Wednesday, August 15, 2018

Wisdsom Wednesday: C- Reactive Protein (CRP) Test

A C-reactive protein test measures the level of C-reactive protein (CRP) in your blood. CRP is a protein made by your liver. It’s sent into your blood stream in response to inflammation. Inflammation is your body’s way of protecting your tissues if you’ve been injured or have an infection. It can cause pain, redness, and swelling in the injured or affected area. Some autoimmune disorders and chronic diseases can also cause inflammation. Normally, you have low levels of c-reactive protein in your blood. High levels may be [a] sign of a serious infection or other disorder.

If you’ve already been diagnosed with an infection or have a chronic disease, this test may be used to monitor your treatment. CRP levels rise and fall depending on how much inflammation you have. If your CRP levels go down, it’s a sign that your treatment for inflammation is working.

The CRP test is sometimes confused with a high-sensitivity-(hs) CRP test. Although they both measure CRP, they are used to diagnose different conditions. An hs-CRP test measures much lower levels of CRP. It is used to check for risk of heart disease.

My Take:
This is the kind of “dummied-down” information currently being released by NIH (National Institutes of Health) rather than reporting on cutting edge research.

Although the information presented is fairly accurate, it is also misleading. The hs-CRP also measures inflammation but it is specific for vascular inflammation. As such, it can be an indicator of cardiac risk. When elevated, the hs-CRP stimulates LDL cholesterol to bind with homocysteine and create plaque in an inflamed artery wall. At low levels this is a form of repair, protecting the damaged artery from rupture. However, when excessive, artery occlusion or clots can occur resulting in a CVA, stroke or pulmonary embolism.

Monday, August 13, 2018

Salt Restrictions for Some May Be Better Than for All

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

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

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

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

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

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

Friday, August 10, 2018

Saunas Linked to Numerous Health Benefits

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

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

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

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

Wednesday, August 8, 2018

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

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

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

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

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

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

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

Monday, August 6, 2018

99% of Doctors Need Diagnostic Help

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

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

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

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

Friday, August 3, 2018

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

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

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

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

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

Wednesday, August 1, 2018

Wisdom Wednesday: Mercury in Retrograde

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

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

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

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

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

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

Monday, July 30, 2018

Study Offers Clues for Improving Seasonal Flu Vaccine

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

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

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

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

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

Friday, July 27, 2018

The Trouble with Ingredients in Sunscreens

Sunscreen is a unique body care product: consumers are directed to apply a thick coat over large areas of the body and reapply frequently. Thus, ingredients in sunscreen should not be irritating or cause skin allergies, and should be able to withstand powerful UV radiation without losing their effectiveness or forming potentially harmful breakdown products. People can potentially inhale ingredients in sunscreen sprays and ingest some of the ingredients they apply to their lips, so ingredients must not be harmful to lungs or internal organs. Further, sunscreens commonly include ingredients that act as “penetration enhancers” and help the product adhere to skin. As a result, many sunscreen chemicals are absorbed into the body and can be measured in blood, breast milk and urine samples.

Active ingredients in sunscreens come in two forms, mineral and chemical filters. Each uses a different mechanism for protecting skin and maintain stability in sunlight. The most common sunscreens on the market contain chemical filters. These products typically include a combination of two to 6 of the following active ingredients: oxybenzone, avobenzone, octisalate, octocrylene, homosulfate and octinoxate. Mineral sunscreens use zinc oxide and/or titanium dioxide. A handful of products combine zinc oxide with chemical filters.

Laboratory studies indicate that some chemical UV filters may mimic hormones, and physicians report sunscreen-related skin allergies, which raises important questions about unintended human health consequences from frequent sunscreen application.

The Food and Drug Administration has not reviewed evidence of potential hazards of sunscreen filters – instead it grandfathered in ingredients used in the late 1970s when it began to consider sunscreen safety. The Danish EPA recently reviewed the safety of active ingredients in sunscreen and concluded that most ingredients lacked information to ensure their safety (Danish EPA 2015). Sixteen of the 19 ingredients studied had no information about their potential to cause cancer. And while the published studies suggest that several chemical filters interact with human sex or thyroid hormones, none of the ingredients had sufficient information to determine the potential risks to humans from hormone disruption.

EWG has reviewed the existing data about human exposure and toxicity for the nine most commonly used sunscreen chemicals. The most worrisome is oxybenzone, which was added to nearly 65 percent of the non-mineral sunscreens in EWG’s 2018 sunscreen database. The Centers for Disease Control and Prevention routinely detects oxybenzone in more than 96% of the American population. In a recent evaluation of CDC-collected exposure data for American children, researchers found that adolescent boys with higher oxybenzone measurements had significantly lower total testosterone levels. Three other studies reported statistically significant associations between oxybenzone exposure during pregnancy and birth outcomes.

Wednesday, July 25, 2018

Wisdom Wednesday: Rheumatoid Arthritis or Osteoarthritis?

Rheumatoid Arthritis is an autoimmune disease, a result of the immune system attacking the tissues that line the body’s joints. This causes pain, swelling, and stiffness in the joints and the pain is often symmetrical. It is more common in women and those who are middle aged, but it can happen to anyone.

Osteoarthritis happens over time. It is the most common form of arthritis, and it usually occurs in older people. The protective cartilage on the ends of your bones wear down as you age, making it difficult to move. It usually affects one side of the body. Osteoarthritis can damage any joint in your body, though it most commonly affects joints in your hands, knees, hips and spine.

My Take:
This article is fairly accurate but is an example of the type of health care reporting that has replaced reporting on new research.

Rheumatoid Arthritis (RA) effects women nine times more often than men. It tends to be bilateral and symmetrical. If you left elbow is affected, sooner or later, so will the right, but maybe not with the same intensity. It is typically diagnosed in a woman’s mid-to-late 30’s. But has been going on for years. I don’t consider that middle age but maybe that’s because I’m in my sixties.

There are reliable blood tests for RA including the ANA (antinuclear antibodies), RA factor, and SED rate. However, the diagnosis is based as much on symptoms as lab work. On occasion, the diagnosis is based on x-ray findings but by the time you see the damage on x-ray, the disease is quite advanced.

Osteoarthritis (OA) is the result of wear and tear on a joint over time. So, the joints that get the most use typically show the most damage. The base of the thumb on your dominant hand is the most likely joint for osteoarthritis.

The current theory on the mechanism of osteoarthritis is more complex that just a wearing down of the protective cartilage over time. It is thought that micro trauma (or a single severe traumatic injury) damages the blood supply to the end of the bone. The gradual loss of blood supply causes the cartilage to erode.

Monday, July 23, 2018

Is Melatonin Safe for Kids?

It’s estimated that up to 75% of school-aged children don’t get enough sleep. Unfortunately, poor sleep can affect a child’s mood and ability to pay attention and learn. It has also been linked to health issues such as childhood obesity. This is why some parents consider giving their children melatonin, a hormone and popular sleep aid.

Melatonin levels rise in the evening, which lets your body know it’s time to head to bed. Conversely, melatonin levels start to fall a few hours before it’s time to wake up. It also helps regulate your blood pressure, body temperature, cortisol levels and immune function.

In the US, melatonin is available over-the-counter at many drug and health food stores. However, in other parts of the world, including Australia, New Zealand and many European countries, melatonin is only available with a prescription.

An analysis of 35 studies in children with autism found that melatonin supplements helped them fall asleep faster and a stay asleep longer. Similarly, an analysis of 13 studies found that children with a neurological condition fell asleep 29 minutes faster and slept 48 minutes longer on average when taking melatonin.

Similar effects have been observed in healthy kids and teenagers who struggle to fall asleep. However, sleep problems are complex and can be caused by a variety of factors.

For instance, using light-emitting devices late at night can suppress melatonin production. If this is the case, simply limiting technology use before bed can help treat sleep issues.

Most studies show that short-term melatonin use is safe for kids with little or no side effects. However, some children may experience symptoms such as nausea, headaches, bed wetting excessive sweating, dizziness, morning grogginess, stomach pains and more.

Friday, July 20, 2018

Low Dose Aspirin May Not Be Effective in Heavier Patients

Low-dose aspirin may not be effective in preventing cardiovascular events in people weight 70 kg (154 pounds) or more, a Lancet study suggests.

Researchers analyzed 10 trials that evaluated aspirin versus controls for primary prevention of cardiovascular events in 120,000 people.

Daily, low-dose aspirin (75-100 mg) was associated with reduced risk for cardiovascular events among those weighting less than 70 kg (odds ratio, 0.77), but there was no significant effect for heavier patients – roughly 80% of men in the study and nearly half of women weighted 70 kg or more. In the heavier group, low-dose aspirin may be even less effective in smokers and in those who take enteric-coated aspirin.

