Wednesday, August 30, 2017

Wisdom Wednesday: How Sate Is Your Drinking Water?

Even if local health officials say it’s safe, cloudy drinking water may have the potential to cause vomiting and diarrhea, a new research review finds.

Researchers looked at past North American and European studies exploring the link between water cloudiness, or turbidity, and tummy troubles. “More than 10 studies found a link between water turbidity and acute gastrointestinal illness incidence,” said researcher Anneclaire De Roos. She is an associate professor at Drexel University’s Dornsife School of Public Health in Philadelphia.

Waterborne germs such as norovirus, Giardia and Cryptosporidium can cause gastrointestinal illness. The researchers estimate that water systems in the United States may cause more than 16 million cases of stomach distress.

Cloudiness in water is caused by undissolved particles, or it could be evidence of runoff containing not just sediment but also harmful germs, the researchers said. In the review, De Roos said, “the association between turbidity and acute gastrointestinal illness was found in cites with relatively high turbidity levels, often in unfiltered drinking water supplies.”

That wasn’t a surprise. However, “the findings that go against the conventional wisdom are the associations between turbidity and acute gastrointestinal illness that were seen at very low levels of turbidity, levels lower than the regulatory limits,” she said.

Monday, August 28, 2017

Alzheimer’s Prevention: A Summary of What We Know

Alzheimer disease (AD) prevalence in the United States currently exceeds 5 million, and the Alzheimer’s Association estimates a US prevalence of 16 million by the year 2050 unless an effective treatment is developed. Increasing age is still the leading risk factor for AD, with a prevalence of 42% by age 82 years. Other nonmodifiable risk factors include female sex, positive family history, and presence of the apolipoprotein E 4 allele.

At present, only four FDA-approved medications are available for memory and behavioral AD symptoms. Disease-modifying treatment trials have been unsuccessful, although several new trials are underway and research continues. Prevention strategies are therefore essential and are now facilitated by advances in diagnostic criteria, biomarker development, and greater understanding of the biophysiologic underpinnings of AD.

Risk-factor prevention should target diabetes mellitus and insulin resistance, obesity, metabolic syndrome, hypertension, hypercholesterolemia, cerebrovascular disease, depression, psychological and physiologic stress, traumatic brain injury, sleep-disordered breathing, smoking, alcohol abuse, high blood pressure, renal disease, alcohol and tobacco use, high cholesterol, coronary heart disease, sedentary life style, and diet. These potentially modifiable risk factors, when combined, account for more than 50% of AD risk, based on observational studies, and many of these risk factors do not appear to affect amyloid tau proteins. In sporadic and genetic forms of AD, pharmacologic trials of antiamyloid therapies are ongoing.

Modifiable factors appearing to protect against AD include cognitive reserve and mental activity, educational attainment and lifelong learning, cognitive leisure activities, physical activity and exercise, social engagement, mindfulness and wellness activities, optimism and purpose in life, healthy diet and omega-3 intake. A review of 19 studies suggests that certain brain-stimulating activities may help reduce AD risks. These include crossword puzzles, card games, computer use, arts or crafts, taking classes, group discussions, and listening to music.

Depending on the typed of exercise and its intensity, physical activity may lower AD risk by up to 65%. Underlying mechanisms may include reduction in blood vessel disease, better pulmonary function, increased cell survival, and anti-inflammatory effects.

Friday, August 25, 2017

FDA May Limit ‘Risk Info’ in Direct-to-Consumer TV Drug Ads

The U.S. Food and Drug Administration may shorten the list of caveats for drugs you see advertised on television.
Prescription drug makers must now mention all benefits and risks in direct-to-consumer advertising, presenting viewers with a litany of potential harms, both major and minor. But a new approach being considered could trim those lists to feature only the most serious and potentially fatal side effects, the FDA said Friday.

The “FDA’s own research on broadcast TV drug advertisements suggests that a more targeted method for delivering risk information may lead to better retention of those risks,” FDA Commissioner Dr. Scott Gottlieb said in an agency news release.

