Concierge or boutique medicine is growing as busy people of means look for a way to bypass the red tape, waiting times, and inconveniences that may accompany a visit to the doctor.  On the physicians' side, doctors, including primary care physicians have joined concierge groups to avoid the long hours, incessant forms and high overhead of an overworked, understaffed practice.

Basically, concierge medicine is generally a small practice of physicians who limit the number of patients they see for an additional fee or "membership" that the client pays. In return for this fee (usually $1000-2000 per year over actual treatment fees), the patient gets return phone calls and same day appointments, in most cases. The doctors get to see fewer patients but are able to provide more customized care and be able to navigate their patients more efficiently to any needed hospital care or specialists.

So what about the good, the bad and the ugly?

The good (on the patient side)  includes more personalized care and as a result, more timely preventive care, when most diseases are caught early and interventions can prevent more serious problems.    Most people work hard because it enables them to lead a better life.   People work to send their kids to better schools, take more vacations, and have a better house.   Why shouldn't an executive be able to see a doctor at his or her convenience!   This is the American dream, right?   We all want the best for our loved ones.

The good (on the doctor's side) includes a less stressful workplace, more time to really spend with a patient, and more time to have a personal life.   They may see this as a better way to get to know their patients and provide better care, without the time limits of an overbooked waiting room.  Because there are less patients, the paper work including insurance forms get processed quickly---no insurance delays here!

For the individual patient and doctor, it looks like a pretty good deal.   But what impact will this have on the middle and lower economic classes that can't afford these 'boutiques' let alone health insurance.  This is where the bad and the ugly come in.

As more primary care providers join concierge practices, less physicians are available to provide general medicine to the masses.  This causes a larger workload for the physicians who are left in the mainstream.    This could lead to lower quality care because visits will be shortened and patients will be referred to see more physician extenders like physician assistants, nurse practitioners, etc.   Not that there is anything wrong with these compassionate and dedicated caregivers who can handle the majority of stomach aches and ear infections (and sometimes are preferred to a busy doctor).  But what about the prediabetic, the child with funny looking blood cells.  Sure, the PA or NP can refer any unusual symptoms to the doctor on duty (if they can catch them between appointments!).  But this only adds to the time needed to get a problem diagnosed and treated. The result could be less healthy patients who often miss the advantage of preventive care.

At the end of the day, this really becomes a social justice and ethical issue.    We have a broken health care system that is forcing some to run away---if they have the money and opportunity.   The others who don't have the resources simply deal with it.   We need some kind of fair and equitable way to ensure that all people have access to basic health care that includes less costly preventive care.   If we keep filtering off resources (e.g. primary physicians) to help those with money, there is little left to ensure the others have basic care.  In the end, we all pay when we miss the opportunity to practice preventative medicine and a patient ends up in an expensive emergency room because their acid reflux wasn't treated and they now have a bleeding ulcer!

The sex hormone estrogen could help protect women from cardiovascular disease by keeping the body's immune system in check, new research from Queen Mary, University of London has revealed.

The study has shown that the female sex hormone works on white blood cells to stop them from sticking to the insides of blood vessels, a process which can lead to dangerous blockages.

The results could help explain why cardiovascular disease rates tend to be higher in men and why they soar in women after the menopause.

The researchers compared white blood cells from men and pre-menopausal women blood donors. They found that cells from premenopausal women have much higher levels of protein called annexin-A1 on the surface of their white blood cells.

The scientists also found that annexin-A1 and estrogen levels were strongly linked throughout the menstrual cycle.

White blood cells play a vital role in protecting the body from infections. When they are activated they stick to the walls of blood vessels. This process normally helps the cells to tackle infection but if it happens too much, it can lead to blood vessel damage, which in turn can lead to cardiovascular disease. However, when annexin-A1 is on the surface of these white blood cells, it prevents them from sticking to the blood vessel wall.