High-dose aspirin (300-325 or 500 mg), meanwhile, appeared to be effective in reducing primary cardiovascular events only [in] patients weight 70 kg or more.

Commentators said that people with more body mass may have more esterases, which clear aspirin and would reduce the bioavailability of the drug.

The authors conclude: “A one-dose-fits-all approach to aspirin is unlikely to be optimal, and a more tailored strategy is required.

Wednesday, July 18, 2018

Wisdom Wednesday: Health Research Dissemination

I’ve been blogging for the past five years trying to inform you about new developments in health and health care. The National Institutes of Health (NIH) has been a constant source of information for those blogs.

PubMed, the official publication of NIH, posts peer reviewed research and research papers presented at conferences all over the world. As you might imagine, that’s a lot of data and unless you know what you are looking for, new information is difficult to find.

Research is arranged by the number of citations in other research, so the new stuff is often buried behind older research. To remedy this issue, a team of writers glom through the web site, pulling out new research of interest to health care professionals and the general public.

At least, that is the way it used to work. Starting in 2018, Medical News Today, the official newsletter of NIH, contains “headlines from the past week.” The weekly publication begins with advertisement for various drugs. This week the ads are for “Relapsed Multiple Myeloma – Updated Treatment Option Info,” “Psoriasis Treatment,” and “Osteoporosis Information.”

Current research is scant. Instead, general health tips are provided in article format. Here is a smattering of this week’s selections: “Causes of shortness of breath during pregnancy,” Chinese restaurant syndrome: What you need to know,” “How men can improve their sexual performance,” “The riddle of human nipple sizes,” “What to know about anal herpes,” “Is having vaginal pressure during pregnancy normal,” “Does nipple stimulation help to induce labor,” “What causes chest pain and vomiting,” “What causes bellybutton pain during pregnancy,” “Why does it hurt when I swallow, “Are Epsom salt baths safe during pregnancy,” “What causes a nosebleed at night,” and “How to fix peeling nails.”

Monday, July 16, 2018

Vitamin D Toxicity: A 16-Year Retrospective Study

Interest in vitamin D has increased during the past 2 decades, with a corresponding increase in laboratory testing of 25-hydroxyvitamin D [25(OH)D]. The vast majority of specimens tested display normal or deficient levels of 25(OH)D; concentrations rarely fall in the potentially toxic range.

We performed a retrospective investigation of elevated 25(OH)D levels during a 16-year period at the University of Iowa Hospitals and Clinics, a 734-bed medical center. Detailed medical-record review was performed for patients with serum/plasma 25(OH)D concentrations higher than 120 ng per mL.

A total of 127,932 serum/plasma 25(OH)D measurements were performed on 73,779 unique patients. Of these patients, 780 (1.05%) had results that exceeded 80 ng per mL and 89 patients (0.12%) had results that exceeded 120 ng per mL. Only 4 patients showed symptoms of vitamin D toxicity. Three of these cases involved inadvertent misdosing of liquid formulations.

Symptomatic vitamin D toxicity is uncommon, and elevated levels of 25(OH)D do not strongly correlate with clinical symptoms or total serum/plasma calcium levels. Our study highlights the potential risks of the liquid formulation of vitamin D.

My Take:
Vitamin D is one of the most common supplements I recommend in my practice. I do use the liquid formulation in which one drop contains 2,000 IU of vitamin D3. I typically recommend two drops daily (4,000 IU) but have recommended higher doses up to 5 drops daily (10,000 IU). Honestly, I have never had an issue with inadvertent overdosing of the supplement.

Friday, July 13, 2018

Cardiovascular Disease: Risk Assessment with Nontraditional Risk Factors

Cardiovascular disease is the most common cause of death among adults in the United States. Treatment to prevent CVD events by modifying risk factors is currently informed by the Framingham Risk Score, the Pooled Cohort Equations, or similar CVD risk assessment models. If current CVD risk assessment models could be improved by adding more risk factors, treatment might be better targeted, thereby maximizing the benefits and minimizing the harms.

Detection - The USPSTF found adequate evidence that adding the ABI, hsCRP level and CAC score to existing CVD risk assessment models may improve calibration, discrimination and reclassification. The USPSTF chose to review these 3 nontraditional risk factor because prior evidence reviews identified them as the most promising to improve on existing CVD risk assessment tools.

Benefits - The USPSTF found inadequate evidence to assess whether treatment decisions guided by ABI, hsCRP level, or CAC score test results, when added to existing CVD risk assessment models, lead to reduced incidence of CVD events or mortality.

Potential Harms – Testing for hsCRP level and the ABI is noninvasive, and there is little direct harm from the tests. Harms of testing for CAC score include exposure to radiation and incidental findings on computed tomography of the chest, such as pulmonary nodules, that may lead to further invasive testing and procedures. Abnormal test results may lead to further testing, procedures, and lifelong medication use without proof of benefits but with expense and potential adverse effects for the patient. Psychological harms may results from reclassification into a higher-risk category for CVD events.

Wednesday, July 11, 2018

Wisdom Wednesday: Lifelong CMV Infection Improves Immune Defense in Old Mice

Epidemiological studies have shown a correlation between CMV infection and immune system aging, especially in elderly populations. It remains unclear whether CMV infection is a key driver of, or simply a factor associated with, aging of the immune system. In this study, we show that CMV infection improves T cell immunity in old animals by broadening the immune response to a different pathogen. Animals that have aged with CMV are able to recruit novel T cells into these immune responses that are present in, but not utilized in, animals aging without CMV. This data squarely challenges the premise that CMV is solely detrimental to the aging of the adaptive immune system.

My Take:
The abstract was very technical so I didn’t repeat it here. However, these researchers basically exposed old mice with a history of CMV and a control group to Listeria monocytogenes then looked at the immune response. They postulate that we share coevolution with CMV that may include potentially positive impacts on adaptive heterologous immunity in late life.

In younger patient populations, CMV and EBV (Epstein - Barr virus) are documented factors in at least a third of all autoimmune cases. So this study showing an immune stimulation by CMV in older patients is not surprising.

In immune compromised patients, like HIV/AIDS, CMV can cause life threatening disease.

The real question is CMV a positive or negative factor in health? In my opinion, it has the potential for both. If your immune system is balanced, then CMV probably plays a positive role. However, if your immune system is compromised or overstimulated (autoimmune disease) then the effects are negative.

As we age, our immune systems tend to decline, so the immune stimulation from a chronic CMV infection may very well provide a boost to immune function. Again, as long as the immune system is healthy to begin with.

Monday, July 9, 2018

Vitamin N Deficiency

For the first time in history, the majority of the world’s population now live in urban setting rather than rural settings. This trending switch has taken us away from nature, which has taken a collective toll on our health.

With urbanization on the rise, people are less engaged with nature. No longer do we have the need to interact with nature for survival. Instead our relationship with the natural world is primarily based on recreation and enjoyment, and it’s minimal at best. As a result, many people suffer from what American writer, Richard Louv, calls “nature deficit disorder,” defined as a “diminished ability to find meaning in the life that surrounds us.”

In Louv’s book, Last Child in the Woods, he explains that nature affects “everything from a positive effect on the attention span, to stress reduction to cognitive development and a sense of wonder and connection to the earth.” With incidences of heart disease, diabetes and cancer continuing to rise, as well as escalating mental health issues, research is linking artificial stimulation to exhaustion and a loss of health and vitality. Simultaneously, mounting scientific evidence points to the positive effects that interacting with nature has on a person’s physical and mental well-being.

Even though the amount and type of nature accessible to people is varied, our desire to connect with it somehow seems to be universally embedded in our DNA. As humans, our cells expect and thrive on natural sunlight, fresh water and air. Not having such a connection is, no pun intended, “unnatural”. Spending days in windowless rooms with artificial light and glowing screens from televisions, computers and smartphones denies us the necessary symbiotic relationship we need with the natural world to thrive. Our bodies haven’t evolved to keep pace with what is now a disconnect from nature. At our core, we’re still hunters and gatherers. In other words, our bodies need what nature give us, and that may always be the case.

The pendulum seems to be swinging back and we are seeing a shift back to nature. From fast food to more “slow” organic foods, a rise in popularity of dietary lifestyles rooted in hunting and foraging ancestral patterns and a resurgence of planned parks amidst urban sprawl, we are seeking a reconnection with nature. “Grounding” or “earthing”, a practice that involves walking barefoot on the earth’s surface, is also gaining popularity. Research has shown “earthing” can reduce inflammation promote wound healing, strengthen the immune system, and prevent or even help to alleviate chronic diseases, including autoimmune diseases.

