Friday, March 16, 2018

Antimicrobial Stewardship

The first antimicrobial stewardship programs were introduced in hospitals more than 30 years ago to address inappropriate antibiotic prescribing and increasing antibiotic resistance. Since then a large body of evidence on the effectiveness and safety of this approach has accumulated.

The purpose of antimicrobial stewardship is to promote the prudent use of antibiotics in order to optimize patient outcomes, while at the same time minimizing the probability of adverse effects, including toxicity and the selection of pathogenic organisms, and the emergence and spread of antibiotic resistance.

The previous Cochrane Review demonstrated that interventions to reduce excessive antibiotic prescribing were successful, with persuasive and restrictive interventions being equally effective in reducing prescribing after six months. The recent update demonstrates that enabling and restrictive interventions are associated with a 15% increase in compliance with desired practice, a 1.95-day decrease in duration of antibiotic treatment, and a 1.12-day decrease in inpatient length of stay, without compromising patient safety.

Initiatives for implementing or strengthening antimicrobial stewardship were primarily developed as a response to increasing antibiotic resistance. Increasing antibiotic use results in increasing antibiotic resistance rates. But does improving antibiotic prescribing reverse antibiotic resistance rates? The updated Cochrane Review does not provide an answer; only 9% of the randomized controlled trials and 19% of the interrupted time series studies reported microbial outcome data. However, a reduction in the rate of Clostridium difficile infections was consistently demonstrated in the studies interventions.

Despite the extensive evidence base, antimicrobial stewardship programs are not a requirement in all hospitals. Antimicrobial resistance requires global action. This requires political commitment and resources, suggesting a role for continued advocacy by public health and specialist professionals and organizations. One significant characteristic of the evidence base is that 183 or the 221 studies in the updated Cochrane Review were performed in Europe or North American.

Wednesday, March 14, 2018

Wisdom Wednesday: U.S. Cancer Treatment Guidelines ‘Often Based on Weak Evidence’

Cancer treatment guidelines produced by the US National Comprehensive Cancer Network (NCCN) are often based on low quality evidence or no evidence at all, finds a study published by The BMJ today.

The researchers, led by Dr. Vinay Prasad at Oregon Health & Science University, say their findings “raise concern that the NCCN justifies the coverage of costly, toxic cancer drugs based on weak evidence.”

These recommendations are used by US private health insurers and social insurance schemes to make coverage decisions, and guide global cancer practice, but it is not clear how the evidence is gathered or reviewed.

In the US, the Food and Drug Administration (FDA) approves all new drugs and grants new indications for drugs already on the market. The NCCN makes recommendations both within and outside of FDA approvals, but patterns of NCCN recommendations beyond FDA approvals have not been analyzed.

So Dr. Prasad and his team compared FDA approvals of cancer drugs with NCCN recommendation in March 2016 for a contemporary sample of drugs. When the NCCN made recommendations beyond the FDA’s approvals, the evidence used to support those recommendations was evaluated.

A total of 47 new cancer drugs were approved by the FDA for 69 indications over the study period, whereas the NCCN recommended these drugs for 113 indications, of which 69 (62%) overlapped with the 69 FDA approved indications and 44 (39%) were additional recommendations.
Only 10 (23%) of these additional recommendations were based on evidence from randomized controlled trials, and seven (16%) were based on evidence from phase III studies. Most relied on small, uncontrolled studies or case reports, or no offered evidence.

And almost two years after their analysis, the researchers found than only six (14%) of the additional recommendations by the NCCN had received FDA approval.

Monday, March 12, 2018

Type 2 Diabetes: New Guidelines Lower Blood Sugar Control Levels

The American College of Physicians have now published their new guidelines regarding the desired blood sugar control levels for people with type 2 diabetes. The recommendations aim to change current therapeutic practices, and doctors should aim for a moderate level of blood sugar when treating their patients.

According to the most recent estimates, almost 30 million people in the United States have type 2 diabetes, which amounts to over 9% of the entire U.S. population.

Once diagnosed with type 2 diabetes, patients are often advised to take what is known as a glycated hemoglobin (HbA1c) test in order to keep blood sugar levels under control. The test averages a person’s blood sugar levels over the past 2 or 3 months, with an HbA1c score of 6.5% indicating diabetes.

But some studies have pointed out that the HbA1c test may currently be overused in the U.S., and they have suggested that such over-testing may lead to over-treating patients with hypoglycemic drugs. These drugs often have a range of side effects, such as gastrointestinal problems, excessively low blood sugar, weight gain, and even congestive heart failure. Additionally, as some researchers have pointed out, “Excessive testing contributes to the growing problem of waste in healthcare and increased patient burden in diabetes management.”

The existing recommendations of a score of 6.5% - or below 7% - decrease the risk of microvascular complications over time. However, the American College of Physicians (ACP) found that the evidence for such a reduction is “inconsistent.”

Friday, March 9, 2018

Could Vitamin D Lower Cardiovascular Death Risk?

People who have cardiovascular disease can reduce their risk of death by almost a third simply by maintaining normal vitamin D levels. This is the finding of a new study recently published in The Journal of Clinical Endocrinology & Metabolism.

Cardiovascular disease (CVD) is the number 1 killer in the United States. Heart disease alone is responsible for around 610,000 deaths in the country every year. Previous research suggests that vitamin D status may play an important role in cardiovascular health. A study in 2016, for example, associated low vitamin D levels with greater risk of stroke, heart failure, heart attack, and cardiovascular death.

The new study – led by Prof. Jutta Dierkes, of the Department of Clinical Medicine at the University of Bergen in Norway – further investigated the role that vitamin D levels play in the risk of death from CVD.

Prof. Dierkes and colleagues analyzed the blood samples of 4,114 adults who had suspected angina pectoris, which is chest pain as a result of coronary heart disease. Subjects were an average age of 62 at study baseline, and they were followed-up for an average of 12 years.

The team assessed the subjects’ blood samples for levels of 25-hydroxyvitamin D, or 25(OH)D, which is the primary circulating form of vitamin D. During follow-up, there were a total of 895 deaths. Of these, 407 were related to CVD.

