Handguns more lethal than rifles in mass shootings

(Reuters Health) – In public mass shootings in the U.S., victims shot with a handgun were more likely to die than in the events associated with a rifle, according to a new study in the Journal of the American College of Surgeons.

“With public mass shootings rapidly on the rise, we wanted to know the reasons why people die and if any aspect is preventable,” said lead study author Dr. Babak Sarani of the George Washington University Center for Trauma and Critical Care in Washington, D.C.

Previous studies show that in mass shootings, about 45 percent of people who are wounded during the event die.

“If we’re going to have conversations around gun violence and public mass shootings, we need to know the facts,” Sarani told Reuters Health by phone. “We started down this road of looking at actual autopsies so there would be no speculation.”

Sarani and colleagues analyzed autopsies from 23 mass shootings from FBI records in 2000-2016 to understand where victims were shot, how many times they were shot, the organs that were hit, the firearm type and if any injuries or deaths were preventable. Of the 232 victims whose bodies were autopsied, 73 were shot with handguns, 105 by rifles, 22 by shotguns and 32 by multiple firearms.

The research team found that events with a handgun were associated with a higher percentage of people killed, whereas events involving a rifle were associated with more people shot. About 26 percent of those shot with a handgun had more than one fatal wound, versus two percent of people shot with a rifle. Handguns were also more likely to be associated with brain and heart injuries.

“All of us were shocked. We came to the table with our bias that an assault weapon would be worse,” Sarani said. “This should inform the medical community about what to expect at trauma centers and lawmakers about reasonable gun laws.”

The differences in firearm lethality could be due to several factors, Sarani explained. Close-range handguns and longer-range rifles change the distance between the shooter and victim, as well as the accuracy and velocity of the bullet. Although the higher muzzle velocity of a rifle is typically associated with more accuracy, public mass shootings with handguns tend to lead to more gunshot wounds per victim and a higher likelihood of injuries to vital organs.

“We’ve been careful in these studies to not come across as anti-Second Amendment but to better understand what reasonable legislation could be aimed at gun-related violence,” Sarani said. “How do you know what’s reasonable when you don’t know what the problem is?”

A limitation of the study is that autopsy reports can’t explain what happened on the scene of the mass shooting or how or when a patient died in route to the hospital, said Dr. Alan Cook, a surgeon and director of trauma research at Dignity Health in Chandler, Arizona. Cook, who wasn’t involved with this study, has previously researched gunshot wounds that result in hospitalization in the U.S.

“Firearm violence has become background noise in this country,” Cook told Reuters Health by phone. “We see these tragedies all the time on the news, and we need a motion that will decrease this feature of American culture.”

SOURCE: bit.ly/2EXYI4G Journal of the American College of Surgeons, online December 7, 2018.

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Fitness affects stroke risk

(Reuters Health) – Low fitness levels have long been tied to higher risk for heart problems. Now researchers say men’s cardiorespiratory fitness is tied to their risk for stroke as well.

Researchers in Norway followed 2,014 middle-aged men for more than 20 years. Those who were unfit for the whole study period, or who started out fit but became less so, were twice as likely to have a stroke as those who stayed fit or became fit, they reported in the journal Stroke.

“Stroke is a devastating condition that can be lethal and leaves most patients disabled or speech impaired for life,” said lead study author Dr. Erik Prestgaard from Oslo University Hospital in a phone interview.

“Prevention is important,” he added, “and patients can directly change their fitness.”

The men in the study were enrolled in 1972-1975 at ages 40 to 59. At the start and again seven years later, their cardiorespiratory fitness was assessed with a bicycle test and with measurements of blood pressure and heart rate.

Researchers then followed the men’s health for about 24 years through medical records and national registries.

Based on the men’s cardiorespiratory fitness trend between the initial assessments seven years apart, about 39 percent of them “remained fit” (i.e., maintained an average fitness level throughout). Another 39 percent “remained unfit” (started out below average and stayed there). Eleven percent “became unfit” (dropped from above average), and another 11 percent “became fit” (improved from below average to above average).

