Wednesday, January 31, 2018

Wisdom Wednesday: Laboratory Trends

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

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

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

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

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

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

Monday, January 29, 2018

Flu Vaccine: Nasal Drops May Succeed Where Shots Have Failed

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

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

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

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

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

Friday, January 26, 2018

Fish Oil Associated with Hemorrhage and Reduced Stroke-Related Sickness

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

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

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

Wednesday, January 24, 2018

Wisdom Wednesday: Epstein-Barr Virus (EBV)

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

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

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

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

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

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

Monday, January 22, 2018

What Makes This Flu Season So Bad?

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

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

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

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

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

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

Friday, January 19, 2018

Diclegis May Not Ease Morning Sickness

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

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

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

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

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

Wednesday, January 17, 2018

Wisdom Wednesday: Complementary and Alternative Medicine

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

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

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

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

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

Monday, January 15, 2018

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

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

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

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

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

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

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

Friday, January 12, 2018

170 Million Americans Drink Radioactive Tap Water

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

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

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

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

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

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

Wednesday, January 10, 2018

Wisdom Wednesday: Diagnosis

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

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

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

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

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

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

Monday, January 8, 2018

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

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

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

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

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

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

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

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

Friday, January 5, 2018

Seniors Don’t Need Calcium, Vitamin D Supplements

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

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

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

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

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

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

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

Wednesday, January 3, 2018

2017 Blog Summary

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

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

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

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

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

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