According the National Institutes of Health (NIH), as 25(OH)D level of 50-125 nanomoles per liter (nmol/l) is “generally considered adequate for bone and overall health in healthy individuals.”

Wednesday, March 7, 2018

Wisdom Wednesday: A Short History of Quinine

As a follow-up to Monday’s blog, I thought you might enjoy some history about quinine. Legend has it that the bark of the fever tree was first used by the Spanish in the early 1630s when it was given to the Countess of Chinchon, who had contracted malaria (know colloquially as the ‘fever’) while living in Peru. The Countess recovered and the healing properties of the fever tree were passed to Europe.
It was imported to Europe under the name ‘Jesuits Powder’ which proved a very poor selling strategy in Protestant England. Even when Charles II in 1679 was cured of the ‘fever’ its popularity was not assured as its use remained the secret of his physician (Robert Talbor).

However, the healing power of this remarkable tree only became world renowned in the 1820’s when officers of the British Army in India, in an attempt to ward off malaria, mixed quinine (the extract from the bark of the fever tree) with sugar and water, creating the first Indian Tonic Water.

It was made more palatable when they added a little expedient of gin to the mixture. The original gin and tonic was thus born, and soon became the archetypal drink of the British Empire, the origins of which were firmly planted in the fever tree.
Medical historians claim that the British lost India primarily because the British forces were too drunk from the daily ritual of drinking gin and tonic to effectively fight.

Colonialism produced a huge demand for the bark of the fever tree. In the 1850s the East India Company alone spend 100,000 pounds annually on the bark, but it still brought in nowhere nearly enough to keep the colonists healthy. The answer was to try and cultivate fever trees in the colonies. This initiative inspired intrepid plant hunters across Europe to risk all and travel to South America to harvest these most valuable seeds. The Englishman, Richard Spruce, brought back seeds from Ecuador, which were subsequently grown in India and Ceylon, but they turned out to be of a species that was relatively poor in quinine. Using the wrong species of herb or wrong part of the plant remains a significant issue in herbology today with up to 80% of commercial products being ineffective as a result of this practice.

Monday, March 5, 2018

Quinine for Muscle Cramps

Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. This review was first published in 2010 and searches were updated in 2014.

Three review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. We identified 23 trials with a total of 1586 participants. Fifty-eight percent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials), vitamin E (4 trials), a quinine-vitamin E combination (3 trials). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg).

The risk of bias in the trials varied considerably. All 23 trials claimed to be randomized, but only a minority described randomization and allocation concealment adequately.

Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected.

A significantly greater number of people suffered minor adverse events on quinine than placebo, mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo.

There is low quality evidence that quinine (200 mg to 400 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials, but because serious adverse events can be rarely fatal, in some countries prescription of quinine is severely restricted.

Friday, March 2, 2018

How Fasting Boots Exercise’s Effects on Endurance

Intermittent fasting, such as eating only on alternate days, might enhance the ability of aerobic exercise to increase endurance because the body switches to using fats and ketones as a source of fuel for muscles instead of carbohydrates.

This was the conclusion that researchers came to after studying the effect in mice with such a regimen for a limited period of time. Their study is to be published in the FASEB Journal.

The findings suggest that three meals per day and snacking may not be the only eating habit for people who engage in endurance sports to reach peak performance and maintain good health.

“Emerging evidence,” explains senior study author Dr. Mark Mattson, from the Laboratory of Neurosciences in the National Institute on Aging in Baltimore, MD, “suggests that [intermittent dietary energy restriction] might improve overall health and reduce risk factors for diabetes and cardiovascular disease in humans.”

He and his team say that their findings propose that a similar pattern of eating and fasting may boost the beneficial effect of moderate aerobic exercise on endurance, and that it should be studied further.

For the study, the team put mice into four groups and observed them for 2 months as they went through the following exercise and eating patterns:

The control (CTRL) mice did not exercise at all and could eat as much food as they wanted every day.

The exercise (EX) mice could eat as much daily food as they wanted, but they also ran on a treadmill for 45 minutes each day.

The “alternate day food deprivation: (ADF) mice were only fed a fixed amount on every other day and did not exercise at all.

The EXADF mice were restricted to the ADF eating pattern but also exercised every day on a treadmill for 45 minutes.

Wednesday, February 28, 2018

Wisdom Wednesday: Olfaction and the Microbiome-Gut-Brain Axis

This review covers the field of olfaction and chemosensation of odorants and puts this information into the context of interactions between microbes and behavior; the microbiome – gut – brain axis (MGBA). Recent emphasis has also been placed on the concept of the holobiome which states that no single aspect of an organism should be viewed separately and thus must include examination of their associated microbial populations and their influence. While it is known that the microbiome may be involved in the modulation of animal behavior, there has been little systematized effort to incorporate into such studies the rapidly developing knowledge of the wide range of olfactory systems.

The classical olfactory system is evolutionarily conserved in multiple taxa from insects through to fish, reptiles and mammals, and is represented by the largest gene families in vertebrates. Mice have over 1000 different olfactory receptors and humans about 400. They are distributed throughout the body and even found in spermatozoa where they function in chemotaxis. Some ectopic olfactory receptors have been shown to have functional effects in the gut and kidney, highlighting the complexity of the systems engaged by odorants. However, there are, in addition to classical olfactory receptors, at least two other families of receptors involved in olfaction that are also widely found expressed on tissues in many different organs in addition to the nervous system and brain: the trace-amine associated and formyl peptide receptors.

Bacteria can make many if not most odorants and are responsible for recognition of species and relative relatedness as well as predator presence, among many other examples. Activation of different combinations of olfactory receptors by bacterial products such as B-phenylethylamine have been shown even to control expression of emotions such as fear and aggression.

Olfaction is one of the five senses, however, it is perhaps not widely appreciated that it represents a form of chemical communication which is widely distributed and has been extensively conserved evolutionarily. Linda Buck and Richard Axel jointly received the Nobel Prize in 2004 for their discoveries of ‘odorant receptors and the organization of the olfactory system’. Their description of olfactory genes occupying roughly 3% of our total gene pool was first published in 1991.

