Monday, July 31, 2017

Sperm Counts Continue to Decline in Western Nations

Sperm counts in Western countries have decreased by half in recent years, suggesting a continuing and significant decline in male reproductive health, a new evidence review reports.

Sperm concentration decreased an average 52% between 1973 and 2011 while total sperm count declined by 59% during that period, researchers concluded after combining data from 185 studies. The research involved nearly 43,000 men in all.

“We found that sperm counts and concentrations have declined significantly and are continuing to decline in men from Western countries,” said senior researcher Shanna Swan.

The new findings come on the 25th anniversary of the first study to observe a decline in sperm counts, Swan said. The original study, published in 1992, found that sperm counts had declined 50% over 50 years.

“The story has not changed over the past 25 years. Whatever is going on, it’s not transient and it’s not disappearing,” Swan said. “When we look at the data for the last five or 10 years, we don’t see a leveling off of this decline.”

The continued decline raises concerns about male fertility, and also male health in general, Swan said. “We are worried about these low sperm counts not only because people have trouble conceiving, but also because men with low sperm counts go on to have higher all-cause mortality,” Swan said. Studies have shown they die younger and they have more disease, particularly cardiovascular disease and cancer,” she said.

No one knows why sperm counts continue to decline, but researchers believe it’s likely due to factors associated with a modern lifestyle, Swan said. These factors include exposure to man-made chemicals, increased levels of stress, widespread obesity, poor nutrition, lack of physical exercise and smoking.

Friday, July 28, 2017

Many Primary Care Docs May Miss Prediabetes

Most primary care doctors can’t identify all 11 risk factors for prediabetes, a small new survey finds.

Researchers for Johns Hopkins University said their finding should prompt doctors to learn more about this condition that affects an estimated 86 million adults in the United States and could eventually lead to type 2 diabetes.

“We think the findings are a wake-up call for all primary care providers to better recognize the risk factors for prediabetes, which is a major health issue,” said study first author Dr. Eva Tseng in a university news release. She’s an assistant professor at Hopkins’ School of Medicine.

It’s estimated that 90% of those with prediabetes are unaware that they have the condition, according to the U.S. Centers for Disease Control and Prevention.

The American Diabetes Association (ADA) explains that changes in diet, exercise and certain medications can help prevent people with prediabetes from going on to develop type 2 diabetes.

To investigate why so many people with prediabetes go undiagnosed, the researchers asked primary care doctors attending a medical retreat to complete a survey testing their knowledge of key risk factors for the condition.

The ADA has guidelines that list a total of 11 specific risk factors that determine if a patient should be screened for prediabetes. They include physical inactivity, a first degree relative with diabetes, high blood pressure, and a history of heart disease.

A total of 140 doctors took the survey. Nearly one-third of those surveyed weren’t even familiar with the ADA’s prediabetes guidelines. Only 6% were able to identify all 11 risk factors. On average, the doctors could correctly identify just eight of the warning signs.

Only 17% identified the correct values for fasting glucose and another key measure of glucose, known as HbA1c, which are used to diagnose prediabetes, the study authors said.

Wednesday, July 26, 2017

Wisdom Wednesday: Rates of Two Nerve Conditions on the Rise

Two particular types of neuropathy have been increasing as more and more people develop diabetes in the United States. An expert says.

Autonomic and small fiber neuropathy were once rare conditions. Both occur when small blood vessels supplying the nerves are damaged by diabetes because they don’t get enough oxygen and nutrients, said Dr. Divpreet Kaur, a neurologist at Penn State Health Milton S. Hershey Medical Center.

Diabetes is one of the main causes of neuropathy, and about 30 million Americans currently have diabetes, Kaur said. More commonly, people with diabetes have nerve damage that causes numbness in the feet and toes. This is called peripheral neuropathy, according the American Diabetes Association.

Autonomic neuropathy affects involuntary bodily functions such as blood pressure, digestion, sexual function, urination, temperature control and sweat regulation.

“The most common symptom is light-headedness, especially when standing up. The blood pressure drops so much when they stand up that they feel like they are going to pass out,” Kaur said in a Penn State news release.

People with small fiber neuropathy often have burning pain in their feet that eventually progresses up their legs. Their hands can also be affected. “People don’t know about it or recognize the symptoms, and they keep going to different physicians without receiving a diagnosis,” Kaur said.

“It isn’t that every patient who has these symptoms will definitely have such a neuropathy. Once common things have been ruled out by their primary care physician, they can be referred to the neuromuscular clinic for consultation or the autonomic laboratory for further testing,” she said.

Monday, July 24, 2017

Not All Plant Foods Are Equal

For years, the mantra has been that eating lots of fruits, vegetables and grains will ward off heart disease, but a new study suggests that choosing the wrong ones may backfire.