Overall, 199 men had strokes, with the highest risk seen among those who became unfit.

The average age of first stroke was 73 in both of the unfit groups, 75 in the “remained fit” and 77 in the “became fit” groups, the study team notes.

Men who had higher fitness levels while younger and became unfit had twice the stroke risk as men who remained fit, study also found. Similarly, those starting with low fitness levels who became fit cut their stroke risk in half compared to those who stayed unfit.

“You would expect that fitness would reduce the risk of stroke, but we were surprised by the large reduction,” Prestgaard said. In further analyses, he added, “each small improvement in fitness helped.”

Future studies should confirm these findings using better measures of cardiorespiratory fitness than were available in the 1970s, the authors note.

In addition, fitness levels should be evaluated based on gender, race and ethnicity, body composition, medications, smoking status and nutrition, said Dr. Jari Laukkanen of the University of Eastern Finland in Kuopio, who wasn’t involved in the study.

“Research is needed to show if decreased stroke can be achieved by incorporating regular exercise and following the widely recognized recommendations for physical activity,” he told Reuters Health by email.

The recently updated Physical Activity Guidelines for Americans (bit.ly/2QS3ojP) say adults should do at least 150-300 minutes of moderate-intensity activity per week and muscle-strengthening activities at least two days per week.

“Fitness recognizes no age, and it’s never too old to start exercising,” said Peter Kokkinos of the Veterans Affairs Medical Center of Washington, D.C.

“This study shows that exercise benefits last for years, and you can see the difference all the way to 25 years,” he said in a phone interview. “Early changes have lasting effects.”

SOURCE: bit.ly/2BKcDbm Stroke, online December 10, 2018.

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New Jersey clinic sued after HIV infection warning

NEW YORK (Reuters) – A former patient has filed the first lawsuit against a New Jersey surgery center that may have exposed nearly 3,800 patients to HIV and hepatitis due to poor sterilization and medication practices.

The HealthPlus Surgery Center in Saddle Brook recently told the patients that a state probe of its facilities found “lapses in infection control” and “the injection of medications” could have exposed them to the diseases.

A state report released on Friday said operating rooms at the center were not properly cleaned and surgical tools were sometimes found with “brown rust-like stains” before use.

It was the latest scare at a new Jersey healthcare facility after 11 children died at a rehabilitation center since October in a deadly viral outbreak.

Friday’s lawsuit was filed in Bergen County against the surgery center on behalf of a woman who was a patient there between Jan. 1 and Sept. 7 2018, according to a statement by her lawyer Michael Maggiano.

It claimed the center showed “wanton misconduct — on a continuing basis” for exposing patients to dangerous pathogens.

It was not immediately clear whether the woman had been infected by any disease due to treatment at the center. Though criticizing the center’s sanitation practices, the health department report said risks of infection were low and it was not aware of any illness as a result of the infection control issues.

In a statement on Friday, HealthPlus lawyer Mark Manigan said the center now conducted weekly inspections and had been in compliance with health department regulations since Sept. 27.

The company is testing patients who attended the center between Jan. 1 and Sept. 7 for possible infections.

Reporting by Peter Szekely; Additional reporting by Andrew Hay; Editing by Christopher Cushing

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U.S. medic quarantined in Nebraska for possible Ebola exposure

(Reuters) – A U.S. healthcare worker who may have been exposed to the Ebola virus while treating patients in the Democratic Republic of Congo arrived in the United States on Saturday and was put in quarantine in Nebraska.

The medic, who is not exhibiting symptoms of Ebola, will remain under observation for up to two weeks at the University of Nebraska Medical Center (UNMC) in Omaha, Nebraska Medicine said in a statement.

The individual’s name was not released for privacy reasons.

Symptoms such as fever and abdominal pain may appear up to three weeks after contact with the deadly virus, according to the Centers for Disease Control and Prevention.