Animals use olfaction to distinguish each other, recognize individuality and kin and even use this ability for the purposes of mate selection and preference. This is not limited to vertebrates. Indeed, bacterial synthesis of phenol was first shown to account for male sexual attraction in grass grub beetles.

Monday, February 26, 2018

Vitamin B3 Could Be Used to Treat Alzheimer’s

New research finds a compound that prevents brain damage in mice. The substance is a form of vitamin B3, and the findings suggest a potential new therapy for Alzheimer’s disease in humans.

Vitamin B3 has previously been proposed as an alternative for treating Alzheimer’s disease. In an older study, large doses of nicotinamide – also referred to as B3 – reversed Alzheimer’s-related memory loss in mice.

A new study, however, focused on the effect of nicotinamide riboside (NR), which is a form of vitamin B3, on Alzheimer’s-related brain damage in mice. NR is “critical for mitochondrial health and biogenesis, stem cell self-renewal, and neuronal stress resistance,” said Dr. Vilhelm Bohr, chief of the National Institute of Aging’s Laboratory of Molecular Gerontology.

The team added NR to the drinking water of mice that had been genetically engineered to develop the hallmarks of the neurodegenerative disorder. The mice drank the water for 3 months, and their brains and cognitive health were compared with those of the control mice. The findings were published in the journal Proceedings of the National Academy of Sciences.

Compared with the controls, the NR-treated mice had less of the protein tau in the brain, less DNA damage, and more neuroplasticity – that is, the brain’s ability to “rewire” itself when it leans new things, stores new memories, or becomes damaged. Additionally, the mice in the intervention group produced more neurons from neuronal stem cells.

Fewer neurons died or were damaged in these mice. Finally, the researchers say that in the hippocampi – a brain area involved in memory that often shrinks or is damaged in Alzheimer’s – of the mice that received the treatment, NR appeared to get rid of the existing DNA damage or stop it from spreading.

Friday, February 23, 2018

‘Too Much’ Brain Calcium May Cause Parkinson’s

Insights from a new study – by the University of Cambridge in the United Kingdom – about the role of calcium in brain cells’ signaling mechanisms brings us close to understanding the causes of Parkinson’s disease.

The presence of toxic protein deposits, or Lewy bodies, inside brain cells is a recognized hallmark of Parkinson’s disease. The deposits contain clusters of alpha-synuclein and other proteins that have folded into the wrong shape.

The new study – now published in the journal Nature Communications – shows that calcium affects the way in which alpha-synuclein binds to synaptic vesicles. Synaptic vesicles are small compartments in nerve terminals that hold the neurotransmitters, or chemical messengers, that carry signals between brain cells.

“There is a fine balance,” notes co-first author Dr. Amberley Stephens, a postdoctoral researcher in molecular neuroscience at the University of Cambridge, “of calcium and alpha-synuclein in the cell, and when there is too much of one or the other, the balance is tipped and aggregation begins, leading to Parkinson’s disease.”

Worldwide, there are more than 10 million people living with Parkinson’s disease, including around 1 million in the United States. In Parkinson’s disease, there is a progressive destruction of brain cells that produce a neurotransmitter called dopamine, which is important for controlling movement. Therefore, as the disease progresses, there will be a worsening of symptoms such as slowness of movement, rigidity, tremor, and impaired coordination and balance.

Wednesday, February 21, 2018

Wisdom Wednesday: Human Microbiome Project

This study is an extension of the Human Genome Project we reviewed last Wednesday. It began in 2008 with a goal of determining how microbes are associated with health and disease.

The initial study involved 242 “healthy” U.S. participants. Over 5,000 samples were collected, taken from 15 sites on men and 18 on women. This included mouth, nose, skin, stool and vagina. All samples were analyzed using DNA sequencing.

Researchers found that bacterial cells outnumber human cells by 10:1. Bacterial genes may outnumber human genes by 100:1. A majority of the cells were bacterial but they also found archaea (single-celled organisms), yeasts/fungus, protozoa, helminths (worms) and virus.

The human gut alone contained 1,200-1,400 species of which only 24% have been named. Another 8% have been cultured but not named. The remaining 68% have no manes and have not been cultured. Over 600 of the bacterial species documented are common to the human race in general.

Microbes contribute more to human survival than human genes do. Bacterial protein coding genes are 360 times more abundant than human genes. Microbial activities can be shared between different species. Diet, medications, and disease state can change composition and equilibrium and the microbial balance returns to a new norm that is often dysfunctional over time.

The initial colonization should be at birth. Afterward, they enter the body through ingestion of food or liquids, through the respiratory system, through a break in the skin and into the blood supply or through genital and anal openings.

The mother’s lifelong history of health will set the stage for postpartum delivery of the microbial “fingerprint”. Negative factors in this delivery are antibiotic use, GMO foods, birth control, vaccinations, stress and microbial health.

Monday, February 19, 2018

Home Remedies for Pneumonia

Pneumonia is an inflammatory disorder of the lungs caused by an infection of the airways. It is a serious condition, and home remedies cannot be used to treat it. However, they can help ease the symptoms.

Pneumonia infections can be critical and may even be life-threatening in some cases. It is essential to visit a doctor for a diagnosis, as well as to monitor symptoms and avoid any complications.

Using a blend of medical treatments and home remedies may help many people manage their symptoms more easily. Every pneumonia treatment plan will involve some antiviral, antibiotic, or antifungal medication to treat the infection.

Here are some home treatments that may help clear up the annoying symptoms of pneumonia:

peppermint and eucalyptus tea have a soothing effect on the upper respiratory tract according to a study in Evidence-Based Complementary and Alternative Medicine. Fenugreek tea appears to break down mucus based on a review in the Journal of Saudi Society of Agricultural Sciences.

Saltwater gargle may help eliminate mucus or germs in the throat and the caffeine in a cup of coffee or green tea may open the airways.

