Nagging Your Kids About Weight Might Backfire

By Randy Dotinga
HealthDay Reporter

THURSDAY, April 21, 2016 (HealthDay News) — When parents believe their children are overweight — regardless of whether they are or not — those kids are likely to gain weight, a new study suggests.

“Parental perceptions may be something of a self-fulfilling prophecy,” said study co-author Angelina Sutin. She is an assistant professor with the department of behavioral sciences and social medicine at Florida State University College of Medicine in Tallahassee.

But shouldn’t parents notice and take action if their kids weigh too much?

Not necessarily, the researchers said. Kids who were overweight gained less weight if their parents thought they were normal weight, the study found.

“In this case, misperception may be protective,” Sutin said.

Findings from the study were released online April 21 in the journal Pediatrics. And, while the study found a link between parental perception and kids’ weight, it wasn’t designed to prove cause-and-effect.

Sutin said she and a colleague were inspired by studies that found “adults who perceive themselves as overweight tend to gain more weight over time than adults who perceive themselves as normal weight” — no matter what their starting weight status.

In the new study, the researchers looked at the results of an Australian research project that tracked more than 3,500 children and their parents. The project followed the kids at two-year intervals from ages 4 to 5 through ages 12 to 13. The parents (97 percent mothers) answered questions about how they perceived their children’s weight.

At ages 4 to 5, three-quarters of the children had a healthy weight. Twenty percent were actually overweight or obese, but their parents generally thought they had a normal weight, the investigators found.

Over time, “among children who measured in the overweight category, children gained more weight if their parents perceived them as overweight,” Sutin said.

The study that the researchers reviewed didn’t have specific information on the number of extra pounds gained. Sutin said that can be “difficult to quantify because children are still growing and the meaning of weight gain in childhood varies by height.”

The study relied on the commonly used measurement called body mass index (BMI). BMI provides a rough estimate of a person’s body fat based on height and weight, and for children, it also includes age and gender.

But the study also didn’t specify how much BMI increased when parents perceived kids as overweight. Instead, the study simply suggested that a connection exists between parental perceptions and extra pounds when a parent thinks a child is overweight.

The researchers didn’t find any connection to the parents’ weight. But they also didn’t have any information on how parents perceived their own weight.

What do the researchers think might be at play?

“One explanation may be that when parents perceive their children as overweight, they may be less likely to monitor their children’s food intake and physical activity,” Sutin said.

“In adulthood, individuals who feel stigmatized because of their weight tend to overeat and avoid physical activity. Similar mechanisms may also operate in childhood. And, even if parents try to limit their children’s food intake, children may rebel and subsequently eat more,” she added.

Dustin Duncan, an assistant professor in the department of population health at the New York University School of Medicine, endorsed the study. Like Sutin, he noted that it’s not clear why parental perceptions about overweight kids might become reality.

It’s possible, he said, that parental obsessions about weight could transfer to their kids, playing out through poor mental health and “coping strategies,” such as overeating.

Duncan cautioned that because this is a single study, parents shouldn’t try to alter how they perceive their children’s weight based on this study’s findings.

There’s little research into the best ways that parents can address weight in their kids, he said. More studies are needed to help parents understand how to best communicate with their children about weight issues, he added.

In the meantime, what can parents do?

“Parents should talk to their children about what it means to be healthy, rather than focusing specifically on weight,” Sutin recommended.

“It may be more effective for parents to discuss the importance of healthy eating and physical activity for overall health — and provide plenty of opportunities for both in the daily lives of their children — than focus specifically on weight,” she said.

More information

For more on children and weight, visit the U.S. Centers for Disease Control and Prevention.

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Anatomy May Be Key to Female Orgasm

By Dennis Thompson
HealthDay Reporter

THURSDAY, April 21, 2016 (HealthDay News) — Despite what’s often portrayed in movies and on TV, most women can’t orgasm with penetration alone during sexual intercourse.

And simple anatomy is to blame, a new evidence review suggests.

Each woman’s ability to orgasm during sex depends almost wholly on physical development that occurred while she was still in the womb, according to the review authors.

During gestation, the clitoris begins to drift up and away from the vaginal opening, the researchers said.