Even in hospital settings, people are planting trees and gardens. Studies have shown that connecting to nature can speed recovery from surgery just being around plants or images of nature helped to heal the body faster and more efficiently. Patients with garden access on hospital grounds demonstrated positive health outcomes, such as less stress and anxiety, a positive outlook and faster healing.

Friday, July 6, 2018

Water Quality Reports

I just received the 2017 Annual Drinking Water Quality Report from the City of Deerfield Beach. The city has a longstanding reputation for providing high-quality drinking water. Their monitoring program tests over 90 regulated and unregulated compounds, with some tested regularly, following the standards required by the Environmental Protection Agency (EPA) and the Florida Department of Health in Broward County.

The source of water for the City of Deerfield Beach is ground water pumped from two aquifers: the Biscayne and the Floridian aquifers. The Biscayne aquifer is an underground geologic formation made up of highly permeable limestone and less permeable sandstone located under a portion of South Florida. The Biscayne is the shallower of the two aquifers, extending to depths of approximately 240 feet along the coast of South Florida and is the major source of ground water for Miami-Dade, Broward and Palm Beach counties. The Florida aquifer is deeper than the Biscayne and extends to depths of about 3,000 feet and has much higher mineral content, thus making the treatment process considerably more expensive. The raw water pumped from these aquifers is treated by three distinct processes: Lime Softening, Nanofiltration, and Reverse Osmosis.

Lime softening reduces the hardness of water from the Biscayne aquifer with quicklime. Then the water passes through high rate granular media filters to reduce turbidity. Disinfection is then achieved by choramination, combining chlorine and ammonia. Low levels of fluoride are also added to help with the prevention of tooth decay.

Nanofiltration of water, also from the Biscayne aquifer runs in a parallel path to lime softening and is then mixed with the softened water prior to disinfection.

Reverse osmosis is reserved for the deeper Florida aquifer water. The source water is treated under high pressures and sent through semipermeable membranes to remove salt and other inorganic minerals to produce drinking water. Again, the waters are blended with those produced from Lime Softening and Nanofiltration prior to disinfection.

The water quality test results include microbiological contaminants like E. coli from human and animal fecal waste. Radium, from erosion of natural deposits is the most common radioactive contaminant measured. Several inorganic contaminates are also monitored. A few examples are: Antimony from petroleum refineries, fire retardants, ceramics, electronics and solder. Arsenic runoff from orchards. Barium from drilling waste water. Fluoride discharged from fertilizer and aluminum factories and as a water additive. Copper and lead come from the corrosion of household plumbing systems and leaching from wood preservatives.

Monday, July 2, 2018


Toxicity is a ubiquitous health issue. I frequently have new patients fill out a symptom survey. It groups symptoms by organ systems. Over 95% of patients will show liver toxicity as their number one source of symptoms. The other 5% generally show a tie between liver and some other organ.

Many nutritionists start their patients with a detox program. However, I don’t believe detox is the place to start. In the QA (Quintessential Applications) protocol, liver detoxification is step 19 of 32. Inflammation is where treatment must begin, followed by immune system, general metabolism and endocrine function. Then, and only then can liver detoxification truly be effective. Digestion is a wild card and may have to be addressed before or after any of these other systems.

Toxins can contribute to fatigue, difficulty sleeping, indigestion, food cravings and weight gain, reduced metal clarity, low libido, skin issues and joint discomfort.

There are currently 80,000 synthetic chemicals registered for use in the United States. Over 800 million pounds of herbicides are used each year on our crops. Current research shows 167 industrial chemicals are found in adults with no employment-related exposure.

There are three phases of detoxification, the first two occur in the liver:

Phase 1 – The body transforms fat-soluble toxins to an “unlocked” state that is more water-soluble, and in many cases, more toxic than its original form. For almost all natural substances however, phase 1 is all that is need prior to transport to the bowel or kidneys. Caffeine, for example, only has to go through phase 1 detox.

Phase 2 – The highly toxic substances produced in Phase 1 convert to non-toxic molecules and become even more water-soluble. Up until about 100 years ago, phase 2 liver detox was reserved for hormone and alcohol detoxification. And those hormones were produced by you (endogenous) as no exogenous hormones existed. Estrogen, becomes dehydroxyestrogen in phase 1, some forms of which are carcinogenic. In phase 2 estrogen becomes a harmless, water-soluble compound excreted in the bowel and urine.

Phase 3 – Elimination of water-soluble toxins via the bowel and kidneys.

Most detox programs ramp up phase 1 detox. When phase 2 detox lags behind the result is an increase in highly toxic substances produced in phase 1 and the patient experiences “detox symptoms.”

The key is to support phase 2 detox first, then phase 3 and finally phase 1. We accomplish that by addressing steps 1-18 in the QA protocol prior to attempting liver detoxification.

The Bottom Line:
Detoxification is a significant issue for anyone living in the twenty-first century. However, you must improve general health and specific systems prior to a successful detox program.

Friday, June 29, 2018

16:8 Fasting Diet Actually Works

A form of intermittent fasting known as the 16:8 diet helps obese individuals to lose weight and lower their blood pressure, according to a new study.

More and more people now turn to intermittent fasting as a fast and effective way to lose weight. There are different forms of this diet, depending on the time intervals of “fasting” and “feasting.” The so-called 5:2 diet, for instance, consists of eating normally for 5 days every week and fasting for 2 days. In the fasting days, the dieter restricts their calorie intake to 500 or 600 per day. In the daily fasting, or the 16:8 diet, people eat whatever they like for 8 hours and fast for the remaining 16.

A new study evaluates the benefits of this 16:8 pattern for obese individuals and finds that not only does the diet work, but also that it helps to lower blood pressure.

As many as 93.3 million adults have obesity in the United States, according to the latest data from the Centers for Disease Control and Prevention (CDC). That’s almost 40% of the country’s entire population.

This research was led by corresponding author Krista Varady, an associate professor of kinesiology and nutrition at the University of Illinois at Chicago, and the findings were published in the journal Nutrition and Healthy Aging.

Varady and colleagues recruited 23 obese study participants who were aged 45 years, on average, with the average body mass index (BMI) of 35. Between 10 a.m. and 6 p.m., the participants could eat whatever and however much they liked, but they were only allowed to drink water and calorie-free drinks for the remaining 16 hours.

Wednesday, June 27, 2018

Wisdom Wednesday: Fish Oil Consumption Does Not Increase Bleeding Risk

Fish oil is rich in omega-3 fatty acids EPA and DHA. Increased intake of EPA and DHA is beneficial for cardiovascular health, cognitive function, mental health, maternal and child health, immunity and inflammation. EPA and DHA supplements are becoming more and more popular across a wide diversity of people, from healthy individuals to vulnerable population with impaired health.

Higher omega-3 concentrations may compete with fatty acids such as arachidonic acid for metabolizing enzymes. The interaction results in a decreased production of compounds that induce platelet aggregation and an increased production of compounds with anti-platelet properties, hence the anticoagulation benefits of omega-3. However, for patients who are under antithrombotic therapy (either with platelet aggregation inhibitors such as aspirin or anticoagulant drugs such as warfarin), the potential risk of bleeding due to the concurrent use of omega-3 fatty acids has been a concern by many clinicians, particularly surgeons.

Multiple clinical studies have been conducted to investigate whether omega-3 fatty acids pose a clinically significant bleeding risk. So far, the findings have been consistent:

A 2004 Cochrane review of 48 randomized controlled trials and 41 epidemiological analyses concludes that 0.4-7 g/day omega-3 fatty acids do not result in any change in clinical bleeding manifestations.

A 2007 review of 19 clinical studies involving nearly 4400 surgical patients concludes that the risk for clinically significant bleeding was virtually nonexistent with the use of 1.4-21 g/day of omega-3 fatty acid supplements, even with the concurrent use of antiplatelet or antithrombotic medications.

A 2013 systematic review of 10 randomized trails involving nearly 1000 adults 60 years or older concludes that there is no difference in total adverse event rates between daily use of placebo or 0.03-1.86 g EPA and/or DHA for 6-52 weeks.

A 2014 review of 7 randomized controlled trails and 3 epidemiological studies concludes that omega-3 fatty acid treatment has no effect on the risk of clinically significant bleeding and there is no support for discontinuing the use of omega-3 fatty acids before invasive procedures.

A 2017 systematic review based on 32 publications on healthy subjects and 20 publications on patients undergoing surgery finds that fish oil supplements reduce platelet aggregation in healthy subjects and do not increase intra- or post-operative bleedings in patients, and concludes that discontinuation of fish oil supplements prior to surgery is not recommended.

Monday, June 25, 2018

Florida Red Tide

A red tide, or harmful algal bloom, is a higher-than-normal concentration of microscopic alga. In Florida and the Gulf of Mexico, the species that causes most red tides is Karenia brevis.