Chest pain:
ginger or turmeric tea may reduce chest pain. The roots of both plants have a natural anti-inflammatory effect in the body.

again, from the earlier study, fenugreek tea encourages a person to sweat and reduce their temperature. Hydration is also vital.

often a secondary symptom caused by a fever. When the fever breaks, the chills will typically subside. However, drinking warm liquids or a bowl of soup may help warm the body.

Friday, February 16, 2018

Cranberries for Preventing Urinary Tract Infections

Cranberries have been used widely for several decades for the prevention and treatment of urinary tract infections (UTIs). This is the third update of our review first published in 1998 and updated in 2004 and 2008.

Objectives – To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations.

This updated review includes a total of 24 studies with a total of 4473 participants. Thirteen studies (2380) participants) evaluated cranberry juice/concentrate; nine studies (1032) participants) evaluated cranberry tablets or capsules; one study compared cranberry juice and tablets; and one study cranberry capsules and tablets.

Many studies reported low compliance and high withdrawal/dropout problems which they attributed to palatability/acceptability of the products, primarily the cranberry juice. Most studies of the other cranberry products (tablets and capsules) did not report how much of the ‘active’ ingredient the product contained, and therefore the products may not have had enough potency to be effective.

Prior to the current update, it appeared there was some evidence that cranberry juice may decrease the number of symptomatic UTIs over a 12-month period, particularly for women with recurrent UTIs. The addition of 14 further studies suggests that cranberry juice is less effective than previously indicated. Although some of the small studies demonstrated a small benefit for women with recurrent UTIs, there were no statistically significant differences when the results of a much larger study were included. Given the large number of dropouts/withdrawals from studies and the evidence that the benefit for preventing UTI is small, cranberry juice cannot currently be recommended for the prevention of UTIs. Other preparations (such as powders) need to be quantified using standardized methods to ensure the potency and contain enough of the ‘active’ ingredient, before being evaluated in clinical studies or recommended for use.

Wednesday, February 14, 2018

Wisdom Wednesday: Human Genome Project

In 1953, James Watson and Francis Crick described the double helix structure of deoxyribonucleic acid (DNA), the chemical compound that contains the genetic instructions for building, running and maintaining living organisms.

Methods to determine the sequence of the chemical letters in DNA were developed in the mid-1970s.

In 1990, the National Institutes of Health (NIH) and the Department of Energy jointed with international partners in a quest to sequence all 3 billion letters, or base pairs, in the human genome.

The Human Genome Project’s goal was to understand the genetic factors in human disease, paving the way for new strategies for their diagnosis, treatment and prevention.

All data generated by the project was made freely and rapidly available on the Internet. This accelerated the pace of medical discovery around the world. It spurred a revolution in biotechnology innovation and made the U.S. the global leader in the arising biotechnology sector.

In April of 2003, researchers successfully completed the Human Genome Project, under budget and more than two years ahead of schedule.

Today over 1,800 genetic diseases have been discovered. There are more than 2,000 genetic tests for human conditions that enable patients to learn their genetic risks and help physicians diagnose disease. At least 350 biotech products have been developed and are in clinical trials.

Monday, February 12, 2018

Bacteria Phobia

As a society, we are obsessed with hygiene. Most of us wash our entire bodies at least once per day with hot, soapy water. Grocery store shelves are filled with antibacterial soaps that advertise they kill 99.9% of bacteria viruses. However, the testing of antibacterial soaps was not conducted on hands or kitchen surfaces. Instead, research was done in large pots where testers placed a large numbers of bacteria into liquid soap containing triclosan. After an hour, the solution was tested to see how many bacteria survive.

The safety of antibacterial soaps has never been tested. Triclosan, the most common active ingredient, has never been shown to be more effective than plain soap or even just hot water. After several years on the market Triclosan has been found in human fat tissue, umbilical cord blood, breast milk and nasal secretions. Approximately 75% of humans will pass it in their urine daily.

A clear correlation between triclosan exposure and an increased risk of infection has been documented. The greater the concentration of triclosan in nasal mucus, the higher the rate of colonization of Staphylococcus aureus. The resistant form of this bacteria you know as MRSA.

Triclosan has also been shown to interfere with the action of thyroid hormones, estrogen and testosterone. It is an endocrine disruptor at the level of the cell membrane.

In December of 2017, the FDA had a final ruling that limits the use of triclosan in certain OTC health care antiseptic products. They will not be able to use triclosan or any of the 23 other active ingredients used in antibacterial soaps “without a premarket review due to insufficient data regarding their safety and effectiveness”. Although the governor of Minnesota banned triclosan in all consumer products over concerns of bacteria developing resistance, the FDA failed to follow suit.

Friday, February 9, 2018

Vitamin and Mineral Supplements: What Clinicians Need to Know

Dietary supplementation is approximately a $30 billion industry in the United States, with more than 90,000 products on the market. In recent national surveys, 52% of US adults reported use of a least 1 supplement product, and 10% reported use of at least 4 such products. Vitamins and minerals are among the most popular supplements and are taken by 48% and 39% of adults, respectively, typically to maintain health and prevent disease.

Despite this enthusiasm, most randomized clinical trials of vitamin and mineral supplements have not demonstrated clear benefits from primary or secondary prevention of chronic diseases not related to nutritional deficiency. Indeed, some trials suggest that micronutrient supplementation in amounts that exceed the recommended dietary allowance (RDA) – eg, high doses of beta carotene, folic acid, vitamin E, or selenium – may have harmful effects, including increased mortality, cancer, and hemorrhagic stroke.

In this Viewpoint, we provide information to help clinicians address frequently asked questions about micronutrient supplements from patients, as well as promote appropriate use and curb inappropriate use of such supplements among generally healthy individuals. Importantly, clinicians should counsel their patients that such supplementation is not a substitute for a healthful and balanced diet and, in most cases, provides little if any benefit beyond that conferred by such a diet.

Wednesday, February 7, 2018

Wisdom Wednesday: Cytokine-mediated Inflammation and Neuropathy from Metabolic Syndrome

Painful neuropathy (PN) is a prevalent condition in patients with metabolic syndrome (MetS). However, the pathogenic mechanisms of metabolic syndrome-associated painful neuropathy (MetSPN) remain unclear.