The study, of over 200,000 U.S. health professionals, found those who ate plenty of healthy plant foods – such as vegetables, beans and whole grains – did have a lower risk of heart disease.

That was not true, however, if people loaded up on foods that are technically plant-based, but not all that healthy. In fact, diets heavy in pasta, bread, potatoes and sweets appeared just as bad as, if not worse than, diets high in animal products.

“Plant-based foods are not all the same,” said lead researcher Ambika Satija, a postdoctoral fellow at the Harvard School of Public Health, in Boston. So it’s crucial that people consider the nutritional quality of the plant foods they choose, she said.

The study did not specifically examine vegetarian or vegan diets, Satija noted. So the findings do not shed light on how those diets affect heart disease risk. But other studies have tied vegetarian and vegan diets to lower risks of diabetes, high blood pressure and heart disease, according to Dr. Kim Williams, chief of cardiology at Rush University Medical Center in Chicago.

“Plant-based nutrition is superior when it comes to most diseases,” Williams said. “But what people don’t always understand is that there are healthy ways to do it, and not-so-healthy ways,” he said. “You can do it wrong.” Williams co-wrote an editorial published with the study in the July 25 issue of the Journal of the American College of Cardiology.

The findings involved three studies that began in the 1980s and 1990s. Every two to four years, the participants gave detailed information on their diets.

Friday, July 21, 2017

Teens Keep Building Bone After They Stop Growing

A new study included more than 2,000 youngsters who had annual bone and growth measurements for up to seven years as they moved into their late teens and early adulthood.

The findings highlight the importance of a healthy diet and physical activity during the late teen years, according to authors of the study published recently in JAMA Pediatrics.

“We often think of a child’s growth largely with respect to height, but overall bone development is also important,” said lea author Dr. Shara McCormack, a pediatric researcher at Children’s Hospital of Philadelphia.

“This study shows that roughly 10% of bone mass continues to accumulate after a teenager reaches his or her adult height,” McCormack said in a hospital news release.

The study also found that bone growth develops at different rates in different parts of the skeleton, that it peaks earlier in black Americans that in other racial groups, and that height growth far outpaces bone growth before adolescence.

The later finding could help explain why children and teens have high fracture rates. Between 30 and 50% will have at least one broken bone before adulthood.

Wednesday, July 19, 2017

Wisdom Wednesday: Bacopa

Bacopa, commonly known as water hyssop, is an Ayurvedic herb traditionally used as a tonic for nervous disorders, hoarseness, as a cardiac tonic, and for urinary incontinence especially in combination with constipation.

As with all saponin-containing herbs, it is considered an adrenal adaptogen but might irritate the digestive tract if taken on an empty stomach. However, because it is also fat soluble, it should be taken with a meal containing additional fat to add in absorption anyway.

I have used Bacopa for many years in formula that also contains Ashwaganda and Bladderwrack called Thyroid Complex. The Bacopa supports pineal and pituitary function, the Ashwaganda is a great adrenal adaptogen and the Bladderwrack is a good source of iodine for the thyroid. This supplement is my “go to” for Hashimoto’s thyroiditis.

More recently, I have been using Bacopa as a stand-alone herb. Primarily because of improvements in cognition and reduced anxiety reported in multiple double blind studies of this herb. These benefits are noted in both young and old patients putting Bacopa in the general classification as a nootropic herb.

Bacopa interacts with dopamine and serotonergic systems, but its main mechanism concerns promoting neuron communication. It does this by enhancing the rate at which the nervous system can communicate by increasing the growth of nerve endings, called dendrites. Bacopa also has some antioxidant activity.

The beneficial effects of Bacopa take time to truly be appreciated. Typically improvement is much more notable at 8-12 weeks then at 4-6 weeks. However, the anxiolytic effects may occur much more quickly and often are not sustained.

Monday, July 17, 2017

Daily Jolt of Java May Bring Longer Life

Researchers, in two new studies, found that daily coffee drinkers were up to 18% less likely to die over the next 10 to 16 years, versus non-drinkers.

The findings – based on over 700,000 middle-aged and older adults – add to the growing list of benefits linked to moderate coffee drinking.

Studies have already tied the habit to lower risks of various diseases – from heart disease and type 2 diabetes, to liver cancer, to neurological diseases like Parkinson’s and multiple sclerosis. None of those studies prove coffee, per se, provides the benefit.

This runs counter to the common belief that coffee drinking is a bad habit – a belief the evidence does not bear out, according to Veronica Setiawan, the senior researcher on one of the studies.

“Moderate coffee consumption can be incorporated into a healthy lifestyle,” said Setiawan. She’s an associate professor of preventive medicine at the University of Southern California’s Keck School of Medicine.