At high enough concentrations, Florida red tide can discolor water a red or brown hue. Other algal species can appear red, brown, green or even purple. At lower concentration, the water color appears normal during a bloom.

Red tides were documented in the southern Gulf of Mexico as far back as the 1700s and along Florida’s Gulf coast in the 1840s. Fish kills near Tampa Bay were even mentioned in the records of Spanish explorers.

The duration of a bloom can be as little as a few weeks or longer than a year. In nearshore Florida waters, it depends on sunlight, nutrients and salinity. The speed and direction of the wind a water currents are also factors.

K. brevis cannot tolerate low-salinity waters for very long, so blooms usually remain in salty coastal waters and do not penetrate upper reaches of estuaries. However, other harmful algae, including cyanobacteria (blue-green algae), typically bloom in freshwater lakes and rivers.

Many red tides produce toxic chemicals that can affect both marine organism and humans. The Florida red tide organism, K. brevis, produces brevotoxins that can affect the central nervous system of fish and other vertebrates, causing these animals to die. Wave action can break open K. brevis cells and release these toxins into the air, leading to respiratory irritation. The red tide toxins can also accumulate in molluscan filter-feeders such as oysters and clams, which can lead to Neurotoxic Shellfish Poisoning in people who consume contaminated shellfish.

Wednesday, June 20, 2018

Wisdom Wednesday: Vitamin D May Decrease Breast Cancer Risk

The merits of vitamin D when it comes to cancer prevention have long been at the heart of medical debates. Where some studies have revealed that overall cancer risk is lower in people with higher levels of this vitamin, others have suggested that vitamin D has no impact on a person’s vulnerability to the disease.

Still, the case for ensuring that you get enough vitamin D is fairly strong, as low blood levels of this nutrient have been associated with raised risk of bladder cancer and, in a study that was published earlier this year, an elevated risk of bowel cancer. Previous research has also suggested a link between high vitamin D levels and better survival rates in people going through breast cancer treatment.

In a pooled analysis of a prospective cohort study and two randomized clinical trials, researchers at the University of California, San Diego School of Medicine have now investigated whether and to what extent high levels of vitamin D in the blood were associated with a lower risk of developing breast cancer.

Their analysis – which was conducted in collaboration with specialists from Creighton University in Omaha, ND, the Medical University of South Carolina in Columbia, and the nonprofit organization GrassrootsHealth in Encinitas, CA – suggests that certain levels of vitamin D correlate with a “markedly lower” risk of breast cancer. These results are now published in the journal PLOS ONE.

“We found that participants with blood levels of 25(OH)D that were above 60 nanograms per milliliter (ng/ml) had one-fifth the risk of breast cancer compared to those with less than 20 ng/ml.” – Cedric F. Garland.

Monday, June 18, 2018

Parkinson’s: Vitamin B-3 May Stop Brain Cell Death

Vitamin B-3 may help to stop the death of nerve cells that occurs in Parkinson’s disease, according to a recent German-led study that may lead to new treatments for the brain-wasting disease.

The researchers’ paper is now published in the journal Cell Reports. In it, they report how a form of vitamin B-3 called nicotinamide riboside helped to preserve nerve cells by boosting their mitochondria, or energy-producing centers.

“This substance,” explains senior study author Dr. Michela Deleidi, who leads brain research projects at the University of Tubingen and the Helmholtz Association – both in Germany – “stimulates the faulty energy metabolism in the affected nerve cells and protests them from dying off.” In the case of Parkinson’s disease, studies have shown that the dopamine cells that die off have damaged mitochondria.

Dr. Deleidi and her colleagues wondered whether faulty mitochondria are a cause or whether they are “merely a side effect” of the disease. First, they took skin cells from individuals with Parkinson’s disease who carried versions of the GBA gene that are known to increase risk for the disease.

They got the skin cells to regress into immature stem cells, and they then coaxed the stem cells to become nerve cells. These nerve cells show similar mitochondrial dysfunction as that found in the brain cells in Parkinson’s disease.

The team then fed the cells with a form of vitamin B-3 called nicotinamide riboside, which is a precursor of the coenzyme. This caused NAD levels to rise in the cells and resulted in new mitochondria and increased energy production.

Friday, June 15, 2018

Fewer Than 1 in 10 Adults Get All High-Priority Preventive Care

Only 8% of US adults aged 35 years or older received all of the high-priority preventive care recommended for them, according to results of a survey published in the June issue of Health Affairs. Conversely, 5% of adults received none of those services.

Amanda Borsky, DrPH, MPP, a dissemination and implementation adviser in the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality in Rockville, Maryland, and colleagues found that the most commonly received preventive service in 2015 was blood pressure screening (87.3%), and the least commonly received was zoster vaccination for shingles (37.9%).

Common reasons for not getting preventive services include lack of insurance, lack of a usual source of care, and delayed access to care.

The researchers used data from the Preventive Services Self-Administered Questionnaire of the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey from January to May 2015 to examine receipt of 15 preventive measures: screenings for blood pressure, cholesterol, breast cancer, colon cancer, cervical cancer, osteoporosis, and prostate-specific antigen; screening and counseling for tobacco, obesity, alcohol use, and depression; influenza, zoster, and pneumococcal vaccines; and counseling for aspirin use.

Among the 2759 adults aged 35 years and older eligible to complete the Preventive Services Self-Administered Questionnaire, 2186 (79.2%) did.

With respect to the proportion of respondents who received all appropriate preventive care, there was no significant difference between men and women or by age. However, men were almost twice as likely as women to receive 25% fewer of the services. Men were also 3 times as likely as women to have received no recommended services. “The only service received more often by men than women was counseling on aspirin use,” the authors write.

Wednesday, June 13, 2018

Wisdom Wednesday: PSA Versus Free PSA

Prostate-specific antigen (PSA) is a protein made mainly in the prostate. A bit of PSA is released into the bloodstream during each ejaculation, and PSA in ejaculate makes it easier for the semen to carry sperm to the fallopian tubes during conception. PSA can have two basic states. It may be bound to another protein or float free.

The total PSA and free PSA tests both measure levels of PSA in the blood. Results help doctors to diagnose issues like prostate cancer and inflammation of the prostate. A total PSA measures all the PSA, including the antigens that are bound and those that are floating freely. A free PSA test only measures the amount of PSA that is floating freely in the bloodstream without being bound to a different protein.

Both tests are used to diagnose prostate issues. A person may have an increased risk of prostate cancer when they have higher levels of total PSA and lower levels of free PSA.

A free PSA test is typically given after a total PSA test to help doctors rule out cancer or to indicate how far cancer has progressed after treatment. The free PSA test is often used before a biopsy to provide initial confirmation of a doctor’s diagnosis.

There are some drawbacks to using PSA testing. There may be high rates of false positives, normal results do not rule out prostate cancer, and people may also have elevated levels of PSA without having cancer.

Monday, June 11, 2018

‘Millions’ Prescribed Wrong Dose of Common Drugs

According to updated calculations published this week, over 11 million people in the United States may have been given the wrong prescription for a range of commonly used drugs.

Scientists from the Stanford University School of Medicine in California recently investigated the reliability of so-called pooled cohort equations (PCEs). PCEs help doctors to determine each patient’s overall risk of stroke or heart attack. Assessing cardiovascular risk helps to inform the physician about the exact level of medication that will be both effective and safe. These equations are available as online web tools and smartphone apps, and they are even built into digital medical records.

In recent years, some have called into question the accuracy of PCEs, asking whether the data that they rely on are outdated. If this were found to be the case, patients could potentially be at risk of taking dangerously high or ineffectively low doses of drugs.

Dr. Sanjay Basu, Ph.D., an assistant professor of primary care outcomes research at Stanford published his findings this week in the journal Annals of Internal Medicine.

The first issue was updating the data used to derive the equations. Some of the datasets are relatively old. For instance, one included information from people who were aged 30-62 in 1948. Diet, lifestyle and health risks have changed since those days. The study authors say that, because of the age of this information, people’s risks were being estimated at around 20% higher than they truly were. Dr. Basu notes that “relying on our grandparents’ data to make our treatment choices is probably not the best idea.”

“Another issue the researchers identified was the lack of African-Americans in the datasets. It is now known that cardiovascular risk is significantly higher in the African-American population. So, while many Americans were being recommended aggressive treatments that they may not have needed according to current guidelines, some Americans – particularly African-Americans – may have been give false reassurance and probably need to start treatment given our findings.” – Dr. Sanjay Basu, Ph.D.

Friday, June 8, 2018

Is Chemo for Breast Cancer overprescribed?

According to a landmark study, a large percentage of individuals with the most common form of early breast cancer could safely skip chemotherapy. The findings could impact thousands of people each year.