In the current study, high-fat-fed mice (HF mice) were used to study MetSPN. HF mice developed MetS phenotypes, including increased body weight, elevated plasma cholesterol levels, and insulin resistance in comparison with control-fat-fed (CF) mice.

Subsequently, HF mice developed mechanical allodynia and thermal hyperalgesia in hind paws after 8 weeks of diet treatment. These pain behaviors coincided with increased densities of nociceptive epidermal nerve fibers and inflammatory cells such as Langerhans cells and macrophages in hind paw skin.

To study the effect of MetS on profiles of cytokine expression in HF mice, we used a multiplex cytokine assay to study the protein expression of 12 pro-inflammatory and anti-inflammatory cytokines in dorsal root ganglion and serum samples. This method detected the elevated levels of pro-inflammatory cytokines, including tumor necrosis factor (TNF)-a, and interleukin (IL)-6, IL1B as well as reduced anti-inflammatory IL-10 in in lumbar dorsal root ganglia (LDRG) of HF mice.

Monday, February 5, 2018

Is Cannabis an Effective Treatment for Joint Pain?

Cannabis has been used to treat pain for thousands of years. However, since the early part of the 20th century, laws restricting cannabis use have limited its evaluation using modern scientific criteria. Ove the last decade, the situation has started to change because of the increased availability of cannabis in the United States for either medical or recreational purposes, making it important to provide the public with accurate information as to the effectiveness of the drug for joint pain among other indications.

The major psychotropic component of cannabis is deta9-terahydrocannabinol (THC), one of some 120 naturally occurring phytocannabinoids. Cannabidiol (CBD) is another molecule found in herbal cannabis in large amounts. Although CBD does not produce3 psychotropic effects, it has been shown to produce a variety of pharmacological effects. Hence, the overall effects of herbal cannabis represent the collective activity of THC, CBD and a number of minor components.

The action of THC is mediated by two major G-protein coupled receptors, cannabinoid receptor type 1 (CB1) and CB2, and recent work has suggested that other targets may also exist. Arachidonic acid derived endocannabinoids are the normal physiological activators of the two cannabinoid receptors.

Natural phytocannabinoids and synthetic derivatives have produced clear activity in a variety of models of joint pain in animals. These effects are the result of both inhibition of pain pathway signaling (mostly CB1) and anti-inflammatory effects (mostly CB2).

Friday, February 2, 2018

Fish-derived Omega-3 Best for Preventing Breast Cancer

Scientists at the University of Guelph in Ontario, Canada, have revealed that omega-3 fatty acids derived from fish oil may be around eight times more effective for halting the development of aggressive breast cancer tumors than those from plant-based sources.

Study co-author Prof. David Ma, who currently works in the Department of Human Health and Nutritional Sciences at the University of Guelph, and colleagues recently reported their findings in the Journal of Nutritional Biochemistry.

After skin cancer, breast cancer is the most common cancer among women in the United States. It is expected that around 266,120 new cases of invasive breast cancer will be diagnosed in the U.S. this year, and around 40,920 women will die from the disease.

There are two types of omega-3 fatty acids found in fish oil: one is eicosapentaenoic acid (EPA) and the other is docosahexaenoic acid (DHA). The third type ofomega-3 is the plant-based a-linolenic acid (ALA), which is found in soy, canola oil, and flaxseed.

For their study, Prof. Ma and colleagues compared the effects of these three types ofomega-3 on breast tumor development in mice that were bread to develop HER2-positive breast cancer.

“This study is the first to compare the cancer-fighting potency of plant-versus marine-derived omega-3s on breast tumor development,” says Prof. M. “There is evidence that both omega-3s from plants and marine sources are protective against cancer and we wanted to determine which form is more effective.”

Wednesday, January 31, 2018

Wisdom Wednesday: Laboratory Trends

During the months of December, January and February we reduce our lab fees to encourage patients to run a yearly profile. The profile changes from year-to-year but basically has become more extensive over the years.

This year’s standard tests include a hemoglobin A1c, comprehensive metabolic profile (fasting glucose, kidney and liver function, electrolytes, etc.), iron profile, ferritin, serum lipids (total cholesterol, triglycerides, HDL, LDL), CRP (C Reactive Protein), homocysteine, thyroid profile, CBC, vitamin D, and urine analysis.

I often add tests like a PSA for men or TPO (thyroid peroxidase) and thyroid auto-antibodies for Hashimoto’s thyroiditis, if the history indicates the need.

As January ends, I’ve spent hours reviewing lab tests and making nutritional recommendations. I typically use laboratory tests to confirm indications from QA testing but also find them valuable to see disease development in the early stages, when it’s relatively easy to correct.

Every year I see patterns emerge from my patient population. When you review 4-5 tests in a day, you can’t help but see certain trends developing. I thought you might enjoy seeing these trends through this clinician’s eyes.

The eGFR or glomerular filtration rate is a measure of kidney function. It’s a relatively new test and I wrote a blog about it last fall. Initially, the test results were only listed if the result was less than 60. This indicates kidney damage. However, levels between 60 and 90 indicate loss of kidney function. Now that most labs actually list the test results, I am finding a higher and higher percentage of patients in that fall in that 60 to 90 range. They are losing microcirculation to the kidney which may be the result of some aspect of metabolic syndrome, especially insulin resistance. However, the more medication a patient takes, the more likely their eGFR will be below 60.

Monday, January 29, 2018

Flu Vaccine: Nasal Drops May Succeed Where Shots Have Failed

Flu viruses adapt and mutate, making influenza vaccines less effective. New research – published in the journal Science – has found a way to break down the virus’s defenses, giving future flu vaccines a boost.

Researchers from the University of California, Los Angeles – led by Ren Sun, a professor of molecular and medical pharmacology working in the university’s David Geffen School of Medicine – came up with a wholly new approach to developing flu vaccines.

Conventional vaccines reduce “immunogenicity” – that is, the ability of a substance to trigger the body’s immune response – by attenuating the virus. But the new approach preserves robust immune responses and works by identifying and eliminating the so-called immune evasion function of the viruses.

