not working. That’s why we have to start directing more money toward evaluating standard practices — all the tests and treatments that doctors are already providing. 

There are many places to start. Mammograms are increasingly finding a microscopic abnormality called D.C.I.S., or ductal carcinoma in situ. Currently we treat it as if it were invasive breast cancer, with surgery, radiation and chemotherapy. Some doctors think this is necessary, others don’t. The question is relevant to more than 60,000 women each year. Don’t you think we should know the answer? 

Or how about this one: How should we screen for colon cancer? The standard approach, fecal occult blood testing, is simple and cheap. But more and more Americans are opting for colonoscopy — over four million per year in Medicare alone. It’s neither simple nor cheap. In terms of the technology and personnel involved, it’s more like going to the operating room. (I know, I’ve had one.) Which is better? We don’t know. 

Let me be clear, answering questions like these is not easy. The Veterans Affairs Cooperative Studies Program is in fact preparing to take on the colonoscopy versus fecal occult blood testing question. The trial, which will involve up to 50,000 patients, will last a decade and surely cost millions of dollars. 

Research like this takes more than grant money. For starters, it takes a research infrastructure that monitors what standard practice is — data on what’s actually happening across the country. Because of Medicare, we have a clear view for patients age 65 and older, but it’s a lot cloudier for those under 65. Basic questions like how common annual physical exams are and what testing is part of them are unanswerable. 

It also takes a research culture that promotes a healthy skepticism toward standard medical practice. That requires physician researchers who know what standard practice is, have the imagination to question it and the skills to study it. These doctors need training that’s not yet part of any medical school curriculum; they need mentoring of senior researchers; and they need some assurance that investigating accepted treatments can be a viable option, instead of career suicide. 

We have to move quickly. The administrative demands of clinical care, on one side, and the competition for research funding on the other, make it increasingly difficult for researchers to see patients. They become isolated from standard practice, and their ability to study it diminishes. Clinicians who are well positioned to study these issues are increasingly directed toward enhancing productivity — questions about how can we do this better, faster or more consistently — instead of questions about whether the practices are warranted in the first place. 

Here’s a simple idea to turn this around: devote 1 percent of health care expenditures to evaluating what the other 99 percent is buying. Distribute the research dollars to match the clinical dollars. Figure out what works and what doesn’t. The Patient-Centered Outcomes Research Institute (created as part of the Affordable Care Act to study the comparative effectiveness of different treatments) is supposed to tackle questions of direct relevance to patients and could take on this role, but its budget — less than 0.03 percent of total spending — is far from sufficient. 

A call for more medical research might sound like pablum. Worse, coming from a medical researcher, it might sound like self-interest (cut me some slack, that’s another one of our standard practices). But I don’t need the money. The system does. Or if you prefer, we can continue to argue about who pays for what — without knowing what’s worth paying for. 

H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, is a co-author of “Overdiagnosed: Making People Sick in the Pursuit of Health.”