David L. Keller

Benefits of Moderate Alcohol Consumption Not Disproven.

Goulden’s conclusion that moderate alcohol consumption is not associated with reduced all-cause mortality in older adults conflicts with the findings of other studies, which he attributes mainly to residual confounding and bias. However, Goulden’s own Table 2 indicates that regular drinkers who consume less than 7 drinks per week (whom I shall call “light drinkers”) actually do exhibit the lowest average mortality hazard ratio (HR), compared with nondrinkers or heavy drinkers (>21 drinks per week), even when fully adjusted by Goulden, for all 11 categories of subjects, based on age, sex, health, socioeconomic, and functional status. Likewise, for those who consume 7 to 14 drinks per week (“moderate drinkers”), Table 2 reveals that their average mortality HR is less than that of nondrinkers or heavy drinkers, with only 1 outlying category (of 11 categories). This outlier data point is for subjects aged less than 60 years, which may be explained by the fact that the ratio of noncardiovascular mortality (particularly automobile accidents) to cardiovascular mortality is highest in this youngest age category. Thus, the trends exhibited by Goulden’s average data are consistent with the previously

Caution regarding testosterone therapy.

In their review article “Testosterone Deficiency,” the uthors state “we believe there is adequate evidence to upport the use of TRT [testosterone replacement therapy] n selected cases for metabolic and general health indicaions” even though they also admit that “no long-term, arge-scale studies on the safety of T [testosterone] therapy ave been performed.” This advocacy of testosterone replacement for “general ealth indications” is reminiscent of the once-widespread nthusiasm for hormone replacement in postmenopausal omen. The adverse outcomes associated with hormone eplacement in the Women’s Health Initiative demonstrated the value of waiting for results from “long-term, large-scale studies” before exposing patients to the risk of such interventions. In a recent study, community-dwelling men aged 65 years or older with testosterone deficiency and limitations in mobility were randomized to receive placebo gel or testos-

Hypertensives May Safely Consume Ethanol and Coffee in Moderation.

In their discussion of alternative approaches in the management of hypertension, Brook et al present a clinical vignette example. A 54-year-old woman presented with a history of “borderline” hypertension over the previous year, and 3 clinic blood pressures, which averaged 152/88 mm Hg. She reported drinking “a few caffeinated and alcoholic beverages per week.” Her physician prescribed a trial of lifestyle therapy composed of moderate exercise, a low sodium diet, and stopping all caffeine and alcohol intake. I question the evidence on which her mild ethanol intake was discontinued. A recent meta-analysis found that “low to moderate alcohol consumption was inversely significantly associated with the risk of cardiovascular disease and allcause mortality in patients with hypertension.” Her physician should have encouraged this patient to continue her “few alcoholic beverages per week,” with the understanding that her intake should be distributed evenly (eg, half a serving of ethanol per day, or one serving every other day) rather than in binges (eg, 3 or 4 servings on 1 day per week). In addition to being associated with better outcomes when consumed in moderation, ethanol can contain as few as 65 calories per 1-ounce serving if comprised of 40% neutral

Stern but Illuminating Words on Imaging: An Internist Replies

As a general internist, I was not happy with Stern’s editorial suggesting that my discretion in ordering radiological studies should be limited by the enforcement of “imaging use policies.” Yet, I must admit that his arguments have certain merits. No patient should undergo an expensive and invasive study like computed tomography (CT) pulmonary angiography without a clear evidence-based indication. These scans involve risks: radiation-induced malignancies, contrast reactions, impairment of kidney function, and the discovery of incidental nodules requiring further workup—and potential for further harm. While CT should not be ordered reflexively or without due consideration, there must be a better solution than “restriction of image-ordering privileges” for clinicians whose “diagnostic yield” of positive test results falls below some threshold percentage. Few internists would admit a patient for hematemesis without consulting a gastroenterologist, and fewer would admit a psychotic patient without consulting a psychiatrist. Similarly, we should be able to obtain an urgent clinical consultation from a radiologist before ordering an advanced imaging test to verify that it is best for the patient. When an internist is in the emergency department at night treating a sick patient who might benefit from such expert evaluation, why is the closest available radiologist often located in