The body’s “first-line defense” function is for interferons to neutralize viruses as quickly as possible, while the “second line” of defense is to modulate our immune response, thereby offering us long-term protection against viruses. Interferons are signaling proteins that coordinate our immune response. As Sun explains, “If viruses do not induce interferons, they will not be killed in the first-line defense; and without interferons, the adaptive immune response is limited. “For these reasons, viruses have evolved strategies to evade detection and limit the production of the interferons by host organisms,” he added.

So, Sun and team found and disabled a genomic sequence of the influenza virus responsible for the interferon induction. “By disabling these interferon-evasion function,” explains first study author Yushen Du, “the engineered virus is weakened in typical hosts.” “At the same time,” she adds, “due to interferon stimulation, the engineered virus generates very strong immune responses.”

Friday, January 26, 2018

Fish Oil Associated with Hemorrhage and Reduced Stroke-Related Sickness

Ischemic stroke is associated with motor impairment and increased incidence of affective disorders such as anxiety/clinical depression. In non-stroke populations, successful management of such disorders and symptoms has been reported following diet supplementation with long chain omega-3-polyunstaurated-fatty-acids (PUFAs). However, the potential protective effects of PUFA supplementation on affective behaviors after experimentally induced stroke and sham surgery have not been examined previously. The study investigated the behavioral effects of PUFA supplementation over a 6-week period following either middle cerebral artery occlusion or sham surgery in the hooded-Wistar rat. The PUFA diet supplied during the acclimation period prior to surgery was found to be associated with an increased risk of acute hemorrhage following the reperfusion component of the surgery. In surviving animals, PUFA supplementation did not influence infarct size as determined 6 weeks after surgery, but did decrease omega-6-fatty-acid levels, moderate sickness behaviors, acute motor impairment, and longer-term locomotor hyperactivity and depression/anxiety-like behavior.

My Take:
Obviously, this study is a couple of years old. I ran across it because I have a patient, taking fish oil that had a fall on the ice and suffered a hemorrhage. The hospital physician stopped all her supplements and told her not to take them for three months. I was looking for data to support or refute that position.

Of the four supplements she was taking, only the fish oil might be contraindicated. This study with rats indicates the omega 3-fatty acids may have contributed to some additional risk of bleeding during reperfusion, if performed. Reperfusion is the medical treatment that restores blood to tissue after a blockage of blood supply. This is why physicians advise you to stop taking omega 3-fatty acids prior to surgery.

Wednesday, January 24, 2018

Wisdom Wednesday: Epstein-Barr Virus (EBV)

Epstein-Barr virus (EBV), also known as human herpesvirus 4, is a member of the herpes virus family. It is one of the most common human viruses. EBV is found all over the world and most people will be infected at some point in their lives.

EBV spreads most commonly through bodily fluids, primarily saliva. EBV can cause infectious mononucleosis (the “kissing” disease), also called mono, and other illnesses.

Symptoms of EBV infection can include fatigue, fever, inflamed throat, swollen lymph nodes in the neck, enlarged spleen, swollen liver and rash. Many people become infected with EBV in childhood. EBV infections in children often are asymptomatic or indistinguishable from other mild, brief childhood illnesses. Teenagers or adults typically get better in 2-4 weeks, but some may feel fatigued for several weeks or even months.

After you get an EBV infection, the virus becomes latent (inactive) in your body. In some cases the virus may reactivate. The official statement of the CDC is that this does not always cause symptoms, but people with weakened immune systems are more likely to develop symptoms if EBV reactivates.

Recent research has linked EBV as a potential trigger for autoimmune disease. It has been implicated in up to a third of Hashimoto’s thyroiditis and RA (rheumatoid arthritis) cases. Many rheumatologists now test RA patients for EBV. Unfortunately, there is much confusion about interpretation of these tests.

My current Epstein-Barr profile consists of the EBV, Ab VCA (viral Capsid Antigen), IgM EBV Early Antigen Ab, IgG; EBV ab VCA, IgG; EBV Nuclear Antigen Ab, IgG and Interpretation. This tests for current infection, past infection, recurrent infection and vulnerability to infection. It’s helpful to set up an Excel spreadsheet to interpret the results. However, my main interest is the recurrent infection.

Monday, January 22, 2018

What Makes This Flu Season So Bad?

Out of every 100,000 hospitalizations in the U.S., 22.7 were for the flu in the first week in January. According to the CDC, the number had doubled from the week before. During the severe flu season that ended in 2015, rates of hospitalizations reached 29.9 for every 100,000.

The winter season that began in 2017 and will end in 2018 “unquestionably falls into a bad year,” says Anthony Fauci, director of the National Institutes of Health National Institute of Allergy and Infectious Disease. First is the nature of the most dominant flu strain infecting people – H3N2. Flu viruses mutate every year, and it’s common to see several strains of flu during the same season. A similar strain called H1N1 was responsible for the 1918 flu pandemic, and the 2009 “swine flu” outbreak. “H3N2 is historically the bad actor among influenzas,” he says. “It’s also associated with complications.”

The second reason H3N2 has been so pervasive, says Fauci, is people have less exposure to it. When the same flu strain strikes repeatedly, people and thus regions tend to build up immunity.

The third reason this year’s flu has been so bad is complications with the vaccine. Most influenza vaccines are grown in chicken eggs, and when this year’s vaccine was being incubated, the virus mutated while it was growing and became less effective. Scientists think it may only be about 30% effective against H3N2. In Australia, the vaccine was only 10% effective.

At best, says Fauci, flu vaccines are only ever about 60% effective. While that makes it a least 60% more effective than not getting a vaccine at all, it still means the rapidly mutating virus has a fighting chance. Every year, the World Health Organization (WHO) meets to determine what specific flu strains should receive vaccines in the northern hemisphere. H3N2 was one of several identified as a threat.

There are four different types of influenza virus, three of which infect people. Of those three, influenza A and B are the most common and each of those subsets develops different strains. H1N1 and H3N2, for example, are strains of influenza A, and they adapt by constantly changing their surface proteins.