But among women whose clitoris drifted too far up, it may be very difficult or even impossible to have an orgasm during sex, because traditional lovemaking doesn’t provide enough friction to stimulate the clitoris, said Dr. Maureen Whelihan. She’s an obstetrician and gynecologist in West Palm Beach, Fla., and an expert with the American College of Obstetricians and Gynecologists.

“It’s not her fault. She was born that way,” said Whelihan, who was not involved with the research but reviewed the findings.

The researchers said they have figured out the distance between a woman’s clitoris and her urinary opening that can predict whether she will be able to orgasm during sex, without any additional stimulation.

The “magic number” is 2.5 centimeters — slightly less than 1 inch, said Elisabeth Lloyd, who was not involved with the new study. Lloyd is an affiliated faculty scholar with the Kinsey Institute for Research in Sex, Gender and Reproduction at Indiana University-Bloomington.

“It’s so strong a correlation that if you give us a woman who has a distance of 3 centimeters, we can very reliably predict she won’t have orgasm with intercourse,” Lloyd said. “Women can do this measurement themselves or with their partner, to help explain their own sexual experience.”

Other factors, such as penis size, the skill of the sexual partner or the intensity of desire “might have some effect, but it really is the anatomical distance that seems to be predictive,” Lloyd said.

Exposure to male hormones in the womb increases the amount of drift, Lloyd said. “If she’s exposed to a lot of androgen, the clitoral bud migrates far away,” she said.

Between 70 percent to 90 percent of women are unable to achieve orgasm with penetration alone, Whelihan said.

“Of those that claim they can have purely vaginal orgasms, 90 percent of them say they have to be on top,” she added. “Guess what? When you’re on top, sitting on the partner’s erection and grinding on his abdomen, it’s really not just a vaginal orgasm. You’re rubbing your clitoris on his abdomen or pelvis.”

Nine out of 10 women in her practice have had an orgasm during their life, Whelihan said, but nearly all needed direct clitoral stimulation to achieve it.

What about the G-spot, the erogenous area purported to exist inside the vagina? Autopsies haven’t consistently supported the existence of the G-spot, the evidence review said.

A majority of sex experts don’t believe there is such a thing, Whelihan said. “According to most of the experts, we believe if the G-spot exists then it only exists in a few women,” she said.

Couples determined to achieve female orgasm during intercourse should start paying more attention to the clitoris, Lloyd and Whelihan said.

Couples can use positions where the female is on top, which allows the woman to get more friction against her clitoris. Or they can use a sexual position that allows either the man or the woman to rub the clitoris during sex, either with fingers or a sex toy, Whelihan said.

“There are many ways to have an orgasm where she’s having hers while he’s having his,” she said. “Couples should not focus on something that will never change anatomically, and instead find ways to allow for some type of clitoral stimulation during penetration.”

However, couples also should remember that orgasm with intercourse is not necessary for a woman to have a healthy or enjoyable sex life, Lloyd added.

“I think this approach is traditional, and it’s very common, but it’s problematic. We’ve learned in our research there are so many women who do not have orgasm with intercourse on a regular basis,” Lloyd said. “To put this banner of healthiness as having orgasm with intercourse kind of stacks the deck against these women who, because of their anatomy, cannot have orgasm with intercourse.”

The evidence review was conducted by Leslie Hoffman of the department of anatomy at Indiana University School of Medicine, and colleagues. The report was published online April 4 in the journal Clinical Anatomy.

More information

For more on female orgasms, visit the Society of Obstetricians and Gynecologists of Canada.

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Why More and More Young Adults Are Getting Plastic Surgery

Photo: Getty Images

Trend we hate alert: More and more young adults are itching to change their physical appearance by going under the knife.

According to the American Academy of Facial Plastic and Reconstructive Surgery, 64 percent of facial plastic surgeons surveyed saw an increase in injectable treatments or cosmetic surgery in people under 30 in 2015. Experts point to our selfie-obsessed culture and the so-called Kardashian effect—but it’s not just a millennial mind-set. Eighty-two percent of the surgeons surveyed said that celebrities were a big influence on the decisions of patients of all ages to get plastic surgery last year.

RELATED: 7 Celebs Who’ve Said Goodbye to Breast Implants

“Patients bring pictures of celebrities on their cell phones or show me photos they found on social media of what they want to look like,” says Eugene Kim, MD, a board-certified plastic surgeon in Beverly Hills.