To that end, “the agency is exploring the usefulness of limiting the risks in the major statement for most drug advertisements to those that are severe [life-threatening], serious or actionable, couple with a disclosure to alert consumers that there are other product risks not included In the advertisement,” Gottlieb said.

While this might spare TV viewers lengthy lists of relatively insignificant physical complaints, it might also deprive them of critical information. To come to the best solution, the FDA is asking consumers, doctors and others to comment on which risk information is most helpful in TV and other broadcast ads.

Dr. Nachum Katlowitz, director of urology at Staten Island University Hospital in New York City, thinks it’s time to reconsider the advertising requirements. “In a one minute direct-to-consumer advertisement, they spend 55 seconds in a kind, clear, pleasing voice discussing all the wonderful things this product will do to help your life,” said Katlowitz. “Then, in the last five seconds in a rapid, audible but difficult to understand monotone voice, they discuss the risks and end with, ‘Ask your doctor.’”

Wednesday, August 23, 2017

Wisdom Wednesday: When Stress Hormone Falters, Your Health May Suffer

Steady daytime levels of the stress hormone cortisol are associated with serious health problems, such as inflammation, obesity and cancer, researchers say.

“Cortisol is naturally high in the morning to help perk you up, and it decreases into the evening,” said study lead author Emma Adam. She is a professor of human development and social policy at Northwestern University.

“The loss of this cycle – or the lack of variation of cortisol – is what is associated with negative health outcomes in our study,” Adam said in a university news release. The researchers suspect that chronic stress may be behind the less variable cortisol levels. They call it “stress-related circadian dysregulation.”

For the research, the study team reviewed data from 80 studies. The investigators looked specifically at 12 health problems and found that 10 seemed associated with the loss of variation in cortisol levels.

“While inflammation and the immune system dysfunction had the strongest associations, fatigue, cancer, depression, and obesity were all worse in people who had less variation in their cortisol,” Adam said.

The findings suggest that restoring daily cortisol rhythms could benefit people’s health. “It’s the righting of the rhythms that are important, more so than the righting of levels,” the researchers wrote.

Adopting healthy habits – such as regular exercise and adequate sleep – are important steps in restoring strong daily cortisol rhythms, Adam and her colleagues said.

Monday, August 21, 2017

Skeletons Give Clues to Americans’ Rising Arthritis Rates

Rates of knee osteoarthritis have doubled in the United States since the 1940s, but it’s not just because Americans are living longer and weight more, a new study suggests.

To come to this conclusion, Harvard University researchers examined more than 2,000 skeletons from across the Unites States.

“We were able to show, for the first time, that this pervasive cause of pain is actually twice as common today as even in the recent past. But the even bigger surprise is that it’s not just because people are living longer or getting fatter, but for other reasons likely related to our modern environments,” said study first author Ian Wallace.

Wallace is a post-doctoral fellow in the lab of senior study author Daniel Lieberman, a professor of biological sciences at Harvard University.

The researchers are now working to find out what’s causing the increase. They said learning more about knee osteoarthritis is important not only because it affects a third of Americans over age 60, but because it is responsible for more disability than almost any other musculoskeletal disorder.

“Wouldn’t it be great if people could live to be 60, 70 or 80 and never get knee osteoarthritis in the first place?” Lieberman said in a Harvard news release. He noted that the disease is “almost entirely untreatable apart from joint replacement,” and once someone has it, it creates a vicious cycle. “People become less active, which can lead to a host of other problems, and their health ends up declining at a more rapid rate,” Lieberman explained.

For the study, published Aug. 14 in the Proceedings of the National Academy of Sciences, the authors examined research spanning more than 6,000 years of human history to search for a tell-tale sign of osteoarthritis.