Friday, January 19, 2018

Diclegis May Not Ease Morning Sickness

\Doxylamine-pyridoxine (Diclegis), recommended to treat nausea and vomiting in pregnancy, may not be as effective as previously reported, according to a reanalysis published in PLOS One.

Briefly, roughly 250 women at 7 to 14 weeks’ gestation reporting pregnancy-related nausea and vomiting were randomized to receive Diclegis or placebo for 2 weeks. The treatment group had a statistically significant improvement of 0.73 points on the 13-point PUZE symptom scale, researchers reported in 2010. However, in this reanalysis, a separate group of researchers point out that a 3-point difference is required to be considered clinically significant. In addition, another analysis of the data found no statistical difference between the two groups.

The authors conclude: “Clinical practice and guidelines should be updated. This reanalysis underscores the importance of public access to individual participant level data from clinical trials and verification of the findings.

My Take:
How did this study pass peer review in 2010 to be published? Once published several medical journals, including the Journal of the American Medical Association (JAMA) cited this study, endorsing the use of this drug for morning sickness. The articles spanning the past seven years announce “a new day for pregnant women”, listing the drug as “one of the best studied drugs of all time.”

After a drug is approved and use with the public begins, post-release reports of side effects are gradually compiled. Some of the side effects associated with Diclegis are: dyspnea, palpitation, tachycardia, vertigo, visual disturbances, abdominal pain, constipation, diarrhea, fatigue, irritability, malaise, headaches, migraines, anxiety, insomnia, nightmares, itching and rash. During clinical trials side effects were reported in greater than 5% of subjects.

Wednesday, January 17, 2018

Wisdom Wednesday: Complementary and Alternative Medicine

People have used complementary and alternative medicine (CAM) practices for thousands of years in pursuit of health and well-being. However, rigorous, well-designed clinical trials for many CAM therapies are often lacking; therefore, the safety and effectiveness of many CAM therapies are uncertain. The National Center for Complementary and Alternative Medicine (NCCAM) is sponsoring research designed to fill this knowledge gap by building a scientific evidence base about CAM therapies - whether they are safe, whether they work for the conditions for which people use them and, if so, how they work.

Millions of American use CAM for health concerns and general wellness and spend tens of billions of dollars each year on such care. The 2007 National Health Interview Survey found that 38% of adults and 12% of children had used CAM in some form during the 12 months prior to the survey. The survey also revealed that Americans spent $33.9 billion out-of-pocket on CAM practices and products.

In 1999, NCCAM was established as the arm of the HIH to rigorously evaluate the safety and efficacy of CAM therapies, train researchers to conduct CAM research, and provide information to the public and health care professionals. Since its inception, NCCAM has funded more than 2,500 research projects to learn about how CAM therapies work as well as their safety and efficacy.

Studies have shown that spinal manipulation can provide mild-to-moderate relief from low-back pain and appears to be as effective as conventional medical treatments. Results from one trial that examined long-term effects in more than 600 people with low-back pain suggest that chiropractic care involving spinal manipulation is at least as effective as conventional medical care for up to 18 months.

In one of the largest clinical trials to date to test the safety and efficacy of acupuncture, NIH-supported researchers found that acupuncture significantly reduced pain associated with osteoarthritis of the knee when used as a complement to conventional therapy. Other studies and reviews demonstrated that acupuncture provides relief for vomiting and nausea from chemotherapy, shows possible effect for tension headaches, and that acupuncture and simulated acupuncture can both provide relief for those suffering from low-back pain.

Monday, January 15, 2018

Trump Said to Be in ‘Excellent Health’ After Annual Physical

President Donald J. Trump has just finished receiving his first physical since he entered the White House in January 2017, and has been declared in excellent health, though details have not yet been released.

At a press briefing immediately after the physical, Navy Rear Adm. Ronny L. Jackson, MD said the exam went very well, according to a statement tweeted by Sarah Sanders, the White House press secretary.

The last health information about Trump was released in September 2016 in the form of a five-paragraph letter from his personal physician, Harold Bornstein, MD.

The president was described as 6’ 3”, 236 pounds, with blood pressure of 116/70, a blood sugar level of 99, and lipid readings within the normal range – with an HDL of 63, LDL of 94, and triglycerides of 61. His coronary artery calcium score was 98, which is defined as mild heart disease, but an electrocardiogram and chest x-ray conducted in April 2016 were normal, Dr. Bornstein said.

The then-candidate’s PSA score was low. His last colonoscopy, in 2013, found no polyps. The one-page letter stated that Trump’s testosterone level – 441.6 – was in the normal range, as were liver and thyroid function tests.

At the time, Dr. Bornstein noted that Trump was taking rosuvastatin (Crestor, AstraZeneca), a low-dose aspirin for heart attack prevention, finasteride (Propecia) to treat male-pattern baldness, and antibiotics for rosacea.

Friday, January 12, 2018

170 Million Americans Drink Radioactive Tap Water

Drinking water for more than 170 million Americans in all 50 states contains radioactive elements that may increase the risk of cancer, according to an EWG investigation released today.

Radiation in tap water is a serious health threat, especially during pregnancy, and the Environmental Protection Agency’s legal limits for the most widespread radioactive elements are more than 40 years old. But President Trump’s nominee to be the White House environmental czar rejects the need for water systems to comply even with those inadequate standards.

The most common radioactive element in American tap water is radium. EWG’s analysis of test data from almost 50,000 public water systems found that from 2010 to 2015, more than 22,000 utilities in all 50 states reported radium in the treated water delivered to customers’ taps.

Only a small percentage of those systems exceeded the EPA’s legal limits for radium, set in 1976. But almost all exceeded California state scientists’ public health goals for two separate radium isotopes, set in 2006, which are hundreds of times more stringent than the EPA’s standard for the two isotopes combined. The elevated risk of cancer, as well as potential harm to fetal growth and brain development, decreases with lower doses of radiation but does not go away.