Deep breaths, everyone. Whatever happened to just slapping on a Valencia filter and loving your features exactly as they are?

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Eating Disorders Seem More Common in Schools Where Girls Predominate

WEDNESDAY, April 20, 2016 (HealthDay News) — Eating disorders may be more prevalent at schools where a greater portion of the student body is female, a new study suggests.

British and Swedish researchers analyzed data from Sweden, and also found the risk increased when more of the students’ parents had a university education.

“Eating disorders have an enormous effect on the lives of young people who suffer from them — it is important to understand the risk factors so that we can address them,” said study leader Dr. Helen Bould.

Bould is a child and adolescent psychiatrist at the University of Oxford in England.

“For a long time, clinicians in the field have noted that they seem to see more young people with eating disorders from some schools than others, but this is the first empirical evidence that this is the case,” she said in a university news release.

However, the study did not prove that these factors caused an increased risk of eating disorders among students.

“Unfortunately, this study can’t tell us what it is about schools that affects the rates of eating disorders: it might be an unintentional effect of the aspirational culture of some schools that makes eating disorders more likely; it might be that eating disorders are contagious and can spread within a school,” Bould said.

“On the other hand, it could be that some schools are better than others at identifying eating disorders in their students and ensuring they get diagnosed and treated,” she added.

Girls are more than 2.5 times as likely as boys to have an eating disorder such as anorexia nervosa, bulimia and binge eating, according to the U.S. National Institute of Mental Health.

More information

The U.S. National Institute of Mental Health has more on eating disorders.

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Alcohol Processed Meats May Raise Stomach Cancer Risk

By Dennis Thompson
HealthDay Reporter

WEDNESDAY, April 20, 2016 (HealthDay News) — Alcohol, processed meats — such as hot dogs, ham and bacon — and excess weight all may raise a person’s risk of stomach cancer, a new review finds.

Further, the risk seems to increase as a person drinks more alcohol, or eats more processed meats or gains more weight, the review states.

It was released Wednesday by the American Institute for Cancer Research and the World Cancer Research Fund.

The review concludes that in the United States, about one in seven stomach cancer cases could be prevented if people did not drink more than three alcoholic drinks a day, did not eat processed meat and maintained a healthy weight. That’s approximately 4,000 stomach cancer cases every year.

“This is the first report to find strong evidence of these links,” said Alice Bender, head of nutrition programs at the cancer institute. “There are things we can do to lower our risk for cancer. There are choices we make every day that can make a difference.”

However, the report did not prove that these factors cause stomach cancer; it only showed an association.

The report suggests that:

• Three or more alcoholic drinks per day every day increases risk of stomach cancer. A standard drink is 12 ounces of beer, 5 ounces of wine or 1.5 ounces of distilled spirits, according to the U.S. National Institutes of Health.
• For every 1.8 ounces of processed meat eaten every day — the equivalent of one hot dog or two slices of bologna — the risk of cancer in the lower stomach rises by 18 percent.
• Every five-unit increase in body mass index — BMI, a ratio of weight to height — causes a 23 percent increased risk of cancer in the upper stomach.

Stomach cancer is the fifth most common cancer worldwide and the third most common cause of death by cancer, the report stated. Just last October, the World Health Organization determined that processed meat can cause cancer.

Nearly 1 million new stomach cancer cases are recorded each year around the world, accounting for 7 percent of all new cases of cancer. The five-year survival rate is 25 percent to 28 percent, largely because symptoms only appear at a late stage, according to the report.

Men are twice as likely as women to develop stomach cancer, and it is more common in older adults. The average age at diagnosis in the United States is 72, the report added.

For the report, researchers combined and analyzed all scientific data available on stomach cancer, diet, physical activity and weight. The analysis included 89 studies covering 17.5 million adults, including 77,000 with stomach cancer.

“You usually can’t take the result of a single study as proof. You like to see patterns,” said study co-author Dr. Anne McTiernan, an epidemiologist with the Fred Hutchinson Cancer Research Center in Seattle. “By combining all this evidence, you’re able to really see what these associations look like.”

The researchers took an additional step by looking at how the risk factors affected the two different types of stomach cancer — cancers of the upper stomach near the esophagus, and cancers of the lower stomach.

Overweight and obesity appear to increase risk of upper stomach cancer, possibly because the excess weight causes acid reflux that irritates the lining of the upper stomach and esophagus, McTiernan and Bender explained.