Should symptoms develop, the healthcare worker would be moved to the Nebraska Biocontainment Unit, one of only a few in the United States for treating infectious diseases.

The Ebola outbreak in Democratic Republic of Congo is the second worst ever and has killed 356 of the 585 people infected since it began six months ago, according to the World Health Organization.

Nebraska Medicine, a network of hospitals, clinics and healthcare colleges, together with academic partner UNMC, are among world leaders in the treatment of Ebola, which spreads through contact with bodily fluids and causes hemorrhagic fever with severe vomiting, diarrhea and bleeding.

Nebraska Medicine cared for three patients with the virus in 2014 and monitored several others for exposure during a 2013-16 outbreak in West Africa that was the worst on record, with more than 28,000 cases confirmed.

Reporting by Andrew Hay in New Mexico, editing by G Crosse

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Leafy green neighborhoods tied to better heart health

(Reuters Health) – People who live in neighborhoods with more green spaces may have less stress, healthier blood vessels and a lower risk of heart attacks and strokes than residents of communities without many outdoor recreation areas, a small study suggests.

Trees and plants frame a building in the “eco-neighbourhood”, Clichy-Batignolles, one of several new ecological housing developments with low energy use and carbon emissions, in Paris, France, October 22, 2015. REUTERS/Benoit Tessier

At the population level, residential green space has long been linked to a lower risk of death from heart disease and respiratory problems, as well as a lower risk of hospitalization for events like heart attacks and strokes, researchers note in the Journal of the American Heart Association. But there isn’t as much evidence showing whether this connection holds true for individuals.

For the current study, researchers tested for a variety of biomarkers of stress and heart disease risk in blood and urine samples from 408 patients at a cardiology clinic in Louisville, Kentucky. They also used satellite data from the National Aeronautics and Space Administration (NASA) and the United States Geological Survey (USGS) to estimate the extent of greenery where each person lived.

Compared to people in areas with the least amount of green space, residents of the greenest neighborhoods had lower urinary levels of the hormone epinephrine, indicating lower stress levels, the study found. They also had lower urinary levels a marker of oxidative stress known as F2-isoprostane.

In addition, people in greener areas had a higher capacity to maintain healthy blood vessels than residents of places without much green space.

“Both the magnitude of the effect and the pervasiveness of the influence of greenery on health are surprising,” said senior study author Aruni Bhatnagar of the University of Louisville.

“If the results of this study bear out, it would mean that frequent interactions with nature may be one way of decreasing risk of heart disease,” Bhatnagar said by email.

Participants in the study were 51 years old on average, most were overweight, and many had high blood pressure or high cholesterol. The majority lived in areas with limited green space.

Beyond its small size, the study also wasn’t a controlled experiment designed to prove whether or how green space might directly reduce stress or improve heart or blood vessel health.

However, the connection between residential greenery and a lower levels of certain markers of heart problems held up even after researchers accounted for other factors that can independently influence the risk of heart disease like age, sex, ethnicity, smoking status, patients’ use of statins to control cholesterol, neighborhood poverty and proximity to pollution from traffic fumes.

“While it is true that in most U.S. cities, those of higher socioeconomic status live in greener areas, in our study, we statistically adjusted for income and education within that neighborhood, so it seems that the effect of greenness is independent of socioeconomic status,” Bhatnagar said.

It’s possible that green space might encourage more physical activity, and a higher density of trees and shrubs may also improve air quality by reducing levels of some pollutants, said Annemarie Hirsch, an environmental health researcher at Geisinger in Danville, Pennsylvania, who wasn’t involved in the study.

“Green spaces can also increase the sense of social cohesion, a factor that has been associated with health and wellbeing, by facilitating interaction with neighbors,” Hirsch said by email.

More greenery might also make it easier for people to be in a better mood.

“Green space may also provide a barrier to stressful environmental features, including traffic noise and displeasing structures,” Hirsch said. “At the same time, green space has been described as restorative, blocking negative thoughts and feelings and thus reducing stress.”