Both studies were published online in the July 11 issue of the Annals of Internal Medicine.

Still, neither study proved that coffee can extend a person’s life, according to an editorial published with the findings. “We are not in a position to recommend people drink coffee for health benefits,” said Dr. Eliseo Guallar, one of the editorial’s authors.

Friday, July 14, 2017

Recurring Intestinal Infections on the Rise in U.S.

Recurring Clostridium difficile intestinal infections are rising sharply in the United States, researchers warn.

These infections sicken about 500,000 people a year, cause tens of thousands of deaths, and cost the U.S. health care system about $5 billion, according to investigators at the University of Pennsylvania.
C. difficile causes diarrhea, severe gut inflammation and can lead to deadly blood infections, especially in the elderly.

A review of nationwide health insurance data found a nearly 200% increase in the annual incidence of multiple recurring C. difficile infections between 2001 and 2012. For ordinary C. difficile, incidence rose by about 40%.

Patients with multiple recurring C. difficile infections tended to be older (average age 56 versus 49), female, and were more likely to have used antibiotics, corticosteroids or acid-reducing drugs, the findings showed.

The reasons for the rise in multiple recurring C. difficile cases remain unclear, but the researchers said the findings highlight the need for new therapies.

The most promising new treatment is fecal microbiota transplantation. In the procedure, helpful gut bacteria are transferred to a patient’s digestive tract to restore a balance that makes it easier to fight infection. While these stool transplants have shown promise in small studies, they have yet to be thoroughly evaluated, the study authors noted.

“The increasing incidence of C. difficile being treated with multiple courses of antibiotics signals rising demand for fecal microbiota transplantation in the United States,” study senior author Dr. James Lewis said in a university news release.

Lewis is a professor of gastroenterology and senior scholar in the Center for Clinical Epidemiology and Biostatistics.

Wednesday, July 12, 2017

Wisdom Wednesday: Guidelines on nonradicular low back pain by the American College of Physicians

Most patients with acute or subacute low back pain improve over time regardless of treatment and can avoid potentially harmful and costly treatments and tests. First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture, or spinal manipulation. When nondrug therapy fails, consider NSAIDs or skeletal muscle relaxants.

For chronic low back pain, consider nondrug therapy, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercises, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive-behavioral therapy, or spinal manipulation.

For chronic low back pain that does not respond to nondrug therapy, consider NSIADs as first-line therapy. For second-line consider tramadol or duloxetine. Consider opioids only in patients in whom first- and second-line therapy has failed, in whom risks are outweighed by benefits, and only after full discussion of the potential risks and benefits.

My Take – Nonradicular low back pain is well localized pain that does not radiate down either leg. Acute low back pain is limited to patients with an onset of 7-10 days maximum. Subacute low back pain extends from a week to six weeks and chronic low back pain is anything greater than subacute.

In general, I agree with these guidelines. For over 40 years, I have used spinal manipulation successfully in the treatment of acute, subacute and chronic low back pain.

Monday, July 10, 2017

Polypharmacy and Deprescribing

A recent survey among older adults in 11 countries reported the highest rates of multiple conditions, such as hypertension, heart disease, diabetes, lung problems, mental health problems, cancer and/or joint pain and arthritis, in the United States (68%) and Canada (56%) compared with European countries and Australia. As a result, older adults are likely to be prescribed multiple medications (polypharmacy) and utilize more healthcare, at a higher cost, compared with patients with no or fewer chronic conditions.

Polypharmacy and potentially inappropriate medications in older individuals are associated with adverse drug events, death, impaired physical and cognitive function, falls, and hospitalization. Approximately 53% of over-65s in the United States and 42% in Canada take four or more prescription drugs. Many over-65s take five or more prescription drug, and this rate is increasing. Reports indicate that in Canada, seniors with three or more chronic conditions take an average of six prescription medication and more than 30% are believed to be taking at least one medication that is potentially inappropriate.

Dr. Barbara Farrell, assistant professor in the Department of Family Medicine, University of Ottawa, Canada, notes that at her hospital it is not unusual to see a patient on 25-30 medications. “Frequently, a medication is started to see whether it will help with certain symptoms –almost like a diagnostic test – but then the medication is never stopped,” she explains. “Ten years go by, and the family doctor retires or dies, and the patient sees a men family doctor who doesn’t know why the drug was prescribed in the first place but is scared to stop it. I see patients in the 80s and 90s who have been on a medication for 30 years, and no one can remember why they are taking it.”

Although the term “deprescribing” (defined as reviewing and identifying medications to be stopped, substituted, or reduced) first appeared in the literature in 2003, the problem of polypharmacy in the elderly has been recognized for 30 years. “People had been trying to raise the alarm all that time, but only in past 4-5 years have we seen greater awareness of the increasing cost to the system,” Dr. Farrell points out.