The new research shows that estrogen can move annexin-A1 from inside the white blood cell, where it is normally stored, to the surface of the cells, thereby preventing the cells from sticking to blood vessel walls and causing vascular damage. This may have important implications in cardiovascular disease.

Dr Suchita Nadkarni from the William Harvey Research Institute, Queen Mary, University of London, who led the research, said: "We've known for a long time that estrogen protects pre-menopausal women from heart disease, but we don't know exactly why. This study brings us a step closer to understanding how natural estrogen might help protect our blood vessels.

"We've shown a clear relationship between estrogen levels and the behaviour of these white blood cells. Our results suggest that estrogen helps maintain the delicate balance between fighting infections, and protecting arteries from damage that can lead to cardiovascular disease.

"Understanding how the body fights heart disease naturally is vital for developing new treatments."

The study is published in American Heart Association journal Arteriosclerosis, Thrombosis and Vascular Biology. It was co-funded by the British Heart Foundation, the Wellcome Trust and the National Institutes of Health Research (NIHR).

15 Aug 2011

High-dose vitamin D relieves joint and muscle pain for many breast cancer patients taking estrogen-lowering drugs, according to a new study from Washington University School of Medicine in St. Louis.

The drugs, known as aromatase inhibitors, are commonly prescribed to shrink breast tumors fueled by the hormone estrogen and help prevent cancer recurrence. They are less toxic than chemotherapy, but for many patients, the drugs may cause severe musculoskeletal discomfort, including pain and stiffness in the hands, wrists, knees, hips, lower back, shoulders and feet.

"About half of patients can experience these symptoms," says Antonella L. Rastelli, MD, assistant professor of medicine and first author of the study published online in the journal Breast Cancer Research and Treatment. "We don't know exactly why the pain occurs, but it can be very debilitating to the point that patients decide to stop taking aromatase inhibitors."

Because the drugs reduce cancer recurrence, finding a way to help patients stay on them is important for long-term, relapse-free survival, according to Rastelli. Aromatase inhibitors are prescribed to post-menopausal women for at least five years and often longer after a breast cancer diagnosis. There is some evidence that patients who experience the drugs' side effects are less likely to see their cancer return, providing even more incentive to help these patients continue taking them.

It was Rastelli's colleague, Marie E. Taylor, MD, assistant professor of radiation oncology, who first noticed that patients on aromatase inhibitors who experienced this pain found some relief from high doses of vitamin D.

So Rastelli's group recruited 60 patients who reported pain and discomfort associated with anastrozole, one of three FDA-approved aromatase inhibitors. The patients they studied also had low vitamin D levels. Half the group was randomly assigned to receive the recommended daily dose of vitamin D (400 international units) plus a 50,000-unit vitamin D capsule once a week. The other half received the daily dose of 400 units of vitamin D plus a weekly placebo. All subjects received 1,000 milligrams of calcium daily throughout the study.

Patients in the study reported any pain they experienced through three different questionnaires. They were asked to quantify their pain intensity, as well as report how much the pain altered their mood, affected their work and interfered with relationships and daily activities. The results show that patients receiving high-dose vitamin D every week reported significantly less musculoskeletal pain and also were less likely to experience pain that interfered with daily living.

"High-dose vitamin D seems to be really effective in reducing the musculoskeletal pain caused by aromatase inhibitors," Rastelli says. "Patients who get the vitamin D weekly feel better because their pain is reduced and sometimes goes away completely. This makes the drugs much more tolerable. Millions of women worldwide take aromatase inhibitor therapy, and we may have another 'tool' to help them remain on it longer."

Like anastrozole used in this study, the other two FDA-approved aromatase inhibitors, letrozole and exemestane, also cause musculoskeletal pain. Given the similar side effects, Rastelli says patients on these drugs may also benefit from high-dose vitamin D.

The vitamin used in this study is a plant-derived type called vitamin D2. Rastelli says it achieves the best results when given weekly because the body metabolizes it within seven to 10 days. Rastelli and her colleagues did not use high-dose vitamin D3, which remains in the body longer.