“Most radioactive elements in tap water come from natural sources, but that doesn’t take away the need to protect people through stronger standards and better water treatment,” said Olga Naidenko, Ph.D., EWG’s senior science advisor for children’s environmental health. “Millions of Americans are drinking water with potentially harmful levels of radioactive elements, but the outdated federal standards mean many people don’t know about the risk they face when they turn on the tap.”

California has the most residents affected by radiation in drinking water. From 2010 to 2015, about 64% of the state’s residents were served by public water systems that reported detectable levels of the two radium isotopes. In Texas, which has a smaller population, about 80% of the population was served by utilities reporting detectable levels of those elements.

Wednesday, January 10, 2018

Wisdom Wednesday: Diagnosis

This term has been in use since the early 1800’s to describe the “label” given to a particular disease process. Its use has gradually grown over time to be common place today.

The Mayo Clinic in Minnesota is self-proclaimed as the best diagnosis facility in the world. I’ve had a couple of patients evaluated there and I am impressed with their team approach to diagnostic evaluation.

Once evaluated by Mayo, they follow your medical history until death and then hope to be allowed to perform an autopsy. The sole purpose of which is to verify the diagnosis they gave you years earlier. No other medical facility in the world has this kind of follow-up protocol.

So how accurate are they? Mayo Clinic states that their given diagnosis is correct about one-third of the time. That’s really seeing the glass a third full. Others may say that Mayo Clinic is wrong two-thirds of the time.

If they are indeed the best and arrive at the wrong diagnosis twice as often as the correct diagnosis, where does it leave the rest of the health care profession?

The term diagnosis is a combination of two Greek terms, “di” meaning two and “agnostic” meaning to lack knowledge or not know. So, the literal translation of diagnostic is to be of two minds and not know.

Monday, January 8, 2018

Kidney Disease Can Lead to Diabetes, Not Just the Other Way Around

Kidney disease increases the risk for diabetes, a new study finds. Medical experts already knew that the reverse is true – that diabetes increases the risk for kidney disease. The authors of the new study, though, found that kidney dysfunction can lead to diabetes – and, that a waste product called urea plays a role in the two-way link between the two diseases.

Urea comes from the breakdown of protein in food. Kidneys normally remove urea from the blood, but poor kidney function can lead to increased levels of urea.

The study involved the analysis of medical records over a five-year period for 1.3 million adults who did not have diabetes. About 9% had elevated urea levels, a sign of reduced kidney function. That’s the same rate as in the general population, according to the researchers.

People with high urea levels were 23% more likely to develop diabetes than those with normal urea levels, the study found. The results were published online recently in the journal Kidney International.

“The risk difference between high and low levels is 688 cases of diabetes per 100,000 people each year,” said study senior author Dr. Ziyad Al-Aly. He’s an assistant professor of medicine at Washington University School of Medicine in St. Louis.

“When urea builds up in the blood because of kidney dysfunction, increased insulin resistance and impaired insulin secretion often result,” Al-Aly said.

The findings about the role of urea could help in efforts to improve treatment and possibly prevent diabetes, the researchers said. Urea levels can be lowered in a number of ways, including medication and diet.

Friday, January 5, 2018

Seniors Don’t Need Calcium, Vitamin D Supplements

Seniors are wasting their time and money taking calcium and vitamin D supplements to ward off the brittle bones of old age, a new review concludes.

It turns out there’s little evidence supplements protect against hip fractures and other broken bones in older folks, according to data gathered from dozens of clinical trials.

“The routine use of these supplements is unnecessary in community-dwelling older people,” said lead researcher Dr. Jia-Guo Zhao, an orthopedic surgeon with Tianjin Hospital in China. “I think that it is time to stop taking calcium and vitamin D supplements.”

Zhao and his colleagues combed through medical literature to find clinical trials that previously tested the usefulness of calcium and Vitamin D supplements. They wound up with data from 33 different clinical trials involving more than 51,000 participants, all of whom were older than 50 and living independently.

Most of the clinical trials took place in the United States, the United Kingdom, New Zealand and Australia Zhao said. The dosage of the supplements varied between the clinical trials, as did the frequency at which they were taken.

The pooled data revealed no significant association between calcium or vitamin D supplements and a person’s risk of hip fracture or other broken bones, compared with people who received placebos or no treatment at all.

Potential dietary sources of these nutrients prove one of the weaknesses of the evidence review, argued Dr. Daniel Smith, an assistant professor of orthopedics at the Icahn School of Medicine at Mount Sinai in New York City. “While this study addresses concerns regarding calcium and vitamin D supplementation, it fails to address or even consider whether the patients in question are obtaining either adequate calcium and vitamin D intake in their diets or sunlight exposure, obviating the need for supplementation,” Smith said.

Wednesday, January 3, 2018

2017 Blog Summary

I posted 147 blogs in 2017. I began writing my blog late in 2013 and will exceed 600 total posts sometime this month.

For me, the most important benefit is personal. Reviewing studies keeps me abreast of the latest health research. As a result, I’m a better physician, providing a higher level of service to my patients. I hope that you also glean information to guide you in making health decisions.

Reviewing my blogs for the past year always brings some surprises and some fond memories. I really enjoyed researching and writing the series on food allergies. I try to strike a balance between criticism of our current health care system and positive steps you can take to improve your own health.

This year it appears I’ve done a pretty good job in that department. Tied for first were blogs about diet and blogs about drugs. Together, they accounted for a full third of my blogs. Medical testing was the next most popular topic, followed by supplementation and hormone imbalance. Each accounting for 10% of my blog material. I also covered exercise, autoimmune disease, medical procedures, and cardiovascular disease repeatedly.

I was surprised that infection, genetics and toxicity in the environment were not more popular. Look for more blogs on these topics this year. In fact, emerging studies are showing a strong correlation with these factors and chronic diseases like ALS (Lou Gehrig’s disease), MS (multiple sclerosis), RA (rheumatoid arthritis) and AD (Alzheimer’s disease).

You can view any of my blogs since 2013 just by scrolling through the years and months in the right-side column. If you prefer, you can also search by key word. Just enter your topic in the left-hand upper corner and press enter.