It’s also possible that excess fat increases cancer risk because it promotes the release of hormones such as insulin, human growth factors and other inflammatory chemicals into the bloodstream, they added.

On the other hand, alcohol and processed meat appear to mainly increase the risk of lower stomach cancer, the report found.

Processed meats contain preservatives like nitrates and salt, or byproducts like polycyclic aromatic hydrocarbons (PAHs) when smoked. These have previously have been linked to cancer risk, McTiernan and Bender said.

“We can’t pinpoint any one thing, but there are a number of plausible mechanisms why processed meat would increase the risk of stomach cancer,” Bender said.

Alcohol also has been linked to the risk for other types of cancer, McTiernan added. Bender noted that alcohol might serve as a solvent that helps carcinogens get into a person’s cells, or that the body might break alcohol down into pro-cancer substances.

People might want to consider processed meat a once-in-a-while treat based on these findings, said Marji McCullough, strategic director of nutritional epidemiology for the American Cancer Society.

“People should lower their intake of processed meat and consider it something they eat more on occasion, rather than a regular part of their diet,” she said.

On the other hand, current guidelines already restrict alcohol consumption to one drink daily for women, and two drinks daily for men, so people sticking to that wouldn’t have to change their habits.

“If you follow current cancer prevention guidelines, that would definitely be consistent with this report,” McCullough said.

Experts differed on whether these individual risk factors can combine to increase a person’s odds of developing stomach cancer. For example, would a person who drinks alcohol and eats processed meat have a greater risk than a person who only drinks?

McTiernan said that risk factors often overlap — like the fact that drinkers also are more likely to smoke. “It can be hard to tease those apart,” she said, making it difficult to tell whether the risks add up or not.

But several studies have shown that if people adopt multiple cancer-reduction strategies in their everyday life, they have a reduced risk of either developing or dying from cancer compared with people who only adopt a single strategy, McCullough said.

“It does seem the more healthy things you do, the more benefit in terms of lowering risk,” she said.

More information

For more on stomach cancer, visit the American Cancer Society.

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Previous Mental Distress May Slow Concussion Recovery

WEDNESDAY, April 20, 2016 (HealthDay News) — Athletes may take longer to recover after a concussion if they had psychosomatic symptoms — aches and pains caused by mental distress — before their head injury, new research suggests.

The study included 127 high school and college athletes who had concussions; 80 percent of the athletes were male.

About two-thirds of the head injuries occurred during football. About one-quarter of the concussions happened during soccer. The remaining concussions occurred during lacrosse, wrestling, hockey, rugby and field hockey.

Concussion symptoms lasted an average of five days. But athletes with psychosomatic symptoms prior to their concussion took longer to recover, the study authors said.

The majority of those with concussion and previous psychosomatic symptoms recovered within about 20 days. In comparison, most of those with concussion and no previous psychosomatic symptoms got better in about 10 days, the researchers said.

While the study found a link between prior pyschosomatic symptoms and longer recovery, it wasn’t designed to prove a cause-and-effect relationship.

The researchers also found that the most significant factor in recovery speed was how serious the concussion symptoms were soon after the injury. Athletes with more severe symptoms — such as headache and balance problems — recovered more slowly than those with less severe symptoms, the study revealed.

The study was published online April 20 in the journal Neurology.

“We found the greatest predictor of recovery after a concussion was the severity of early post-concussion symptoms. But somatic complaints before injury also play an important role, either by possibly enhancing how a person experiences the injury or affecting their reporting of post-concussive symptoms,” study author Lindsay Nelson said in a journal news release.

Nelson is an assistant professor of neurosurgery at the Medical College of Wisconsin in Milwaukee.

He said that because the players in the study were generally healthy physically and psychologically, the findings highlight the important role psychosomatic symptoms can play in recovery.

“Our hope is our study will lead to further research, because identifying those at risk for prolonged recovery is critical to developing early interventions that improve outcomes for people who suffer concussions,” Nelson said.

More information

The American Academy of Family Physicians has more on concussion.

