The serious side effects associated with fluoroquinolone antibacterial drugs.

 “The FDA issues advisory regarding treatment with fluoroquinolone antibacterial drugs. The tendon side effects include tendon ruptures. I was not aware of the central nervous system side effects. I posted a list of the brand names below for your information. The best known antibiotic in this class is Cipro.” Bill Chesnut, MD

(Return to New Health News,

The U.S. Food and Drug Administration (FDA) is advising that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with sinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options. An agency safety review has shown that, when used systematically, fluoroquinolones are associated with disabling and potentially permanent serious side effects that can occur together. Side effects can involve the tendons, muscles, joints, nerves, and central nervous system. As a result, FDA is requiring the drug labels and medication guides for all fluoroquinolone antibacterial drugs to be updated to reflect this new safety information. The agency states that healthcare professionals should stop systemic fluoroquinolone treatment immediately if a patient reports serious side effects, and switch to a non-fluoroquinolone antibacterial drug to complete the patient’s treatment course.



The second-generation class is sometimes subdivided into “Class 1” and “Class 2”.[78]


Unlike the first- and second-generations, the third-generation is active against streptococci.[78]


Fourth-generation fluoroquinolones act at DNA gyrase and topoisomerase IV.[82] This dual action slows development of resistance.

In development[edit]



Acupuncture may help with chronic pain and high blood pressure.

Acupuncture in my practice experience continues to improve with some results that are astonishing. I have patients who find acupuncture relieves their sinus obstructions during their allergy seasons when nothing else works.” Bill Chesnut, MD


May 9, 2016 Cleveland Clinic Wellness Newsletter
Get stuck, in a good way! Acupuncture may help with chronic pain and high blood pressure.
Sometimes needles are used to deliver treatment, and other times they are the treatment. Acupuncture, the use of very thin needles to stimulate points on the body, has been practiced for more than 3,500 years as part of Chinese medicine. “It draws on the belief that energy, or qi (pronounced “chee”), circulates throughout our body, from the tops of our heads to the soles of our feet,” notes Cleveland Clinic Medical Director Daniel Neides, M.D. In an exciting new study, nine weekly acupuncture sessions were shown to ease symptoms and improve quality of life in people with fibromyalgia, a hard-to-treat condition characterized by chronic pain. The best part: the positive effects persisted a year later! The study was unusual in that subjects received individualized acupuncture treatments (the way it’s often practiced in the real world) rather than a uniform, one-size-fits-all treatment. Acupuncture has been shown to help a number of chronic pain conditions, from headaches to back pain to arthritis, and a preliminary study suggests it may be helpful for mild to moderate high blood pressure, perhaps in part by lowering levels of norepinephrine, a stress hormone. If you’re dealing with these or other chronic conditions, ask your physician about trying acupuncture as a complementary treatment. As research continues, the day may come when you hear, “Take two needles and call me in the morning!”


Hormone replacement therapy, HRT, in early menopause may slow progression of cardiovascular disease.

“Hormone Replacement therapy in early menopause is important to decrease the bone loss following menopause. I have posted several articles on this website related to osteoporosis. Post-menopausal women not taking hormone replacement lose 60% of their total bone mass between menopause and 60 years of age.

Now another benefit is reported. The study below shows slowing of atherosclerosis by taking hormone replacement.

It is important to know what replacement is most safe. Also know the safety advantages of vaginal or topical HRT versus oral hormone placement. The metabolism is different when taking a medical orally than transcutaneous. Vaginal HRT with estriol elevates estriol a little and transiently if it elevates blood levels at all.

Testosterone is another hormone loss in menopause. Its involvement in bone loss and atherosclerosis has not been as extensively tested. The research available that I found does not report a significant risk of  testosterone replacement to keep the normal pre-menopausal blood level.

This finding is so important in my view that I posted the abstract of the original article just below the announcement in the popular press.

If you know women in the age group to be peri-menopausal please tell them the news.” Bill Chesnut, MD

To go back to New Health News:

Starting HRT in early menopause may slow progression of cardiovascular disease, study indicates

The Wall Street Journal (3/30, Beck, Subscription Publication) reports the findings of a 643-patient study published in the New England Journal of Medicine study add to the evidence that beginning hormone replacement therapy (HRT) in early menopause may be protective against cardiovascular disease.

The NPR (3/30, Bichell) “Shots” blog reports that in the study, investigators “directly tested the effect of starting hormone therapy within the first six years after menopause, versus the effect of starting 10 years or more after menopause.” After five years, researchers found that “women who started hormones within six years of menopause had artery walls that thickened a little more slowly than the women on the placebo, whereas the extra estrogen did not seem to slow thickening in the group that started the hormone therapy later.”



Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol

Howard N. Hodis, M.D., Wendy J. Mack, Ph.D., Victor W. Henderson, M.D., Donna Shoupe, M.D., Matthew J. Budoff, M.D., Juliana Hwang-Levine, Pharm.D., Yanjie Li, M.D., Mei Feng, M.D., Laurie Dustin, M.S., Naoko Kono, M.P.H., Frank Z. Stanczyk, Ph.D., Robert H. Selzer, M.S., and Stanley P. Azen, Ph.D., for the ELITE Research Group*

N Engl J Med 2016; 374:1221-1231March 31, 2016DOI: 10.1056/NEJMoa1505241



Data suggest that estrogen-containing hormone therapy is associated with beneficial effects with regard to cardiovascular disease when the therapy is initiated temporally close to menopause but not when it is initiated later. However, the hypothesis that the cardiovascular effects of postmenopausal hormone therapy vary with the timing of therapy initiation (the hormone-timing hypothesis) has not been tested.


A total of 643 healthy postmenopausal women were stratified according to time since menopause (<6 years [early postmenopause] or ≥10 years [late postmenopause]) and were randomly assigned to receive either oral 17β-estradiol (1 mg per day, plus progesterone [45 mg] vaginal gel administered sequentially [i.e., once daily for 10 days of each 30-day cycle] for women with a uterus) or placebo (plus sequential placebo vaginal gel for women with a uterus). The primary outcome was the rate of change in carotid-artery intima–media thickness (CIMT), which was measured every 6 months. Secondary outcomes included an assessment of coronary atherosclerosis by cardiac computed tomography (CT), which was performed when participants completed the randomly assigned regimen.


After a median of 5 years, the effect of estradiol, with or without progesterone, on CIMT progression differed between the early and late postmenopause strata (P=0.007 for the interaction). Among women who were less than 6 years past menopause at the time of randomization, the mean CIMT increased by 0.0078 mm per year in the placebo group versus 0.0044 mm per year in the estradiol group (P=0.008). Among women who were 10 or more years past menopause at the time of randomization, the rates of CIMT progression in the placebo and estradiol groups were similar (0.0088 and 0.0100 mm per year, respectively; P=0.29). CT measures of coronary-artery calcium, total stenosis, and plaque did not differ significantly between the placebo group and the estradiol group in either postmenopause stratum.


Oral estradiol therapy was associated with less progression of subclinical atherosclerosis (measured as CIMT) than was placebo when therapy was initiated within 6 years after menopause but not when it was initiated 10 or more years after menopause. Estradiol had no significant effect on cardiac CT measures of atherosclerosis in either postmenopause stratum. (Funded by the National Institute on Aging, National Institutes of Health; ELITE number, NCT00114517.)



Low levels of midlife fitness may be associated with smaller brain tissue volume later

“Great study of 1,583 participants without dementia using brain scans and fitness tests. Note this:  “observed that participants who had an especially high heart rate and blood pressure during the most vigorous exercise had notably smaller brain volumes 20 years later“. Bill Chesnut, MD

Low levels of midlife fitness may be associated with smaller brain tissue volume later

Reuters (2/10, Rapaport) reports that people who are not physically fit in midlife have an increased chance of having lower brain tissue volume in late life, compared to people who take part in regular exercise during their middle years, the findings of a study published online Feb. 10 in Neurology suggest.

TIME (2/10, Sifferlin) reports that investigators “looked at 1,583 men and women who didn’t have dementia or heart disease,” all of whom “worked out on a treadmill to assess their fitness levels.” Two decades later, study participant underwent “another treadmill fitness test and had brain scans.”

Newsweek (2/10, Firger) reports that “smaller brain volume” was found to correlate “with lower levels of physical fitness.” In addition, investigators “observed that participants who had an especially high heart rate and blood pressure during the most vigorous exercise had notably smaller brain volumes” 20 years later. While the study did not “measure rates of cognitive decline” in participants, “a decrease in brain volume is a strong indicator of declining function.”


Why you should use self-measured blood pressure monitoring.

“This newsletter for physicians patient instructions is good advice. The graph of the blood pressure readings is very helpful to any provider.” Bill Chesnut, MD.

 Why you should use self-measured blood pressure monitoring

AMA wire­2/8/2016, 3:37 PM

In the last decade, the number of hypertension-related deaths in the United States increased by 66 percent according to the Centers for Disease Control and Prevention (CDC). Self-measured blood pressure monitoring (SMBP) is a great way to engage patients in managing their hypertension. With American Heart Month underway, we’re sharing three key advantages to using SMBP in your practice.

Sometimes called home blood pressure monitoring, SMBP is any self-measured blood pressure that occurs outside the clinical setting. Research has shown that SMBP not only improves blood pressure control, but also increases patient engagement in making healthy lifestyle changes and improving medication adherence.

