Monday, August 13, 2018

Salt Restrictions for Some May Be Better Than for All

Restricting sodium intake seems best suited to communities with the highest consumption levels, according to an 18-country study in The Lancet.

Researchers used urine samples from nearly 100,000 adults to estimate sodium and potassium intakes. Blood pressure was also measured, and cardiovascular events were tracked.

Mean sodium intake was 4.8 g per day, with Chinese communities having higher intakes (5.6 g). During a median follow-up of 8 years, a mean increase of 2.86 mm Hg in systolic pressure was noted for every 1-g increase in sodium intake above the overall average. There was a positive association between sodium intake and stroke, but only in communities with the highest sodium intake. Of note, the frequency of cardiovascular events showed an inverse association with sodium intakes in communities with the lowest intakes.

Higher potassium intakes were associated with lower rates of all cardiovascular events.

The authors suggest that targeting restrictions to communities with sodium intakes above 5 g/day would bring the most benefit. Commentators call the findings "exceedingly provocative."

My Take:
WHO recommends that populations consume less than 2 g/day sodium as a preventive measure against cardiovascular disease, but this target has not been achieved in any country. This recommendation is primarily based on individual-level data from short-term trials of blood pressure (BP) without data relating low sodium intake to reduced cardiovascular events from randomized trials or observational studies. Now a new well-designed study questions the wisdoms of this recommendation.

Friday, August 10, 2018

Saunas Linked to Numerous Health Benefits

A stint in a sauna is not only pleasant and relaxing but may also improve health, according to the authors of a new, comprehensive literature review. Among the benefits they identified were a reduced risk for cardiovascular, neurocognitive, and pulmonary illnesses such as asthma and influenza; amelioration of pain conditions such as rheumatic diseases and headache; decreased risk for mortality; and an improved quality of life.

Overall, “the physiological responses produced by an ordinary sauna bath correspond to those produced by moderate or high intensity physical activity such as walking,” Jari A. Laukkanen, MD, PhD, from the Faculty of Sport and Health Sciences, University of Jyvaskyla, Finland, and colleagues write in an article published online July 31 in Mayo Clinic Proceedings. In fact, the advantages of sauna bathing plus physical activity may be additive, they write.

The findings build on earlier research by the same authors linking sauna use to a decreased risk for stroke. In that study, there was an inverse relationship between frequency of weekly sauna visits and stroke rates per 1000 person-years for follow-up. The authors listed a variety of positive effects associated with sauna baths that might account for that finding, including lower blood pressure and improvements in lipid profiles, arterial stiffness, carotid intima-media thickness, and peripheral vascular resistance, as well as a reduced risk for hypertension, dementia, and cardiovascular and all-cause mortality.

They confined the analysis to traditional Finnish sauna baths, as those have been the most widely studied to date. In a Finnish sauna, temperatures range from 176-212 degrees Fahrenheit, with 10-20% relative humidity. A bather will usually spend 5 t0 20 minutes in the sauna and follow it with a swim, a shower, or just a cooling-off period at room temperature, the authors explain. Finnish people typically have “a sauna bath at least once per week, with the average habitual frequency being 2 to 3 times a week.”

Wednesday, August 8, 2018

Wisdom Wednesday: Clinicians Rarely Ask for Patients’ Input, Often Interrupt

During consultations, clinicians rarely ask patients to explain the reasons for their visit, a recent study published online July 2 in the Journal of General Internal Medicine has shown.

“The patient’s agenda was elicited in 36% of the clinical encounters,” writes Naykky Singh Ospina, MD, from the University of Florida, and colleagues. And, “among those in which the agenda was elicited, patients were interrupted seven out of ten times, with a median time to interruption of 11 seconds.”

According to the authors, patient-centered decision-making is a key feature of quality healthcare. In particular, identifying and understanding the patient’s agenda for the visit both improves and facilitates patient-clinician communication, they emphasize.

My Take:
The remainder of the article was devoted to a statistical analysis of the methods used to analyze these videotaped clinician-patient encounters.

I was taught, and still believe, that 80% of a good diagnosis is a detailed history. I often tell my patients who are not forthcoming during consult that without hearing their story I might as well be a vet. Of note, this article was written by Dr. Nicola M Parry, a veterinarian.

In theory, the consult guides your examination and combination of these two elements leads to confirmatory testing. Unfortunately, modern medicine works in reverse. They run a lot of tests and hope to find a diagnosis. Studies indicate that 80% of medical costs incurred by a patient are for diagnostic testing rather than treatment.

Monday, August 6, 2018

99% of Doctors Need Diagnostic Help

Medical errors have become an accepted if unfortunate part of medical care, but physicians may greatly underestimate how much they contribute to the problem.

“The average clinician is making a lot of mistakes that they are unaware of,” says Dr. Art Papier, a dermatologist and medical informatics specialist. How many doctors fall into this category? All but the “master diagnosticians,” who represent less than 1% of practicing clinicians, he says. That would mean that 99% of doctors regularly make errors that they never realize they make.