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Why We Loved Daisy Ridleys Fake #NoMakeup Selfie

Photo: Getty Images

Daisy Ridley has an empowering reminder for her fans: Don’t believe everything you see on social media. Yesterday the Star Wars: The Force Awakens actress, 24, shared an Instagram selfie with the sentence “I woke up like this #nofilter #nomakeup” across her forehead. In the caption, though, Ridley clarified the obvious—”3 of these statements aren’t true”—and took the opportunity to start a discussion about the toll social media can take on your self-esteem.

RELATED: 5 Body-Positive Resolutions You Should Make in 2016

“Social media is great, but also a bit scary,”Ridley wrote. “[W]hat people post is the most filtered, most carefully chosen and cleverly edited moments of their lives.”

She added that despite what her own Instagram page may suggest, her life is not always picture-perfect: “My skin isn’t great so I don’t post no make up selfies, much as I’d like to; I have a trainer urging me on in workouts and don’t include all the times I say ‘I can’t do it’ and I don’t smile all the time but I like to share the pictures where I am.”

RELATED: How Social Media Is Wrecking Your Sleep

Ridley’s message: Take what you see on Instagram with a grain of salt. The Star Wars actress joins a growing group of stars (including Chrissy Teigen, Vanessa Carlton, Lily Allen, and model Stina Sanders) who have recently used social media to come clean about the less glamorous side of their lives.

“I actually do love myself, I try to think good thoughts always and am surrounded by the most wonderful people,” Ridley said. “[S]o I’m keeping it balanced (like the Force, obvs).”

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Mixing Lab Mice With Pet Store Peers Might Boost Research

WEDNESDAY, April 20, 2016 (HealthDay News) — Placing pet store mice in the same cages as laboratory mice could help improve mouse-based research into human diseases, a new study suggests.

Laboratory mice are used in many areas of medical research, but their immune systems are more similar to the immature immune systems of newborn humans than adult immune systems, according to researchers led by David Masopust at the University of Minnesota.

That’s because lab mice are kept in abnormally clean environments, the researchers said.

When pet store mice were placed in the same cages as lab mice, the immune systems of the lab mice changed to more closely resemble adult human immune systems.

Specifically, the lab mice housed with pet store mice had a more than 10,000 times improved immune response to a bacterial infection than typical lab mice, the study found.

The findings suggest that exposing lab mice to wild or pet store mice could improve the translation of mouse-based research to humans, the researchers said.

The study was published online April 20 in the journal Nature.

More information

Canadians for Health Research has more about mice and research.

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Cow’s Milk Allergy in Childhood May Lead to Weaker Bones: Study

By Kathleen Doheny
HealthDay Reporter

WEDNESDAY, April 20, 2016 (HealthDay News) — Children who are allergic to cow’s milk may have weaker bones than kids with other food allergies, a small study suggests.

Cow’s milk allergy is the most common childhood food allergy in the United States, affecting up to 3 percent of children, the researchers said. The main treatment is elimination of cow’s milk and dairy products — which are major sources of the calcium kids need to build strong bones.

This new study detected low bone density in 6 percent of 52 children with a long-term milk allergy.

“Prepubertal children with persistent cow’s milk allergy have a lower bone mineral density and calcium intake compared with similarly aged children with food allergies other than cow’s milk,” said study co-author Genevieve Mailhot. She is an associate professor at the CHU Sainte-Justine Research Center at the University of Montreal.

The study findings don’t show a direct cause-and-effect link between milk allergy and low bone density.

And the difference in bone density observed in the study wasn’t significant enough, on average, to worry about fractures, said one pediatric expert not involved with the research. But the findings merit attention, he added.

Most kids with cow’s milk allergy — up to 87 percent — outgrow it by about 3 years of age. However, recent reports find it persists in about 15 percent of those affected until they are teens, the study authors noted.

Long-standing cow’s milk allergy in adults has been linked to reduced bone density. But, children with the allergy have not been studied extensively, the authors said.

For the study, they recruited 81 pre-puberty-stage children with food allergies. Fifty-two had cow’s milk allergy, while 29 had allergies to foods other than milk. The kids’ average age was close to 7 years old.

The researchers measured the kids’ bone mineral density using standard testing. They also took blood samples to assess levels of vitamin D, crucial for bone health. In addition, they recorded calcium and vitamin D intake and tracked compliance in those advised to take supplements.

While low bone mineral density was found in 6 percent of those with cow’s milk allergies, none of those in the other group had low bone density, the researchers said.