Here are three clinical benefits of using SMBP in your practice:

  • SMBP is a better predictor of health. Randomized controlled trials have shown that blood pressure measurements conducted at home predict cardiovascular morbidity and mortality better than blood pressure measurements taken at the doctor’s office.
  • You will obtain more blood pressure readings over a longer period of time.Having blood pressure readings that are more representative of a patient’s true blood pressure are crucial to accurately diagnosing and assessing blood pressure control options for patients with hypertension.

    SMBP also helps guide your decision making when trying to diagnose a patient with high blood pressure. Using blood pressures measured outside of the office is now recommended by the U.S. Preventive Services Task Force to confirm the diagnosis of hypertension when office blood pressures are high.

  • SMBP helps patients take control of their own health. Patients often adhere to treatment more often when they feel like they are a part of the process of improving their health.

    Read how one patientpartnered with his physician to improve his health using self-measured blood pressure.

Other ways to improve blood pressure monitoring

Make sure your health care team is getting the most accurate readings and taking the most effective action to help your patients with hypertension get their blood pressure under control. The AMA’s Improving Health Outcomes initiative offers several resources for your team and your patients.

The “M.A.P.” (Measure accurately, Act rapidly, Partner with patients) collection of tools includes:

  • Common errors in blood pressure measurement
  • Posters that shows the proper positioning for the patient and the cuff
  • Additional resources about self-measured blood pressure



High blood pressure should be confirmed outside of physician’s office

“High blood pressure is important! Check your blood pressure! Elsewhere on this site, I posted a short video of how to correctly check your blood pressure. If you are being treated for hypertension, record your blood pressure readings at home on a graph and give this to your prescribing provider. The US Preventive Services Task Force says “ambulatory blood pressure monitoring is the first choice.” I will look for more information about recording ambulatory BP.” Bill Chesnut, MD

 High blood pressure should be confirmed outside of physician’s office, USPSTF says

 NBC News (10/13, Fox, Edwards) reports that while “blood pressure checks definitely save lives and are worth doing, experts said” yesterday, “patients need to get their blood pressure screened outside the doctor’s office, too.” The reason is that “some people’s blood pressure spikes when they see a” physician, “while other people may have dangerous surges when they wake up in the morning, or through the day, the US Preventive Services Task Force [USPSTF] says in new recommendations,” which are published in the Annals of Internal Medicine.

HealthDay (10/13, Reinberg) reports that “ambulatory blood pressure monitoring is the first choice for confirming a diagnosis of high blood pressure…said” the USPSTF. However, “when not available, home monitors are an acceptable alternative.”


Adults with who take hypertension medications at bedtime may be less likely to develop Type 2 diabetes

“Hypertension is serious, complicated and there is a lot to know. I posted elsewhere on this site a video of how to take your blood pressure correctly. I recommend reviewing that. This article associates type 2 diabetes with your control of hypertension. This finding is an important finding and needs wider dissemination than I have seen in my reading.” Bill Chesnut, MD

Adults with who take hypertension medications at bedtime may be less likely to develop Type 2 diabetes

The Los Angeles Times (9/24, Healy) “Science Now” reports that research published in Diabetologia suggests that “adults with high blood pressure who take all of their hypertension medications before they go to bed, rather than in the morning, are less likely to develop Type 2 diabetes.” Another study, “also published in Diabetologia” yesterday “and conducted by the same…researchers, found that subjects whose blood pressure did not dip, and those whose readings dipped more briefly or shallowly, were more likely to develop Type 2 diabetes than those whose sleep-time blood pressure saw a deep and sustained drop from daytime levels.”

AMA Wire 9.26.15

How to take your blood pressure correctly!

“How to take your blood pressure correctly, from the AMA newsletter.” Bill Chesnut, MD

The one video you need for accurate blood pressure readings

Verify that you’re getting the most accurate blood pressure readings from your patients by using this quick video.

Share the video on Facebook or Twitter with your practice team and patients so they understand how seemingly minor factors can affect their blood pressure measurements.

Here are some additional resources to help you improve your practice’s hypertension management:

Why you should take action

The number of hypertension-related deaths in the United States increased by 66 percent over the past decade, according to data from the Centers for Disease Control and Prevention. To put that in perspective, the number of deaths from all other causes combined increased only 3.5 percent during that period.

The AMA’s Improving Health Outcomes initiative is taking steps to reverse this trend. Through this initiative, the AMA and participating physicians and care teams are working with researchers at the Johns Hopkins Armstrong Institute for Patient Safety and Quality and the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities to develop and test evidence-based blood pressure recommendations and provide practical tools for physician practices.