While new therapies such as immunotherapies are becoming increasingly crucial in treating cancer, chemotherapy is still a mainstay. Though chemotherapy is effective, it carries with it a range of significant side effects, such as hair loss, increased risk of bleeding, susceptibility to infection, nausea, vomiting, and anemia. Consequently, chemotherapy is only used when deemed entirely necessary. The challenge lies in determining exactly when it is entirely necessary.

Individuals with breast cancer sometimes have their tumors analyzed using a gene test called the Oncotype DX test. This examines how active 21 specific genes are provides a “recurrence score” of 0-100. When scores are high, chemotherapy will be used following surgery or radiation therapy to lower the risk of the cancer returning. For individuals with low scores, the tumors are considered less dangerous, and chemotherapy is not deemed essential.

This type of testing has proven useful but there is a substantial gray area. As it stands, those who score 1-10 do not receive chemotherapy and those who score above 25 do. The majority of women, however, fall in the intermediate range of 11-25.

To get a better picture of who needs treatment, researchers from Loyola Medicine and Montefiore Medical Center undertook a large-scale investigation. Their findings are now published in the New England Journal of Medicine.

They used data from more than 10,000 women with hormone-receptor-positive, HER-2 negative breast cancer – the most common form of breast cancer, accounting for about half of breast cancer cases in the United States. Of particular interest were the 69% of women who had scored 11-25 on the 21-gene test.

Wednesday, June 6, 2018

Wisdom Wednesday: Plant Pigments May Preserve Lung Function into Old Age

New research finds that flavonoids – which are natural chemical compounds found in plants, such as fruits and vegetables – can help to slow the decline in lung function that tends to occur with age.
As the plants’ pigments, flavonoids are responsible for the vibrant colors of fruits and vegetables. They also attract pollinating insets and regulate cell growth. Research has suggested that dietary flavonoids may hold a lot of benefits for human health.

In vivo and in vitro studies have exposed flavonoids’ range of anti-inflammatory and antidiabetic properties, as well as their anticancer and neuroprotective benefits. New research adds to this list, suggesting that a certain type of flavonoid called “anthocyanins” can help to maintain healthy lung function well into old age.

The research was led by Vanessa Garcia-Larsen, Ph.D., who is an assistant professor in the Human Nutrition Division of the Department of International Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD. The findings were presented at the American Thoracic Society International Conference, held in San Diego, CA.

For this study, the researchers looked at data available from 463 adults from Norway and England – aged 44, on average – who took part in a spirometry test at the beginning of the study and at different follow-up times.

Spirometry is a pulmonary lung function test that measures the airflow and the volume of air that a person can exhale on command.

Additionally, the study participants had filled in a dietary questionnaire, so the researchers were able to divide the participants into quartiles, or fourths, based on their dietary intake of anthocyanins.
The research revealed that the highest quartile of anthocyanin consumers, when compared with the lowest, had a much slower rate of decline in all three aspects of lung function measured by the spirometry.

Monday, June 4, 2018

Pesticides May Cause Parkinson’s in Some People

New research reveals how the pesticides paraquat and maneb alter gene expression and may lead to Parkinson’s disease in people who are genetically predisposed to the illness.

Estimates show that around 50,000 people in the United States are diagnosed with Parkinson’s disease every year. Although it is not exactly known what causes the disease, both genetic and environmental factors are thought to play a critical role.

Senior study author Scott Ryan, a professor of molecular and cellular biology at the University of Guelph in Ontario, Canada explains the motivation behind the research. He notes, “People exposed to these chemicals are at about a 250% higher risk of developing Parkinson’s disease than the rest of the population.”

The findings were published in the journal Federation of American Societies for Experimental Biology.

The researchers used stem cells from patients with Parkinson’s disease who had a mutation in the gene responsible for encoding the a-synuclein protein. At least 30 alterations in this gene have been associated with Parkinson’s, and a-synuclein protein clumps are a well-documented, albeit poorly understood, hallmark of the disease. The scientists also worked with normal embryonic cells that they modified using genetic editing to replicate the a-synuclein genetic mutation.

Prof. Ryan explains why using human cells makes this study particularly valuable. “Until now,” he says, “the link between pesticides and Parkinson’s disease was based primarily on animal studies as well as epidemiological research that demonstrated an increased risk among farmers and others exposed to agricultural chemicals.” “We are one of the first to investigate what is happening inside human cells,” he explained.

It was found that the neurons that had been exposed to the chemical had faulty mitochondria. Mitochondria, the “powerhouses of the cell,” are the organelles inside a cell that turn sugar, fats, and proteins in to the energy our body needs to survive and function.

Friday, June 1, 2018

Shoulder Subluxation

Shoulder subluxation refers to a partial dislocation of the shoulder joint. This occurs when the ball of the upper arm bone, called the humerus, partly comes out of the glenoid socket in the shoulder.

The shoulder is the most mobile joint in the body. It contains several bones, ligaments, and muscles that work together to keep it stable. Because the shoulder is so mobile, it is very susceptible to dislocation. Shoulder subluxation is often the result of trauma, injury or a stroke that weakens the arm muscles.

Symptoms of a shoulder subluxation can include a visibly deformed or out-of-place shoulder, pain, swelling, numbness or tingling or trouble moving the joint. A person may be able to feel the ball of the humerus moving in and out of the shoulder socket. They may also notice a clicking or catching sensation especially when reaching overhead.

Treatment aims to reposition the humerus back into the socket and ensure that it stays in place. Treatment options include: 1. Closed reduction involves a doctor attempting to gently maneuver the bone back into position. When this is achieved, severe pain should improve almost immediately. 2. Surgery may be recommended when dislocations recur or when nerves, blood vessels, or ligament in the shoulder have been damaged. 3. A splint, brace, or sling for a few days or weeks to prevent the shoulder from moving. The length of time will depend on the extent of the dislocation. 4. A muscle relaxant and an anti-inflammatory agent, such as ibuprofen, for pain and swelling. 5. Rehabilitation following surgery or time spent in a sling.

When a person seeks medical attention promptly and receives a correct diagnosis, shoulder subluxation is treatable. When no surgery is recommended, several months may pass before a person call tell how well the treatment is working.

Monday, May 28, 2018

Ulnar Tunnel Syndrome

Ulnar tunnel syndrome occurs when the ulnar nerve in the wrist becomes compressed by a cyst or repeated strain. The nerve compression can cause numbness or tingling in the hands or fingers, burning pain, muscle weakness in the hand, difficulty gripping with the fingers and thumb, and fingers bending into a claw shape.

The ulnar nerve runs from the neck down to the hand. At the wrist, the lunar nerve enters the hand though Guyon’s canal. If the nerve becomes compressed here, it causes ulnar tunnel syndrome. Compression of this nerve at the elbow is called cubital tunnel syndrome. Ulnar tunnel syndrome is less common than cubital tunnel syndrome and carpal tunnel syndrome.

Development of a ganglion cyst in the wrist is a common cause of ulnar tunnel syndrome but anything which places pressure on the ulnar nerve in the wrist can be a cause. The risk of developing ulnar tunnel syndrome is greater if a person has had a previous injury to the wrist, performs repetitive tasks with the hands, does activities or sports that put the wrist under strain or uses vibrating tools.

Diagnosis is typically made by medical history and physical exam. However, a physician may also suggest imaging studies (x-ray, CT scan, and/or MRI), electromyography, and/or nerve conduction study.

Monday, May 21, 2018

Acute Ischemic Stroke and High-Risk TIA

Combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack (TIA). A trial of combination antiplatelet therapy in a Chinese population has shown a reduction in the risk of recurrent stroke. We tested this combination in an international population.

A total of 4881 patients were enrolled at 269 international sites. The trial was halted after 84% of the anticipated number of patients had been enrolled because the data and safety monitoring board had determined that the combination of clopidogrel and aspirin was associated with both a lower risk of major ischemic events and a higher risk of major hemorrhage than aspirin alone at 90 days. Major ischemic events occurred in 121 of 2432 patients receiving clopidogrel plus aspirin and in 160 of 2449 patients receiving aspirin plus a placebo, with most events occurring during the first week after the initial event. Major hemorrhage occurred in 23 patients receiving clopidogrel plus aspirin and 10 patients receiving aspirin plus placebo.

In summary, patients with minor ischemic stroke or high-risk TIA, those who received a combination of clopidogrel and aspirin had a lower risk of major ischemic events but a higher risk of major hemorrhage at 90 days than those who received aspirin alone.

My Take:
The accompanying editorial points out that most of the benefit of this combination therapy is during the first week following a minor stroke or TIA. Limiting the use of both drugs to three weeks was recommended.