Friday, August 18, 2017

Benefits and Safety of Gabapentinoids in Chronic Low Back Pain

Chronic Low Back Pain (CLBP) is very common, with a lifetime prevalence between 51% and 80%. In majority, it is nonspecific in nature and multifactorial in etiology. Pregabalin (PG) and Gabapentin (GB) are gabapentinoids that have demonstrated benefit in neuropathic pain conditions. Despite no clear rationale, they are increasingly used for nonspecific CLBP. They necessitate prolonged use and are associated with adverse effects and increased cost. Recent guidelines from the National Health Service (NHS), England, expressed concerns on their off-label use, in addition to the risk of misuse. We aimed to assess the effectiveness and safety of gabapentinoids in adult CLBP patients.

Methods - Electronic databases of MEDLINE, EMBASE, and Cochrane were searched from their inception until December 20th, 2016. We included randomized control trials reporting the use of gabapentinoids for the treatment of CLBP of >3 months duration, in adult patients. Study selection and data extraction was performed independently by paired reviewers.

Results – Out of 1,385 citations, eight studies were included. Based on the interventions and comparators, studies were analyzed in 3 different groups. GB compared with placebo showed minimal improvement of pain in three studies. Three studies compared PG with other types of analgesic medication and showed greater improvement in the other analgesic group. Studies using PG and an adjuvant were not pooled due to heterogeneity, but the largest of them showed no benefit of adding PG to tapentadol. There were no deaths or hospitalizations reported. Compared with placebo, the following adverse events were more commonly reported with GB: dizziness, fatigue, difficulties with mentation and visual disturbances.

Conclusions and relevance – Existing evidence on the use of gabapentinoids in CLBP is limited and demonstrates significant risk of adverse effects without any demonstrated benefit. Given the lack of efficacy, risks, and costs associated, the use of gabapentinoids for CLBP merits caution. There is need for large high-quality trials to more definitively inform this issue.

Wednesday, August 16, 2017

Wisdom Wednesday: When You Hear Hoof Beats, Don’t Look for Zebras

Many years ago an MD I worked with gave me this answer when I inquired about the possibility of some exotic disease in a common patient. The exact quote was “Oh Bill, when you hear hoof beats, don’t look for zebras, it’s usually horses.”

My response was that during college I lived along the Hillsborough River in Tampa. Every morning, driving to class at USF, I passed Bush Gardens and saw lots of zebras.

Zebras do occur in everyday practice. They just don’t occur every day. However, as a primary care physician, it is my responsibility to see the tell-tale ‘stripes’ and act accordingly.

The patient that comes in with acute low back pain is almost always a horse. But if she has a history of breast cancer or he has a history of prostate cancer, they might be a zebra. Metastasis from breast or prostate loves bone, especially the low back. I am responsible for picking up on that stripe even if the patient doesn’t give me the history. That’s because it’s my responsibility to ask.

I don’t have to diagnose the cancer or treat it, but I have to make the appropriate referral. I may decide to run further testing to make a more educated referral or even co-treat. What I cannot do is delay proper diagnosis or medical treatment.

Diagnosing zebras is also an issue. If I, or any other physician, suspect a particular disease, you cannot tell the patient they have that disease without running the appropriate diagnostic testing. You tell them that you suspect a possible pathology. If pressed, you give them a differential that includes a few possible disease processes.

Monday, August 14, 2017

Kidney Disease May Boost Risk of Abnormal Heartbeat

People with failing kidneys are at increased risk of developing a life-threatening abnormal heart rhythm, a new report suggests.

Chronic kidney disease can as much as double a patient’s risk of atrial fibrillation, a quivering or irregular heartbeat that can lead to stroke or heart failure, said lead researcher Dr. Nisha Bansal. She is an associate professor of nephrology at the University of Washington’s Kidney Research Institute, in Seattle.

The risk of atrial fibrillation increases as kidney function declines, Bansal said. “We saw the worse your kidney function, the greater your risk of developing atrial fibrillation. Even mild changes in kidney function were strongly linked to atrial fibrillation,” Bansal noted.

The study included data gathered from three separate research projects focused on heart health in the United States. The three projects created a combined pool of almost 17,000 patients with follow-up periods averaging between 8.5 and 12.5 years. None of the participants had atrial fibrillation when first recruited.