The children with cow’s milk allergies also had lower average calcium intake — 930 milligrams (mg) a day compared to 1,435 in the other group. Recommended daily intake is 1,000 mg. Vitamin D intake in both groups was well below the recommended 600 International Units (IUs) a day.

Few with the cow’s milk allergies took supplements — 37 percent reported taking calcium and 44 percent reported taking vitamin D. However, those who did take a supplement averaged more than five days a week, which was termed good compliance, according to the study.

The study is published online April 20 in the journal Pediatrics.

The findings aren’t surprising, said Dr. Luis Gonzalez-Mendoza, director of pediatric endocrinology at Nicklaus Children’s Hospital, in Miami. He was not involved with the study.

Prior research has shown that children who don’t reach peak bone mass have a higher risk of the bone-thinning disease osteoporosis in later life, the study authors noted.

But, Gonzalez-Mendoza said the difference in bone density seen in this study wasn’t big enough, on average, to be concerned about fractures.

Still, the finding warrants attention and observation, he added. Parents and pediatricians have to be aware that lower bone density is a possibility and “probably have to take a look at how these kids are getting their calcium,” he said.

Pediatricians who order supplements should also emphasize their importance, he said.

If your child is allergic to cow’s milk, what can you do?

“Parents should encourage the intake of alternate sources of calcium in their children’s diet,” Mailhot said, suggesting soy, almond or rice milk and orange juice fortified with calcium.

Parents can also have a dietitian evaluate their child’s diet, and find out how to increase calcium and vitamin D intake, she said. Also, a bone density scan could be considered if indicated, she said.

More information

To learn more about food allergy, visit the American Academy of Pediatrics.

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Warfarin Can Be Safe Effective for People With Irregular Heartbeat

WEDNESDAY, April 20, 2016 (HealthDay News) — Millions of American heart patients take warfarin — for decades a cheap, but often tricky-to-manage mainstay blood thinner.

Now, new research shows that when it is well-managed, warfarin treatment appears safe for people with atrial fibrillation, a common heart rhythm disorder.

“Well-managed warfarin treatment is a valid alternative in patients with atrial fibrillation who require anticoagulant treatments, with relatively low complication rates and low all-cause [death rates],” concludes a team led by Dr. Fredrik Bjorck of Umea University in Sweden.

The findings come in the context of newer, but much pricier, blood thinners — drugs such as Eliquis, Pradaxa and Xarelto. One expert who reviewed the new study said he would still opt for these medications over warfarin, because they are so much easier to manage.

“In my opinion, the benefits of improved patient compliance, ease of management and safety with [these drugs] as compared to warfarin, outweighs the cost issue and they are my first choice when choosing anticoagulation for atrial fibrillation patients,” said Dr. Nicholas Skipitaris. He directs cardiac electrophysiology at Lenox Hill Hospital in New York City.

The new findings were published online April 20 in the journal JAMA Cardiology.

The study authors explained that atrial fibrillation raises a person’s risk of stroke. And, warfarin therapy reduces the risk of stroke by 64 percent and the risk of death from any cause by 26 percent, the researchers said.

However, like any blood thinner, warfarin does boost the risk of major bleeding, including bleeding inside the skull (intracranial bleeding). So doctors sometimes have trouble managing the drug — balancing its anti-clotting powers against the risk for bleeding.

In the study, Bjorck’s team tracked data from more than 40,000 people in Sweden with atrial fibrillation who took warfarin.

The study found that the annual rate of intracranial bleeding was 0.44 percent and the annual rate of death from all causes was about 2.2 percent.

Among patients who also took another blood thinner, aspirin, the annual rate of any major bleeding was just over 3 percent and the annual rate of blood clots was close to 5 percent, the team noted.

The researchers also found that patients with kidney failure were at higher risk for intracranial bleeding compared to those with healthier kidneys.

But Skipitaris believes that the Swedish population study can’t show the whole picture.

“The problem is that in the ‘real world,’ we cannot predict which patients on warfarin will do well with the drug, and it remains difficult to adjust reliably,” he said.

Warfarin (also known as Coumadin), “requires frequent monitoring and has many interactions with diet and other medications,” Skipitaris said. On the other hand, the newer blood thinners, while more expensive, “do not have these requirements or restrictions,” he added.

More information

The U.S. National Heart, Lung, and Blood Institute has more about atrial fibrillation.

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