SOURCE: bit.ly/2QN7Z5S Journal of the American Heart Association, online December 5, 2018.

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Migrants to affluent nations may be healthier than the native-born

(Reuters Health) – International migrants who relocate to high-income countries to work, study or join family members are less likely to die prematurely than people born in their new homelands, a research review suggests.

For the analysis, researchers examined data from 96 studies with mortality estimates for more than 15.2 million international migrants in 92 countries. Overall, migrants were about 30 percent less likely to experience premature death from all causes than other people in the general populations of the countries where they moved, the analysis found.

“Migrants to rich countries have lower rates of death due to most major disease areas compared to the general population,” said lead study author Robert Aldridge of University College London in the UK.

“We know from UN data that the majority of migrants to these rich countries tend to be moving for work or study,” Aldridge said by email.

About 258 million people worldwide reside outside their country of birth, accounting for more than 3 percent of the world’s population, researchers note in The Lancet.

In many high-income nations, public perception that migrants place an undue burden on society in general and on health resources in particular has led to restrictions on migrants’ access to care, the authors write.

But the current analysis suggests that, if anything, migrants may use fewer health resources than native-born residents, Aldridge said by email.

The only causes of death that were more common among migrants were infectious disease and external causes like homicide, the analysis found.

Immigrants were 28 percent more likely to die of external causes and more than twice as likely to die of infectious diseases such as tuberculosis, hepatitis and HIV than people who were born in their adopted homelands.

However, immigrants were less likely to die from a variety of other causes including heart disease, digestive disorders, endocrine or circulatory problems, mental health disorders, cancers or diseases of the respiratory or nervous systems.

Both men and women appeared to have a longevity advantage after migration. Male immigrants were 28 percent less likely to die prematurely from all causes than native-born men, while female immigrants were 25 percent less likely to die prematurely.

The vast majority of the studies in the analysis focused on migration to high-income countries, not on refugees or asylum seekers. Researchers also excluded studies from their analysis that focused just on migrants with serious or chronic health problems or just on maternal and infant health outcomes.

It may be, however, that migrants in the study were healthier than people in their native countries who didn’t migrate, said Anjali Borhade, director of the Disha Foundation in Gurugram, India, and coauthor of an editorial accompanying the study.

“Educated migrants have better sources of income and being healthy doesn’t affect their choice to migrate,” Borhade said by email. “Also, educated migrants have better living or working conditions and their health status is similar to the host populations, both for risks as well as outcomes.”

Infectious disease and homicide deaths may be higher among migrants than other people in the general population due to unfavorable conditions immigrants face at work and in their new communities, Borhade added. That’s because many young, relatively healthy migrants may take low-paying and dangerous jobs and only be able to afford housing in subpar conditions.

“Hazardous jobs and low living conditions increase their risk of dying due to external causes and infectious diseases,” Borhade said. “However, since migrants are healthier to begin with, their mortality due to other causes might be lower.”

SOURCE: bit.ly/2ASQyqF and bit.ly/2VgflhS The Lancet, online December 5, 2018.

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Health Tip: Caring for a Person With Alzheimer’s

(HealthDay News) — If you are caring for a loved one who has Alzheimer’s disease, you may develop feelings of grief as the person starts to change, the Alzheimer’s Foundation says.

Latest Alzheimer’s News

There are five phases of grieving: denial, anger, guilt, sadness and acceptance.

The association suggests how to cope with grief and loss:

  • Face your feelings and accept them.
  • Prepare to have feelings of loss as dementia progresses.
  • Understand that no two people grieve in exactly the same way.
  • Talk with someone you trust about your feelings.
  • Stay involved in activities that you enjoy.
  • Join a support group.
  • Accept things that you cannot change.
  • Take care of yourself.

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Insured But Still In Debt: 5 Jobs Pulling In $100K A Year No Match For Medical Bills

Robert and Tiffany Cano of San Tan Valley, Ariz., have a new marriage, a new house and a 10-month-old son, Brody, who is delighted by his ability to blow raspberries.