The use of aspirin as secondary prevention (after an ischemic event) is well established as a medical standard. However, the common practice of taking an aspirin daily as primary prevention is not. Several studies have demonstrated that the side effects of daily aspirin, including major hemorrhage and death, exceed any benefit in preventing an initial event. Again, the odds favor the use of aspirin after a patient has suffered a heart attack, stroke, or TIA.

The Bottom Line:
If you are taking an aspirin daily, even a low-dose or “baby” aspirin for primary prevention, please review this practice with your primary care physician. It is not the standard of care. If you have had a vascular event and are taking a daily aspirin with another blood thinner (combination therapy), like this study, please review this practice with your health care provider. Although still an accepted practice, the long term risks involved outweigh the benefits.

Source: May 16, 2018 New England Journal of Medicine

Friday, May 18, 2018

Do Nightshade Vegetables Make Arthritis Worse?

Nightshade foods contain solanine, a chemical which some people believe may aggravate arthritis pain and inflammation. The Arthritis Foundation say that his is not true. However, if a person feels that certain foods trigger their arthritis symptoms, including nightshades, they should avoid these foods.

Nightshade vegetables are part of the plant family Solanaceae. Some species are toxic, including the belladonna plant, which is also called deadly nightshade. Other species are commonly cultivated and eaten by humans. Common nightshade vegetables include white potatoes, tomatoes, eggplant, bell peppers, cayenne pepper and paprika.

Solanine is found in trace amounts in potatoes and is normally safe, though the leafy stalks of the potato plant and green potatoes are toxic, and solanine poisoning has been reported from eating green potatoes.

A person may be allergic to one or more nightshade vegetables if they experience the following symptoms shortly after eating them: hives or a skin rash, shortness of breath, wheezing, coughing, tightness of the throat, pale skin, and anaphylaxis.

Nightshade vegetables are excellent sources of nutrition, and no research to date has linked them specifically to increased inflammation or other symptoms of arthritis. A person should speak with a dietitian if they are concerned about the effects of a particular food on their health.

My Take:
Nightshades are the fifth most common food allergy I find clinically. Only wheat, dairy, soy and corn test positive more often. They are a weird group of foods because the common link is the presence of solanine not their appearance or use in the diet.

Wednesday, May 16, 2018

Wisdom Wednesday: Fibromyalgia vs Rheumatoid Arthritis

Fibromyalgia and rheumatoid arthritis share some symptoms, such as pain and exhaustion. If a person has both conditions, the symptoms may be difficult to distinguish. However, fibromyalgia and rheumatoid arthritis (RA) are unrelated and have different causes.

Fibromyalgia usually causes pain, stiffness, and tenderness in muscles and connective tissues throughout the body. RA tends to cause pain, swelling, and tenderness in certain joints. Other shared symptoms include pain mirrored on both sides of the body, stiffness that is worse in the morning, chronic exhaustion, reduced mobility and range of motion in muscles and joints, depression and anxiety.

While the effects may be similar, these conditions have different causes. Fibromyalgia changes the way the brain and nervous system process and interpret pain. People with the condition tend to feel amplified pain when they experience everyday injuries, such as strains.

RA is an autoimmune condition. It causes the immune system to harm the synovial tissues, which line the joints. This leads to inflammation and pain. Over time, RA can cause permanent damage to the bones and connective tissues in the joints. Inflammation may also spread to the lungs, skin, and eyes.

The medical community currently does not believe that fibromyalgia causes inflammation. However, recent research indicates that fibromyalgia may induce a type of inflammation that is not detected by routine blood tests. No evidence suggests that this inflammation causes joint or muscle damage like RA, and there may be no visible signs.

Though the conditions are unrelated, having RA may increase a person’s likelihood of developing fibromyalgia. An estimated 20-30% of people with RA also have fibromyalgia. Researchers suggest that the chronic inflammation and pain associated with RA may make the nervous system hypersensitive over time, leading to fibromyalgia.

Monday, May 14, 2018

Melatonin for Migraine Headache Prophylaxis

Interest in using melatonin for headache disorders has been developing for decades. Over the years, several clues have emerged to suggest that melatonin plays a role in a variety of headache disorders, including migraine, cluster, and tension. In patients with migraine headaches, for instance, some research shows that melatonin levels are lower on days when migraines occur. Patients with chronic migraine also appear to have lower melatonin levels than those with episodic migraine. Nighttime melatonin levels are also lower in patients with migraine compared with those without.

Imaging studies provide additional evidence for melatonin’s role in migraine prevention. During migraine attacks, the hypothalamus is activated. Given the presence of melatonin receptors within the suprachiasmatic nucleus of the hypothalamus, it is conceivable that melatonin’s binding and action in the hypothalamus could play a role in these headaches.

Melatonin might also affect headaches through direct effects on pain and inflammation. Animal studies show that melatonin can reduce pain perception in models of inflammation and neuropathic pain, possibly by binding receptors in the spinal cord or through a variety of other pathways.

Clinical research evaluating melatonin in patients with migraine headaches has focused on migraine prophylaxis. Most studies have found beneficial effects from melatonin on headache frequency; however, some of these studies also have serious methodologic limitations. Several uncontrolled studies found that taking melatonin over a period of 2-6 months significantly reduced migraine headache frequency in both adults and children. In these studies, about 62-78% of patients had a greater than 50% reduction in migraine frequency at the end of the trial compared with at the beginning.

In all clinical trials, melatonin was well tolerated, with sleepiness being the most commonly reported side effect. Less common side effects included fatigue, dizziness, constipation, stomach upset, and dry mouth. In the placebo-controlled trials, side effects were comparable to those of placebo and less common compared with either amitriptyline of sodium valproate.

Friday, May 11, 2018

A ‘Metabolic Switch’ May Explain Why Fasting Boosts Gut Health

Fasting for 24 hours can reverse the loss of stem cell function in the gut that accompanies aging, according to a study of mice.
Intestinal stem cells are crucial for tissue repair and regeneration, and their decline as we age means that it becomes harder to recover from gastrointestinal conditions and infections.

The researchers, who were led by a team from Massachusetts Institute of Technology (MIT) in Boston, discovered that fasting for 24 hours boosted regeneration of gut stem cells in younger and older mice. They found that fasting exerted this effect by means of a metabolic switch that causes cells to break down fatty acids instead of carbohydrates such as glucose. They also discovered a molecule that can activate the same switch – a finding that might lead to drugs that boost older people’s recovery from gastrointestinal infections or chemotherapy.

Stem cells are immature cells that have remarkable properties. For instance, they can replicate almost indefinitely and develop into virtually any type of cell in the body, forming an essential source of new cells for growth and repair in many tissues. In the gut, they maintain and repair tissue lining, which ‘renews itself’ about every 5 days.

Now published in the journal Cell Stem Cell, co-senior author Omer H. Yilmaz – an assistant professor of biology at MIT – explains that diet is known to have a “profound effect” on the ability of tissue to regenerate itself. There is also evidence that intermittent fasting can benefit health and age-related decline in tissue function.

Wednesday, May 9, 2018

Wisdom Wednesday: These Common Drugs May Raise Your Risk of Dementia

A landmark study has linked the long-term use of certain anticholinergic drugs to a higher risk of dementia later on. This investigation is believed to be the “largest and most detailed” study to date into long-term anticholinergic use and dementia risk.

Anticholinergics work by blocking a chemical messenger, or neurotransmitter, called acetylcholine that carries brain signals for controlling muscles. They are used to treat a variety of conditions, from Parkinson’s disease and loss of bladder control to asthma, chronic obstructive pulmonary disease, and depression.

Anticholinergics for depression, such as amitriphtyline, dosulepin, and paroxetine, have previously been liked to higher risk of dementia, even when they were used up to 20 years beforehand. Some studies have also suggested that use of any anticholinergic is linked to raised risk of dementia.

But the new study – which was led by the University of East Anglia (UES) in the United Kingdom and is now published in The BMJ – discovered that long-term use of only certain types of anticholinergics is linked to higher dementia risk. It confirms the link to long-term use of anticholinergics for depression, and for Parkinson’s disease and loss of bladder control. However, the study found no link between increased dementia risk and other anticholinergic drugs, such as antihistamines and medications for abdominal cramps.

For their investigation, the researchers used data from the Clinical Practice Research Database, which contains anonymized records for more than 11 million people across the U.K. The researchers used a system called the Anticholinergic Cognitive Burden (ACB) scale to score the anticholinergic effect of the drugs that the patients had been prescribed. An ACB score of 1 meant that a drug was “possibly anticholinergic,” whereas a score of 2 or 3 meant that it was “definitely anticholinergic.” Altogether, they analyzed more than 27 million prescriptions.