Papier points to analyses of malpractice claims that show diagnostic errors are the largest cause of lawsuits, not bad outcomes of surgeries or baby deliveries as many people believe. And many of the missed diagnoses that lead to lawsuits are for common diseases such as cancer.
Fortunately, new decision support tools are available that can help streamline the diagnostic process and help clinicians more reliably get to the right answer. Some of these tools employ artificial intelligence (AI), which are techniques that enable computers to mimic human behavior, or they use machine learning, a subset of AI that uses statistical methods to enable machines to improve as they solve more problems.

The FDA has approved three AI-based tools this year for use in the clinic. The LVO Stroke Platform flags signs of stroke on computed tomography scans. The IDx-Dr device can be used by primary care clinicians to screen for diabetic retinopathy. The third device, OsteoDetect, is used to diagnose wrist fractures in adults.

Friday, August 3, 2018

When Patients Come In Quoting ‘The Dr. Oz Show’

If you’re a clinician, you know about the Dr. Oz phenomenon – when a patient comes in asking questions about something that was hear on The Dr. Oz Show. “Should I take that berry to lose weight?” “Will that root extract boost my immunity?” “Can this supplement really prevent cancer?”

Sometimes you know right away that the answer is no. Other times you may not be so sure. My colleagues and I decided to look into the claims being made on two shows: The Dr. Oz Show and The Doctors. Overall, we found that the recommendations made on these shows were only occasionally based on high –quality, evidence-based data. Often, we couldn’t find any literature or medical studies to confirm or refute the claims made on the show. Moreover, the costs and harms of the suggested treatments were often overlooked.

We also discovered that the hosts of the shows frequently discussed products made by companies that advertise on the shows. How did we discover this? We enlisted a group of medical students to tape and view all episodes of The Doctors and The Dr. Oz Show for a full month. The students logged all health recommendations made on these shows, whether harms or cost were discussed, and whether a source or reference was mentioned. They noted the advertisements that were aired during the show and tracked whether the advertisements were related to the show’s content to see if there were any conflicts of interest.

We counted more than 300 health recommendations, with an average of about 6.9 per day on the Dr. Oz Show and 9.5 on The Doctors. Discussion of potential harms or risks was noted in only about 8.6% of Dr. Oz’s recommendations and about 13% of The Doctor’s recommendations. The costs and interventions were mentioned about 23% of the time on the The Dr. OZ Show and only 3% on the time on The Doctors. Statements on The Dr. Oz Show agreed with evidence-based medical guidelines 22.7% of the time. For The Doctors, it was about 20%.

Wednesday, August 1, 2018

Wisdom Wednesday: Mercury in Retrograde

On Thursday, July 26, Mercury entered what's known as apparent retrograde motion, a phrase often shortened to "Mercury in retrograde" or simply "Mercury retrograde."

This phenomenon occurs when the super-speedy planet appears to be moving across the sky in a different direction than it normally does.

It's an optical illusion created when Mercury catches up to and then passes Earth in its orbit around the sun. It's all about perspective.

Since Mercury moves so quickly, a "year" on that planet (the time it takes to complete its orbit around the sun) takes approximately 88 Earth-days. So Mercury's apparent retrograde motion relative to Earth happens three or four times a year, and tends to last approximately three weeks each time. This time, it will last until August 19.

As NASA and countless astronomers have pointed out, there's absolutely no evidence that astrology can tell you anything about the future, how you should behave, or what your personality is based on the position of Earth relative to the stars when you were born.

My Take:
Last week was a real anomaly in my office. The previous week I had three new patients with seemingly simple, but very chronic back issues. Their symptoms dated back years. During consult and examination, I wondered why these three simple cases had not resolved on their own. (Cases of acute low back pain resolve much more quickly with spinal manipulation, but they will eventually resolve without treatment as well) I had the nagging feeling I was missing some factor is each case.

Monday, July 30, 2018

Study Offers Clues for Improving Seasonal Flu Vaccine

The 2017-2018 flu season was rougher than most. During peak flu activity in February, more than 10% of deaths in the U.S. were attributed to the flu or pneumonia, according to the Centers for Disease Control and Prevention.

To help combat the flu, NIH-supported researchers are exploring how to improve vaccines. Current influenza vaccines mainly target the influenza surface protein hemagglutinin (HA) but can sometimes offer varying or limited protection.

Recent studies indicate that seasonal flu vaccines might provide better protection if they were optimized to include an additional target, a different flu surface protein called neuraminidase (NA).

The study is supported by the National Institute of Allergy and Infectious Diseases. This study and related efforts are part of NIH’s larger plan to develop a universal vaccine – one that can durably protect all age groups against multiple strains of the flu.
Remember to get your seasonal flu shot every year to help protect yourself and your loved ones.

My Take:
There are several problems with our current vaccination process. The concepts are over 100 years old and the technology is quite dated as well.