They also have a stack of medical bills that threatens to undermine it all.

In the months since their sturdy, brown-eyed boy was born, the Canos have acquired more than $12,000 in medical debt — so much that they need a spreadsheet to track what they owe to hospitals and doctors.

“I’m on these payment arrangements that are killing us,” said Tiffany Cano, 37, who has spent her lunch hours on the phone negotiating payoff plans that now total $700 a month. “My husband is working four jobs. I work full time. We’re a hardworking family doing our best and not getting anywhere.”

The pair, who earn nearly $100,000 a year, are insured and have had no major illnesses or injuries. Still, the Canos are among the 1 in 4 Americans who report in multiple polls that the high cost of health care is the biggest concern facing their families. And they’re at risk of joining the 62 percent of people who file for bankruptcy tied to medical bills.

“Oh, yes, that worry is always in the back of my mind,” Tiffany said.

The family is part of a struggling group: middle-class folks who have followed the rules and paid for employer-based medical insurance, only to find that soaring health care costs — combined with high deductibles, high copayments and surprise medical bills — leave them vulnerable.

“I thought we’d be covered, and it’s just not enough coverage at all,” she said.

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Robert Cano, also 37, had family health insurance for 2018 through his job as a manager at a large-chain retail store, for which he pays nearly $500 per month. The plan’s $3,000 annual deductible and 40 percent coinsurance fees have added up faster than the Canos anticipated.

First came the nearly $4,000 bill from the in-network hospital where Brody was born Jan. 2, followed by separate fees from the anesthesiologist and the doctor who performed the routine delivery. Then, at 2 months, Brody was hospitalized with breathing problems doctors said could be related to allergies or asthma. In May, Tiffany came down with a stomach virus that sent her to the emergency room for drugs to treat nausea and dehydration. In October, the baby developed a bad case of bacterial conjunctivitis, or pinkeye.

“It’s been, like, $300 here, $700 there,” said Tiffany. “We had a hospital bill for him being sick of, like, $1,800.” Unable initially to find a pediatrician she liked, Tiffany has agonized over whether to use the ER when Brody gets sick. When he had pinkeye, she debated whether to take him in, hoping it would get better on its own.

Then he got worse, she said, pulling up a photo on her phone of her son with half-moons of red, puffy flesh under his dark eyes.

“I let him suffer for a day like that,” she said.

The Canos lost their first child, a girl, midway through her pregnancy in 2016. Tiffany acknowledges that experience has left her more anxious than the average first-time mom.

“It gave me so much fear that something would happen to him,” she said.

As for their own health care needs, the couple put themselves lower on the priority list. Tiffany has used a prosthetic limb since childhood, when her lower left leg was amputated because of a birth defect.

She needs a new prosthesis because her body changed during pregnancy, but she can’t see how to afford it.

Tiffany Cano with her son, Brody. Cano was born with birth defects that left her with only three fingers on her right hand and a left leg that had to be amputated below the knee during childhood. Because of physical changes during pregnancy, her five-year-old prosthetic leg no longer fits, but she can’t afford her share of the cost of the new limb.

A model suitable for the busy life of a working mom would easily cost $10,000 to $15,000, according to Tom Fise, executive director of the American Orthotic & Prosthetic Association.

“I try to push through,” Tiffany said. “I put on that brave face of just walking, but it’s so painful to walk. I have bruises all over my leg. I get blisters all the time.” Lately, she’s been wearing an old prosthesis, one she used in high school, because it’s more comfortable.

The Canos don’t know how exactly they fell into such debt, since they tried hard to make responsible decisions. After meeting three years ago, they knew quickly that they wanted to marry and have a family.

“I waited until I found the right guy,” said Tiffany, who was thrilled when, in 2016, they were able to afford a 2,500-square-foot, two-story home in one of the stucco-and-tile neighborhoods an hour outside Phoenix.