People with worse kidney function at the start of the study were more likely to have atrial fibrillation by the end, the researchers found. Those who did worse on the blood test [GFR] were twice as likely to develop an abnormal heart rhythm, while those who did worse on the urine test [urine protein] were 76% more likely.

“We found that kidney function was independent of all other risk factors,” Bansal said.

A poorly functioning kidney can alter blood levels of a number of nutrients needed to maintain proper heart function, such as potassium, vitamin D, calcium and phosphorus, Bansal said.

The kidneys also are responsible for maintaining a steady volume of blood in your body, removing excess fluid by way of urination. “If your kidney function is impaired, your blood volume increases,” Bansal said. “That increased stress on your heart causes it to stretch and can also trigger this abnormal heart rhythm.”

Friday, August 11, 2017

As Many as 1 in 3 Experience New or Worse Pain with Yoga

Many people try yoga hoping to heal an injury, but some wind up with more aches and pains, a new study finds.

The study, which surveyed hundreds of people doing yoga for more than a year, found that two-thirds said that some existing aches improved because of yoga – most often, lower back and neck pain.

On the other hand, 21% said yoga worsened their muscle or joint pain. And almost 11% said it caused new issues – most commonly, pain in the hand, wrist, elbow or shoulder.

The study didn’t delve into specific injuries, but instead asked people about general aches in different body areas. So it’s hard to know how serious the problems were, said Tom Swain, a researchers with the Center for Injury Sciences at the University of Alabama at Birmingham. “You don’t have to sustain a serious injury to have pain. It could just be sore muscles,” said Swain, who wasn’t involved in the study.

Studies have tied yoga to health gains ranging from lower blood pressure, cholesterol and heart rate to improvements in depression, anxiety and sleep problems. Plus, based on other research, yoga may not be any riskier than other forms of exercise, according to the researchers behind the current study.

The study’s investigators, led by Marc Campo of Mercy College in Dobbs Ferry, N.Y., reported their findings in the Journal of Body work & Movement Therapies.

For the study, the researchers surveyed 354 people, mostly women, who practiced at two yoga studios. Classes there ranged from gentle, “restorative” yoga to fast-paced Vinyasa-style. Each study participant was surveyed twice, one year apart.

Nearly all (87%) said they’d had pain in at least one body area during that year. About two-thirds said their pain had improved because of yoga, while one-fifth believed yoga had worsened some of the aches – often in the wrist or hand.

Wednesday, August 9, 2017

Wisdom Wednesday: Scientists Gain Insight into Allergies

Scientists report they’ve pinpointed which immune system cells trigger allergies. The discovery may someday lead to a blood test that improves treatment, they suggests. These cells “represent a common enemy to every allergic individual that we can now easily track,” said study author Erik Wambre. He’s an immunology researcher at Seattle’s Benaroya Research Institute at Virginia Mason.

Allergic reactions stem from an inappropriate immune response to usually benign substances such as mold, pollen or peanuts. In the United States, almost 50 million Americans have nasal allergies, and as many as 200 die from serious food allergies a year.'

According to Wambre, more “biomarkers” – signs of illness that can show up in tests – are needed to improve allergy detection and assess treatment. At the moment, doctors relay on skin pricks to test your reaction to allergy-causing substances, or use blood tests that show if your immune system reacts to certain substances, Wambre said.

But these tests aren’t always accurate, and there’s no accepted way to use the results to predict someone’s response to treatment affecting the immune system, he explained.

That’s where the blood test Wambre and his colleagues are developing comes in. The study authors report they’ve developed a way to detect so-called type 2 helper T-cells (TH2) that reveal if a person has an allergy, although it doesn’t specify to what substances.

“Up until now, we couldn’t easily identify the TH2 cells triggering allergies from the one protecting the body from parasites, bacteria or viruses,” Wambre said. But the researchers said they found a kind of “signature” on the cells that cause a reaction to common allergens such as peanut, grass pollen, mold, cat dander, tree pollen and dust mites.