Current clinical practice guidelines do not typically take into consideration the long-term net benefits and harms associated with all medications that older patients with multiple chronic conditions would be taking if evidence-based guidelines for each condition were followed. “All the clinical guidelines tell you how to start drugs, but not how to stop them. So, we thought, why don’t we try to create a deprescribing guideline, following the same rigorous processes that you would use for an evidence-based prescribing guideline,” Dr. Farrell recalls.

Friday, July 7, 2017

The Tale of Two Studies

These two studies were published within days of each other. I was fortunate enough to run across both of them prior to writing a blog about either. As you compare and contrast this new research think about to potential goals of the study and the spin applied to publication. Both studies were on proton pump inhibitors (PPIs), drugs commonly used to treat acid reflux and ulcers.

The first study was published in the May, 2017 issue of the Journal of the American Geriatrics Society. Researchers from Emory University in Atlanta analyzed a National Alzheimer’s Coordinating Center database for the study. The data, compiled from 2005 to 2015, included close to 10,500 Americans, aged 50 or older, with normal brain function or mild thinking difficulties. Researchers found those who used PPIs were at a lower risk of a decline in thinking skills. The title of the release “Popular Heartburn Meds Don’t Raise Alzheimer’s Risk”.

The second study was published online July 3, 2017 in the journal BMJ Open. Researchers from the Washington University School of Medicine in St. Louis found that popular heartburn medications like Nexium, Prilosec or Prevacid may increase your risk of early death when taken for extended periods. Further, the longer you take these drugs, the greater your risk of early death. Short-term use of PPIs – up to 90 days – did not appear to affect death risk, the findings showed.

Wednesday, July 5, 2017

Wisdom Wednesday: Nightshade Vegetables

Nightshades are plants in the Solanaceae family. There are more than 3000 varieties, a few of which are fruits, vegetables and herbs in our diet. The common nightshade foods include: tomatoes, peppers, eggplant, potatoes, huckleberries, pimento, paprika, cayenne pepper, and Chili powder.

Nightshades are often used in sauces and seasoning blends, including ketchup, hot sauce, steak sauce and curry.

Lectins are the proteins common to all nightshade plants. They bind that carbohydrates that also can create food sensitivities.

However, the clinical correlation between nightshades and food sensitivity may have more to do with other phytochemicals found in these plants. The alkaloids and glycoalkaloids that occur in nightshades are naturally occurring pesticides. Solanine, capsaicin and nicotine are the most significant of these compounds.

Many nightshades are highly toxic and aren’t meant to be eaten. The herb belladonna is a nightshade that Juliet uses to fake her death in Shakespeare’s Romeo and Juliet. Glycoalkaloid poisoning has been reported and is an irritant to the gut.

Sunlight promotes solanine formation, so it’s important to store potatoes away from natural light. Potatoes that have sprouts or a greenish hue, taste bitter, or have a mushy texture should not be eaten.

Both glycoalkaloids and lectins have been shown to increase intestinal permeability of the small intestine contributing to leaky gut. This in turn may stimulate an autoimmune response to any protein or carbohydrate that slips across the barrier without full digestion.

Capsaicin is actually used to reduce abdominal pain (red pepper powder) but can also irritate the lining of the gut.

Monday, July 3, 2017

Gene Sequencing May Reveal Risks for Rare Diseases

“Genome sequencing” of healthy people reveals that some are at risk for rare genetic diseases, a new study shows. And doctors need to be sensitive when revealing that information, the researchers said.

“Sequencing healthy individuals will inevitably reveal new findings for that individual, only some of which will have actual health implications,” said study lead author Dr. Jason Vassy. He’s a clinical investigator at Brigham and Women’s Hospital in Boston.

Whole genome sequencing entails analysis of the 3 billion pairs of letters in someone’s DNA. Scientists anticipate the technology will usher in a new era of predicting and preventing disease, but how people will react to this personal information is a big question mark.

For this study, the researchers analyzed nearly 5,000 genes associated with rare genetic conditions in 50 healthy people. The investigators found that 11 of the people – almost one-quarter – had gene variants predicted to cause previously undiagnosed rare disease.

Two of those 11 patients had signs or symptoms of the underlying conditions. One had variants linked to an eye disease called fundus albipunctatus, which impairs night vision. The second had a variant associated with variegate porphyria, which explained the patient’s mysterious rashes and sun sensitivity.

As part of the study, the patients’ primary care doctors were taught how to interpret a one-page report of their patients’ genome testing results. They also had access to genetic specialists for consultation. The doctors then used their own judgment in deciding how to handle their patients’ test results.