But, taken together, the medical payment plans and premiums are almost as much as their $1,300 monthly mortgage. All told, the Canos spend about 15 percent of their annual income on health care, almost three times the average for non-Medicare households in the U.S.

That leaves too little for day care, car payments, gas, food and dozens of other domestic expenses, Tiffany said.

For 17 years, Robert Cano had comprehensive health insurance through his job as a soldier in the Army Reserve and paid little or nothing for medical care. He left the Army in 2017, however, after he learned he would be deployed for an extended time away from his wife and new son.

“I told them, ‘I have to be at home,’” he recalled. The Army insurance ended on Dec. 31, 2017, two days before Brody was born.

That meant moving to his employer’s insurance plan. Like more than 40 percent of 152 million Americans who get health insurance through work, the Canos are enrolled in a plan that demands thousands of dollars before any coverage kicks in.

The couple discovered that they earn too much to qualify for financial assistance from medical providers, or for subsidies if they shifted their insurance to a plan under the federal health insurance exchange. She is a full-time bank compliance officer. He is a full-time store manager.

Tiffany wrote to KHN after seeing stories about sky-high medical bills on TV. Dr. Merrit Quarum, the chief executive of WellRithms, a health care consulting firm, reviewed the family’s medical bills and the responses from their health care providers.

Though Quarum had questions about some of the fees in the itemized bills — $4 for a 600-milligram ibuprofen tablet? $3,125 to place an epidural? — he found the charges were legitimate under the terms of the contract between the hospital and the Canos’ insurer. Tiffany’s only recourse was to set up the five payment plans she navigates each month.

“I wish I could say it wasn’t so, but it is,” Quarum said.

Robert Cano plays with his 10-month-old son, Brody, before leaving for work on a recent Saturday morning.(Heidi de Marco/KHN)

Robert Cano of San Tan Valley, Ariz., gets ready for work on Oct. 20, 2018. He estimates he works up to 120 hours a week, mostly to cover the extra costs of his family’s health care. In addition to his retail job, he is a substitute teacher and a nighttime security guard, and delivers sandwiches for a fast-food chain.(Heidi de Marco/KHN)

Tiffany Cano feeds 10-month-old Brody on Oct. 20, 2018. She works 40 hours a week at a local bank as a compliance officer, commuting more than 90 minutes each way, while Brody attends a local day care center. Because her husband works so much, she says, she often feels as if she’s raising their son alone.(Heidi de Marco/KHN)

Mostly to pay off that health care debt, Robert has taken several part-time gigs this year — he works as a substitute teacher and a nighttime security guard and delivers sandwiches for a fast-food chain in Scottsdale, 40 miles away, where tips are better. He said he sometimes works up to 120 hours in a week.

“I’m not ashamed or embarrassed, even as old as I am, to deliver sandwiches,” he said, pulling on his retail chain polo shirt before rushing to a Saturday morning shift.

He continued: “I know people, they’d rather get food stamps and feel sorry for themselves. But I’m a fighter. I will not give up. … If I can bring in an extra $400 a week or $800 a month, she can get what she needs for the baby.”

Often getting home after midnight, he keeps shampoo and shaving cream in his car and naps in parking lots between jobs, relying on Red Bull and aspirin to stay alert.

That means on many nights, when Tiffany picks up Brody from day care after her 90-minute commute, she handles most of the chores at home.

“Sometimes I feel like a single mom because my husband is never around,” she said.

She carefully tracks the family’s medical expenses, trying to juggle them with ordinary outlays that can’t wait — like $500 for the brakes that went out on her car this month.

At the rate they’re going, the bills won’t be paid until Brody is 3, Tiffany said. The Canos are getting older and they’d like to have another baby before it’s too late, but, for now, that seems impossible.

For 2019, the couple have decided to switch to a different plan offered through the regional bank where Tiffany works. The premium is higher — $650 a month — but the deductible is $1,500 with just 10 percent coinsurance.