Their study involved 80 patients with allergies and 34 without allergies. “These cells were present in every person with allergies and almost entirely absent from people who don’t have allergies,” Wambre said.

Monday, August 7, 2017

Doctors Still Overprescribing Opioids in U.S.

More than one out of three average Americans used a prescription opioid painkiller in 2015, despite growing concerns these medicines are promoting widespread addiction and overdose deaths, a new federal study shows.

Nearly 92 million U.S, adults, or about 38% of the population, took a legitimately prescribed opioid like OxyContin or Percocet in 2015, according to results from the National Survey on Drug Use and Health.

“The proportion of adults who receive these medications in any year seemed startling to me,” said study co-author Dr. Wilson Compton, deputy director of the U.S. National Institutes on Drug Abuse.

The survey found that 11.5 million people, or nearly 5% of the population, misused prescription opioids they’d obtained through illicit means. About 1.9 million Americans (0.8%) reported full-fledged opioid addiction.

Overall, the results indicate that the medical profession is doing a poor job of appropriately prescribing opioid painkillers, Compton said.

Previous studies have found “there’s still four times the rate of prescribing there was 15 years ago,” Compton said. “Even though the rates have leveled off, we have a long way to go in improving medical care so these are not as overprescribed as they are currently.”

These painkillers are highly addictive and potentially deadly. The number of overdose deaths involving opioids has quadrupled since 1999, concurrent with the quadrupling of opioid prescriptions, according to the U.S. Centers for Disease Control and Prevention.

Of those who misused prescription opioids, more than 50% got the medications as hand-me-downs from family or friends. Overall, nearly 60% of misuse involved taking opioids without a prescription.

Friday, August 4, 2017

Take the Plunge

You can do more than just beat the heat the next time you go to the pool. Whether you swim or do aquatic exercises, working out in water improves strength, flexibility and cardiovascular health.

Water provides more resistance than air, allowing you to exercise at a higher intensity with less wear and tear on the body and less risk of injury. That’s great for people with joint pain.

Swimming is a perfect water workout, according to the American Council on Exercise. Doing a half hour of the front crawl at an easy pace can burn about 250 calories, depending on your weight. If you pick up the pace, you can burn about 400 calories in the same amount of time.

If you’re new to swimming, start with 5 to 10 minute sessions. As you build stamina, add more minutes. Mixing up your strokes can keep your routine form getting boring as well as work different muscles.

For instance, the breaststroke is great for chest and shoulder muscles. The front crawl and backstroke target many muscles in the back. And the butterfly does a great job of engaging core muscles.

Not a strong swimmer? Consider a few swim lessons or find other ways to work out in the water. Take your jogging routine to the shallow end of the pool. Run in place, lifting your knees up toward the surface and pumping your arms vigorously.

Wednesday, August 2, 2017

Wisdom Wednesday: Is the ‘Anti-Statin” Trend Threatening Lives?

A wave of anti-science skepticism may put people with high cholesterol at risk if they’re convinced to quit life-saving statin medications, heart experts warn.

An “internet-driven cult” is attacking the safety and effectiveness of cholesterol-lowering statins, despite mounds of clinical trial data showing the drugs work and produce minimal side effects, said Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic.

“We as physician scientists have to speak out,” Nissen said. “We have to regain the public’s attention around the fact that it isn’t a good thing to have high cholesterol, and a lot of heart disease is preventable by addressing risk factors like cholesterol.”

Nissen makes his case in an editorial published online July 24 alongside a new study in the journal Annals of Internal Medicine. That study found that patients who stick with statins even after suffering side effects are less likely to die or suffer a heart attack or stroke, compared to people who quit the drugs.

But as many as three-quarters of patients stop statin therapy within two years after they suffer a side effect, or “adverse event,” from the drugs, the authors of the new report said in background notes.

The new study found that patients who keep taking their statins had about a 12% incidence rate of death, heart attack or stroke, while those who quit statins had an incidence rate of about 14%, said senior researcher Dr. Alexander Turchin. He’s an endocrinologist with Brigham and Women’s Hospital in Boston.