Lowering Blood Glucose Without Increasing Mortality

A recent editorial in the Journal discussed the question of increased mortality among patients whose blood glucose levels were intensively decreased to an A1c goal of 6.5% or less. This risk was attributed partly to extensive use of sulfonylureas and insulin, which tend to cause harmful hypoglycemic episodes. The authors advised treating diabetic patients with medications having “the least intrinsic risk of hypoglycemia.” Such medications exist but often are insufficient to achieve intensive blood glucose lowering, even when they are combined. These medications also may present other potential risks, such as the 8.2 mg/dL average increase in low-density lipoprotein seen with canagliflozin dosed at 300 mg/d. If we want to answer the question of how low A1c levels should be driven to optimize long-term macrovascular outcomes, we need a way to lower blood glucose levels in a manner that is free of any confounding adverse effects from the medications, including episodes of dangerous hypoglycemia that could trigger an acute cardiovascular event. Conceptually, this could be accomplished

Correction Regarding Kidney Stone Prevention

There is an important error in the update on medical management and prevention of nephrolithiasis by Chandrashekar et al published in the April 2012 issue of The merican Journal of Medicine. In the section titled “Prohylaxis,” the authors quoted the 2005 guidelines of the merican Urologic Association (AUA), which advised retricting dietary calcium to reduce the risk of recurrent alcium oxalate kidney stones. However, a number of studes have refuted this advice by demonstrating that a diet ontaining foods rich in calcium is more effective for preenting initial or recurrent kidney stones than is a diet with estricted calcium. Unfortunately, the AUA website still ncorrectly advises restriction of dietary calcium to prevent tones. In contrast, the National Institutes of Health Webite recommends: “People who form calcium oxalate stones hould include 800 mg of calcium in their diet every day, ot only for kidney stone prevention but also to maintain one density.” The best evidence at this time supports a iet containing healthy amounts of calcium-rich foods in rder to reduce the risk for either new-onset or recurrent

Comments on Reducing the Health Consequences of Opioid Addiction

No discussion of overdose deaths caused by opioids would be complete without pointing out the exceptional risk posed by methadone. The Centers for Disease Control and Prevention notes that “while methadone accounts for only 2 percent of painkiller prescriptions in the United States, it is involved in more than 30 percent of prescription painkiller overdose deaths” and that “six times as many people died of methadone overdoses in 2009 as died in 1999.” It appears that any effort to slow the rising number of opioid overdose deaths will require special attention to reducing the risk posed by methadone. Methadone is favored because it is an inexpensive generic medication, it has a long half-life, and it is thought to be more effective against neuropathic pain than other opioids. However, it can prolong QT interval,

Ketorolac Use in Acute Coronary Syndromes

I have the following comments regarding the recently published case of a 55-year-old man who presented to the emergency department with substernal chest pain after running a marathon. His angiogram revealed complete occluion of his proximal left anterior descending artery, which equired angioplasty and placement of a stent. On initial resentation, his pain was thought to be similar to dyspepia, but a solution of milk of magnesia and viscous lidocaine id not provide relief. In addition, he was given morphine, etorolac, hydromorphone, and 3 doses of sublingual nitrolycerin (which relieved his symptoms). In a patient such as this, with chest pain of uncertain ause, I believe that ketorolac should not be administered ntil conditions such as peptic ulcer disease, acute coronary yndrome, and aortic aneurysm dissection have been ruled ut completely. Ketorolac (former brand name Toradol Roche Pharmaceuticals, Nutley, NJ]) is a favorite nonteroidal anti-inflammatory drug in emergency departments ecause, given intravenously, it provides rapid and potent elief to patients with musculoskeletal or inflammatory pain.