“It is going to be a lot more per paycheck, which is going to hurt us,” Tiffany said. “But after what just happened, I want to make sure we are prepared in case anything does occur.”

How to fix a health care system that burdens middle-class families so heavily is beyond her, she said.

“The only thing we can do is just keep working,” Tiffany said. “I always wonder: How does everybody else do it?”


KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

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Doctors still prescribing testosterone to men with heart disease, despite risks

(Reuters Health) – Despite warnings that supplemental testosterone may raise the risk of stroke and heart attack, doctors continue to prescribe the hormone off-label to men with cardiovascular disease, a U.S. study finds.

After poring over 10 years of prescription data, researchers found that men with heart disease were no less likely than those without it to receive a testosterone prescription despite warnings from the Food and Drug Administration (FDA) in 2014 that the hormone might increase cardiovascular risk, researchers reported in JAMA Internal Medicine.

“Safety concerns began emerging in 2010,” said lead author Dr. Nancy Mordon of the Dartmouth Institute of Health Policy and Clinical Practice in Lebanon, New Hampshire. “We looked specifically at heart disease patients compared to those with no heart disease trying to find out if we were being careful with patients who are at the highest risk. It turned out that patients were more likely to get testosterone if they had heart disease.”

One of the biggest problems is that testosterone hasn’t been shown to have significant benefits, Mordon said. “Physicians are part of the equation,” she added. “They are prescribing products in a gray zone where efficacy and safety are unclear and they are prescribing to a population at risk. The bottom line is that physicians should be having in-depth discussion with their patients.”

A trial that looked at the impact of testosterone supplementation on sexual function “showed a tiny benefit, 0.2 points on a 13 point scale,” Mordon said.

For the new analysis, Mordon and colleagues examined a large random sample of Medicare fee-for-service data collected between January 1, 2007 and December 31, 2016. They looked separately at testosterone prescriptions for approved conditions and those that were off-label, meaning prescribed to treat a condition for which the drug has not been FDA-approved.

The annual number of patients studied ranged from 1.8 million to 3.1 million, representing 10 to 20 percent of fee-for-service male Medicare enrollees older than 50. The researchers found that testosterone use was consistently higher for men with heart disease compared to those without it.

Dr. Harry Fisch, who wasn’t involved in the study, was not surprised. First of all, he said, men with cardiovascular disease tend to have lower testosterone levels. In addition, people with heart disease are often overweight and “people who are heavier tend to have lower testosterone,” said Fisch, a clinical professor of urology and reproductive medicine at Weill Cornell Medical College in New York City. “The bigger the belly, the lower the testosterone.”

A better solution for these men would be “diet and exercise,” said Fisch. “That will lower the belly fat.”

Fisch said he never prescribes testosterone off-label for low hormone levels. Beyond safety issues, “there is not a study showing what symptoms are improved with testosterone,” Fisch said.

A large, ongoing randomized trial – the Testosterone Replacement Therapy for Assessment of Long-term Vascular Events and Efficacy Response in Hypogonadal Men – should be completed in 2022, said Dr. Erin Michos of the Ciccarone Center for the Prevention of Heart Disease at the Johns Hopkins School of Medicine in Baltimore, Maryland. “The results of that trial could be the tipping point that changes practice patterns.”

Low testosterone “may be a marker of a poorer health state, so it’s not surprising that many men with coronary artery disease have low testosterone,” said Michos, who wasn’t involved in the current study. “Men with diabetes and (coronary artery disease) frequently have vascular erectile dysfunction, stemming from atherosclerosis and endothelial dysfunction. Blaming low testosterone levels may seem like an easy solution when actually the problem stems from a more complicated underlying vascular disorder,” she said in an email.

“Additionally,” Michos said, “there might be a tendency to blame a lot of nonspecific symptoms such as fatigue or lack of fitness on the low testosterone level whereas there might be other modifiable etiologies for those symptoms, such as obesity and sedentary behavior.”

SOURCE: bit.ly/2ESGGAX JAMA Internal Medicine, online December 28, 2018.

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