Monday, May 7, 2018

Melatonin for Migraine Headache Prophylaxis

Interest in using melatonin for headache disorders has been developing for decades. Over the years, several clues have emerged to suggest that melatonin plays a role in a variety of headache disorders, including migraine, cluster, and tension. In patients with migraine headaches, for instance, some research shows that melatonin levels are lower on days when migraines occur. Patients with chronic migraine also appear to have lower melatonin levels than those with episodic migraine. Nighttime melatonin levels are also lower in patients with migraine compared with those without.

Imaging studies provide additional evidence for melatonin’s role in migraine prevention. During migraine attacks, the hypothalamus is activated. Given the presence of melatonin receptors within the suprachiasmatic nucleus of the hypothalamus, it is conceivable that melatonin’s binding and action in the hypothalamus could play a role in these headaches.

Melatonin might also affect headaches through direct effects on pain and inflammation. Animal studies show that melatonin can reduce pain perception in models of inflammation and neuropathic pain, possibly by binding receptors in the spinal cord or through a variety of other pathways.

Clinical research evaluating melatonin in patients with migraine headaches has focused on migraine prophylaxis. Most studies have found beneficial effects from melatonin on headache frequency; however, some of these studies also have serious methodologic limitations. Several uncontrolled studies found that taking melatonin over a period of 2-6 months significantly reduced migraine headache frequency in both adults and children. In these studies, about 62-78% of patients had a greater than 50% reduction in migraine frequency at the end of the trial compared with at the beginning.

In all clinical trials, melatonin was well tolerated, with sleepiness being the most commonly reported side effect. Less common side effects included fatigue, dizziness, constipation, stomach upset, and dry mouth. In the placebo-controlled trials, side effects were comparable to those of placebo and less common compared with either amitriptyline of sodium valproate.

Friday, May 4, 2018

Sheep Disease Toxin Shines a Light on MS

In a recent study, those with multiple sclerosis were found to be more likely to harbor antibodies for a disease toxin normal found in sheep.

Multiple sclerosis (MS) affects an estimated 2.3 million people worldwide. MS affects the central nervous system (CNS) and can cause a range of symptoms – often involving problems with movement, sensation, balance, and vision.

Symptoms generally appear when an individual is in their 20s or 30s. Some can be managed, and, in some cases the progression of the disease can be slowed. However, there is still no cure. MS in an autoimmune disease, in which the immune system attacks otherwise healthy tissue – in this case, the CNS. Why the immune system should turn on itself is still not understood. Despite decades of work, the exact cause of the disease is still shrouded in mystery, though both genetic and environmental factors are thought to be involved.

Recently, a group of researchers at the University of Exeter in the United Kingdom looked for clues about MS’s origins in a surprising place: sheep.

The first clues that sheep might provide some insight into MS came in 2013, when a team in the U.S. noticed that some people with MS had increased levels of antibodies to a toxin known as epsilon toxin (ETX). This toxin is produce by the bacterium Clostridium perfingens, found in the guts of livestock – most commonly in sheep.

ETX crosses the gut wall and builds up in the kidneys and brain. And, once in the brain, it destroys both the myelin that coats nerves and the cells that produce myelin. In sheep, this type of ETX poisoning is called enterotoxaemia, or pulpy kidney disease.

In MS, myelin and the cells that produce it are destroyed by the immune system. This striking similarity between enterotoxaemia and MS makes any potential relationship worth investigating further.

Wednesday, May 2, 2018

Wisdom Wednesday: Dietary Intake and Age at Natural Menopause

Age at natural menopause is a matter of concern for women of reproductive age as both an early or late menopause may have implications for health outcomes.

Study participants were women aged 40-65 years who had experienced a natural menopause from the UK Women’s Cohort Study between baseline and the first follow-up. Natural menopause was defined as the permanent cessation of menstrual periods for at least 12 consecutive months. A food frequency questionnaire was used to estimate diet at baseline. Reproductive history of participants was also recorded. Regression modeling, adjusting for confounders, was used to assess associations between diet and age at natural menopause.

During the 4-year follow-up period, 914 women experienced a natural menopause. A high intake of oily fish and fresh legumes were associated with delayed onset of natural menopause by 3.3 years per portion/day and 0.9 years per portion/day respectively. Refined pasta and rice was associated with earlier menopause. A higher intake of vitamin B6 and zinc was also associated with later age at menopause. Stratification by age at baseline led to attenuated results.

Our results suggest that some food groups and specific nutrients are individually predictive of age at natural menopause.

My Take:
This is the abstract minus some of the statistical analysis. Several studies had shown an association between early onset of menopause and lower bone density, osteoporosis, depression and premature death. Other studies indicate an increased risk of cardiovascular and coronary diseases. However, late menopause has been associated with a higher risk for breast, ovarian and endometrial cancers.

Obviously, there are many other factors affecting the onset of menopause – genetic, environmental, hormonal and general health issues to list a few. But the link between diet is intriguing.

Monday, April 30, 2018

Congestive Heart Failure

Congestive heart failure is a progressive disease that gets worse over time, especially if it remains untreated. It is often caused by other conditions that weaken the heart, such as heart attack, coronary heart disease, high blood pressure and inflammation or damage to the heart muscle.

A 2016 study estimated that about half of people who develop heart failure live beyond 5 years after being diagnosed. However, there is no simple answer for life expectancy rates, as the average life expectancy for each stage of CHF varies greatly. CHF is not curable, but early detection and treatment may help improve a person’s life expectancy. Following a treatment plan that includes lifestyle changes may help improve their quality of life.

When a person has CHF, their heart has difficulty pumping blood to the other organs in the body. This problem occurs because the walls of the ventricles, which typically pump the blood through the body, become too weak, causing the blood [to] stay in the ventricle, rather than pushing it out. Blood remaining in the heart can cause fluid retention because the heart is not pumping enough blood through the body to push out excess fluids.

CHF has four stages based on the severity of symptoms. Common symptoms include swelling in the legs and feet caused by a buildup of excess fluid, bloating, shortness of breath, fatigue, nausea and chest pain.

Medical treatment for CHF involves reducing the amount of fluid in the body to ease some of the strain on the heart and improving the heart’s ability to pump blood. Doctors may prescribe angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to help the heart pump blood more effectively. In some cases, doctors may also prescribe beta-blockers to support these efforts and control the heart rate. Doctors also commonly prescribe diuretics for people with CHF, as they may help the body eliminate excess liquid.

Friday, April 27, 2018

Sugar Cereals Not Just for Breakfast Anymore… Millennials Eat Them as a Snack

Cereal companies are rebranding their cereals as snack foods and bringing back more sugar-laden products because that’s what consumers like. Are Froot Loops and Lucky Charms a breakfast food or a snack? Younger Americans increasingly see highly sweetened cereals as the latter. And the cereal industry has taken notice.

Sales of cold cereal have declined 17% since 2009 – not such sweet news for manufacturers, even though the cereal market remains a $9 billion a year business.

Mintel reported that 43% of people in the United States say they eat cereal as a snack. That includes 56% of millennials, compared with 33% of baby boomers. Research showing the increased popularity of “on-the-go” cereal packages reinforces the trend toward snacking.

Out of the best-selling cereals in the United States, Cheerios, Raisin Bran, and perhaps Frosted Mini Wheats check the “healthy” box in some significant way. Raisin Bran and Frosted Mini Wheats are high in fiber but have added sugar. Cheerios is made of whole grains and has only one gram of sugar per serving. Others – Honey Nut Cheerios, Frosted Flakes, Honey Bunches of Oats, Cinnamon Toast Crunch, Froot Loops, and Lucky Charms – are heavily sweetened.

My Take:
The article goes on and on, trying to convince us that all of these products have varying degrees of health benefits. With or without the added sugar, it’s all refined carbohydrates that promote metabolic syndrome, diabetes and heart disease.

Monday, April 23, 2018

Nanoparticles in Food Packaging May Disrupt Gut Function

Zinc oxide nanoparticles are added to many different types of food packaging. A new study finds that these minute particles might disrupt the way our intestines absorb nutrients.

Nanoparticles are between 1 and 100 nanometers in diameter. To put that into perspective, a human hair is around 75,000 nanometers across, and a red blood cell is roughly 7,000 nanometers across.

Nanoparticles have a relatively large surface area, which makes them more chemically reactive. This increased reactivity gives them unique properties that are utilized by the manufacturers of a vast range of products, including paints, cosmetics, windows, sunscreens, fabrics, and cars.

As nanoparticles are used ever more liberally, some scientists are becoming increasingly concerned about their potential impact on human health. It is very easy for nanoparticles to enter our bodies. They are small enough to pass through cell membranes, potentially disrupting their activity. However, little is known about how they might interfere with biological processes.