"This was a very carefully conducted study, and the placebo control makes the findings quite compelling," says Matthew J. Ellis, MD, PhD, the study's senior author and director of the Breast Cancer Program at the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis. "We should follow up these findings further to determine the most efficacious and safe approach to vitamin D supplementation in our breast cancer patients."

Since vitamin D helps the body absorb calcium, too much of it can cause high levels of calcium in the urine, which may increase the risk of kidney stones. Such possible side effects emphasize the importance of tracking patients' urine calcium levels while taking high-dose vitamin D.

"It's important to monitor the patients, but overall it appears to be very safe," Rastelli says. "Because vitamin D2 is eliminated from the body so quickly, it's very hard to overdose."

In addition to relieving pain, the group wanted to examine whether vitamin D could protect against the bone loss often seen in patients taking aromatase inhibitors. The researchers measured each patient's bone density at the beginning of the study and again after six months.

Perhaps because of its role in calcium absorption, high-dose vitamin D did appear to help maintain bone density at the neck of the femur, the top of the thighbone near the hip joint. Although the result did not reach statistical significance, Rastelli calls the result promising and worth further studies.

"It's great that we have something as simple as vitamin D to help patients alleviate some of this pain," Rastelli says. "It's not toxic it doesn't cause major side effects. And if it is actually protecting against bone loss, that's even better."

Rastelli AL, Taylor ME, Gao F, Armamento-Villareal R, Jamalabadi-Majidi S, Napoli N, Ellis MJ. Vitamin D and aromatase inhibitor-induced musculoskeletal symptoms (AIMSS): a phase II, double-blind, placebo-controlled, randomized trial. Breast Cancer Research and Treatment. Online June 2011.

Source: Washington University in St. Louis

Munching more unprocessed plant foods may help keep the middle-aged bulge away (AKA muffin top) , a new study suggests. On the other hand, meat, french fries and sugar-sweetened drinks can help pack on the pounds. The findings suggest that the types of food you choose, not just calories, are important for avoiding age-related weight gain.

Weight gain results from an imbalance between how much energy you take in and how much you expend. Even small amounts of excess weight can increase your risk for disorders such as diabetes, cardiovascular disease, metabolic syndrome and cancer.

A research team at the Harvard School of Public Health, led by Dr. Dariush Mozaffarian and Dr. Frank Hu, sought to gain insights into the changes in people’s lifestyles that lead to gradual, long-term weight gain.

The team followed the lifestyle and dietary habits of 3 large groups of health professionals, totaling over 120,000 people, for 12 to 20 years.

The researchers found several general lifestyle changes linked to weight gain over a 4-year period. Participants who increased their physical activity gained less weight than those who didn't. However, only increases in activity during the period studied produced this result; absolute levels of physical activity (across the lifespan) weren't associated with weight change. People who slept for less than 6 hours a day or more than 8 hours gained more weight. Increases in TV-watching led to an average gain of about a third of a pound for every hour of TV watching per day.

Food choices also affected weight. Potato chips, sugar-sweetened drinks, processed meats and unprocessed red meat were each linked to weight gain of about a pound or more. Eating more french fries led to an average gain of over 3 pounds. Eating more refined grains and sweets or desserts led to about half a pound of weight gain. By contrast, eating more vegetables, whole grains, fruits, nuts and yogurt was linked to reductions in weight over a 4-year period. Yogurt led the pack, with an average of 0.82 pounds of weight lost.

The researchers suggest that highly processed foods may not satisfy hunger as well as less processed, higher fiber foods, causing a higher total intake of calories. “The idea that there are no ‘good’ or ‘bad’ foods is a myth that needs to be debunked,” Hu says.

This was an observational study, in which people were asked to recall the foods they ate. While the findings are compelling, future controlled studies will be needed to confirm whether eating particular foods can affect long-term weight gain more than simply counting calories.  The study appeared in the June 23, 2011, issue of the New England Journal of Medicine.