Looking to investigate these interactions, researchers from Binghamton University in New York looked at zinc oxide (ZnO) nanoparticles in food packaging in particular. ZnO nanoparticles are included in the packaging of certain food items, such as corn, chicken, tuna, and asparagus, because they have antimicrobial properties. Also, when sulfur-producing foods come in contact with a tin can, it produces a black discoloration; ZnO prevents this reaction, keeping the food fresh-looking.

First, using mass spectrometry, they assessed how much ZnO could realistically be transferred from the packaging into the food. The food was found to contain “100 times the daily dietary allowance of zinc.”

Friday, April 20, 2018

Time to Ditch ACE Inhibitors for CVD?

There is “little, if any, clinical reason” to use angiotensin-converting enzyme (ACE) inhibitors for the treatment of hypertension or other cardiovascular indications because angiotensin receptor blockers (ARBs) are just as effective with fewer side effects, a new review concludes.

The review, published in the Journal of the American College of Cardiology on April 3, was led by Franz Messerli, MD, University Hospital, Bern Switzerland.

Messerli and colleagues reviewed data from 119 randomized clinical trials of ACE inhibitors and ARBs in more than half a million patients and found no difference in efficacy between the two drug classes with regard to the surrogate endpoint of blood pressure and the outcomes of all-cause mortality, cardiovascular mortality, myocardial infarction, heart failure, stroke, and end-stage renal disease. But ACE inhibitors have a higher incidence of adverse reaction – namely cough and very low risks of angioedema and fatalities – that are more prevalent in dark-skinned people, they write.

Despite this, most guidelines for the management of patients with cardiovascular disease recommend ACE inhibitors as first-choice therapy, whereas ARBs are merely considered an alternative for ACE inhibitor-intolerant patients, Messerli and colleagues point out.

My Take:
The rest of the article is rebuttal from various cardiologists on the pros and cons of using ARBs in lieu of ACE. The best quote – “And the side effect of angioedema, although rare, can be fatal, and if ACE inhibitors are proposed as part of the polypill then millions will be exposed and fatalities will occur.”

Wednesday, April 18, 2018

Wisdom Wednesday: Blood Test Detects Alzheimer’s Before Symptoms Appear

One of the major issues that hamper Alzheimer’s research is that the disease is always caught at a relatively late stage. This is because symptoms develop slowly over several years; they become obvious long after the condition has made changes in the brain.

The only reliable methods of diagnosis are positron emission tomography (PET) scan and cerebrospinal fluid (CSF) analysis collected by lumbar puncture.

One of the hallmarks of Alzheimer’s disease is an abnormal buildup of amyloid-beta plaques in the brain. Amyloid-beta is present in the healthy brain, but, in individuals with Alzheimer’s the protein is folded incorrectly and accumulates. Amyloid-beta plaque clusters can begin developing 15-20 years before symptoms of Alzheimer’s appear.

This unhealthy protein is the basis of a new blood test. In a study published in the journal EMBO Molecular Medicine, researchers led by Klaus Gerwert, describe their groundbreaking work.

The new blood test uses immune-infrared sensor technology. Based on an antibody, the sensor extracts all amyloid-beta from the blood sample. The two versions of amyloid-beta absorb infrared light at different frequencies allowing he researchers to measure the relative levels of healthy and unhealthy protein.

In the initial phase of the study individuals who showed subtle, early symptoms of Alzheimer’s, the test detected changes in levels of amyloid-beta that correlated with abnormal deposits visualized using brain scans.

In the next phase, they assessed blood samples from 65 individuals who later went on to develop Alzheimer’s and compared them with 809 individuals who did not develop the disease. On average, the blood test could detect Alzheimer’s in individuals 8 years before clinical symptoms became apparent.

Monday, April 16, 2018

The Bittersweet Truth

Taste receptor cells are not confined to the oral cavity. The gut and pancreas are inundated with taste receptor cells. Taste cells in the gut and pancreas do not convey the sensation of taste to the brain. Instead, they are responsible for sensing nutrients and maintaining the balance of hormones essential in metabolic processes. Activation of these receptors by their respective sweet or bitter substances triggers the release of hormones that regulate appetite and satiety and help maintain appropriate glucose levels in the blood stream. This observation has drawn a plausible link between dysfunction of taste receptor cells and the emergence of diseases such as obesity and diabetes.

Sweet taste receptors in the enteroendocrine cells (cells that secrete hormones) of the gut and pancreas are suggested to play an important role in nutrient sensing and sugar absorption, both processes necessary for energy and maintaining a normal metabolism. When sweet taste receptors sense sugars, they elicit the release of gut hormones. One such hormone, glucagon-like peptide 1 (GLP-1), is responsible for facilitating the absorption of glucose into the bloodstream, enhancing insulin secretion in the pancreas and regulating appetite. Disruptions in any of these physiological processes can result in the development of type II diabetes. In a study aiming at quantifying the levels of sweet taste receptors in the upper gut of healthy and diabetic individuals, researchers observed that the levels of sweet taste receptors were diminished in diabetic type II subjects with elevated blood glucose concentrations. This observation was consistent with previous results showing that type II diabetes patients secreted low levels of GLP-1 in response to a meal in comparison to healthy individuals.

Sweet taste receptors in the gut and pancreas also “taste” artificial sweeteners, also known as non-nutritive sweeteners (NNS). Several research groups found that exposure of mouse cells to sucralose, the sweetener in Splenda, caused the release of GLP-1.

Friday, April 13, 2018

Alzheimer’s: Scientists find the cause of evening agitation

A new study has uncovered a biological clock circuit that may explain why people with Alzheimer’s disease or other forms of dementia can become more agitated or aggressive in the early evening.

Sundowning is a condition that is typically seen in people with Alzheimer’s, when behavior becomes restless, agitated, and aggressive, accompanied by confusion. Its name is derived from the fact that it usually begins or gets worse in the late afternoon or early evening.

Biological clocks are specific groups of proteins that communicate with cells in nearly every organ and most tissue in the body. They respond to changes in light and dark in the environment and give rise to the circadian rhythms – that is physical, behavioral, and mental changes that “follow a daily cycle.”

Scientists have discovered that the genes that make and control the various components of biological clocks are largely similar in humans, mice, fruit flies, fungi and many other organisms. While biological clocks are found nearly everywhere in the body, they are all synchronized by a “master clock’ in the brain.

In humans, mice, and other vertebrates, the master clock is located in the suprachiasmatic nucleus, which is a cluster of neurons inside the hypothalamus region of the brain. The cluster contains around 20,000 cells and receives signals directly from the eyes.

For their study, Prof. Saper and his colleagues measured the frequency and intensity of interactions between male mice as “resident mice” defended their territory against “intruder mice” that were introduced into their cages at different times of the day. “The mice,” explains Prof. Saper, “were more likely to be aggressive in the early evening around lights out, and least aggressive in the early morning, around lights on.” “It looks like aggressiveness,” he continues, “build up in mice during the lights on period, and reaches a peak around the end of the light period.”

In another set of experiments, the researchers manipulated the mice’s master biological clock by tweaking genes in the neurons that regulate it. They found that when they stopped the master clock neurons from being able to make a specific chemical messenger, or neurotransmitter, the mice lost their circadian pattern of aggression. Aggressiveness remained high all the time, showing no highs and lows.

Wednesday, April 11, 2018

Wisdom Wednesday: Oral Vitamin B12 Versus Intramuscular Vitamin B12

Vitamin B12 deficiency is common, and the incidence increases with age. Most people with vitamin B12 deficiency are treated in primary care with intramuscular (IM) vitamin B12. Doctors may not be prescribing oral vitamin B12 formulations because they may be unaware of this option or have concerns regarding its effectiveness.

The goal of the review was to assess the effects of oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency.

The primary outcomes of data collection and analysis were serum vitamin B12 levels, clinical signs and symptoms of vitamin B12 deficiency, and adverse events. Secondary outcomes were health-related quality of life, acceptability to patients, hemoglobin and mean corpuscular volume, total homocysteine and serum methylmaloic acid levels.

Only three RCTs met our inclusion criteria. The trials randomized 153 participants (74 participants to oral vitamin B12 and 79 participants to IM vitamin B12). Treatment duration and follow-up ranged between three and four months. The mean age of participants ranged from 38.6 to 72 years. The treatment frequency and daily dose of vitamin B12 in the oral and IM groups varied among trials. The overall quality of evidence for this outcome was low due to serious imprecision (low number of trials and participants). In two trials employing 1000 ug/day oral vitamin B12, there was no clinically relevant difference in vitamin B12 levels when compared with IM vitamin B12. Orally taken vitamin B12 showed lower treatment associated costs than IM vitamin B12.

Low quality evidence shows oral and IM vitamin B12 having similar effects in terms of normalizing serum vitamin B12 levels. Further trials should conduct better randomization and blinding procedures, recruit more participants, and provide adequate reporting.