Friday, August 31, 2018

Daily Aspirin Unwise for Most

Taking a low-dose aspirin every day has long been known to cut the chances of another heart attack, stroke or other heart problem in people who already have had one, but the risks don’t outweigh the benefits for most other folks, major new research finds.

The research was discussed Sunday at the European Society of Cardiology meeting in Munich.

A Boston-led study gave aspirin or dummy pills to 12,546 people who were thought to have a moderate risk of suffering a heart attack or stroke within a decade because of other health issues.

After five years, 4% of each group had suffered a heart problem. One percent of aspirin takers had stomach or intestinal bleeding, mostly mild – twice as many as those on dummy pills. Aspirin users also had more nosebleeds, indigestion, reflux or belly pain. Bayer sponsored the study, and many researchers consult for the aspirin maker. Results were published by the journal Lancet.

Oxford researchers randomly assigned 15,480 adults with Type 1 or 2 diabetes but otherwise in good health and with no history of heart problems to take aspirin, 1 gram of fish oil, both substances, or dummy pills daily. After 7.5 years, there were fewer heart problems among aspirin users but more cases of serious bleeding, so they largely traded one risk for another.

The same study also tested omega-3 fatty acids, good oils found in salmon, tuna and other fish. Supplement takers fared no better than those given dummy capsules: 9% of each group suffered a heart problem. “We feel very confident that there doesn’t seem to be a role for fish oil supplements for preventing heart disease,” said University of Oxford’s Dr. Louise Bowman, study leader.

Wednesday, August 29, 2018

Wisdom Wednesday: Pesticide Linked to Autism


Autism is a complex neurodevelopmental disorder with a largely unknown etiology. To date, few studies have investigated prenatal exposure to toxins and risk of autism by using maternal biomarkers of exposure. Persistent organic pollutants are lipophilic halogenated organic compounds and include the insecticide dichlorodiphenyltrichloroethane (DDT), as well as its metabolite p,p′-dichlorodiphenyl dichloroethylene (p,p′-DDE), and polychlorinated biphenyls (PCBs). The objective of this study was to test whether elevated maternal levels of persistent organic pollutants are associated with autism among offspring.

The investigation was derived from the Finnish Prenatal Study of Autism, a national birth cohort study based on a nested case-control design. Cases of autism among children born between 1987 and 2005 were ascertained by national registry linkages. In cases of childhood autism and matched control subjects (778 matched case-control pairs), maternal serum specimens from early pregnancy were assayed for levels of p,p′-DDE and total levels of PCBs.

The odds of autism among offspring were significantly increased with maternal p,p′-DDE levels that were in the highest 75th percentile, with adjustment for maternal age, parity, and history of psychiatric disorders (odds ratio=1.32, 95% CI=1.02, 1.71). The odds of autism with intellectual disability were increased by greater than twofold with maternal p,p′-DDE levels above this threshold (odds ratio=2.21, 95% CI=1.32, 3.69). There was no association between total levels of maternal PCBs and autism.

These findings provide the first biomarker-based evidence that maternal exposure to insecticides is associated with autism among offspring. Although further research is necessary to replicate this finding, this study has implications for the prevention of autism and may provide a better understanding of its pathogenesis.

My Take:
Although DDT was banned in the United States in 1972, it still remains in our environment, along with all its’ metabolites. It is still used in many parts of the world and limited uses in the US continue under “public health exception, for emergency agricultural use.” This continued use is not well publicized.

The half-life for DDT is 2-15 years with 97% of it degraded after 5 half-lives. It stores in the fatty tissues of our bodies and has been linked with Alzheimer’s disease, MS and other chronic degenerative conditions.

Clinically, I find reflex testing for both DDT and Round Up quite often. Both of these toxic chemicals are in all of us. It appears that DDT predominates in my older patients while Round Up shows up in younger patients. The real question is do these toxins need to be removed from the body? More and more, the answer is yes, although it often is not the first priority.

Bottom Line:
Autism is multifactorial but I strongly suspect that environmental toxins are a major factor in the dramatic increase in the rate of autism worldwide.

Monday, August 27, 2018

It’s All About the Bass

Music is almost universal. Every society on earth has music blended into its culture, and music, inevitably, brings dance.
But why are we so driven to move out limbs, heads, and bodies to rhythmic sounds? A facet of music that often goes hand in hand with dancing is the heavy use of bass. Be it the beat of a drum or the pulsing sound from a subwoofer, the bass is often a driving factor in our desire to move in time with the music.

A new study set out to investigate music and the brain, and although it does not fully answer the questions above, it does give new insight into music and the human experience. The results were published this week in the journal PNAS.

The scientists – from Western Sydney University’s MARCS Institute in Australia – were particularly interested in the way that our brains process low-frequency sounds. The scientists played each participant rhythmic patterns, in either a high- or low-pitched tone, and recorded the electrical activity of the person’s brain using electroencephalography (EEG). They found that brain activity became synchronized with the frequency of the beat.

In the current study, however, they found that bass-heavy music was more successful at locking the brain into the rhythm. The lower frequencies, it seems, strong-arm the brain into synchronizing. The lower frequencies, as the authors write, boost “selective neural locking to the beat.”

The authors theorize that the synchronizing effect that bass has on the brain could be due to “a greater recruitment of brain structures involved in movement planning and control,” such as the cerebellum and basal ganglia.

Friday, August 24, 2018

A2 Milk: Breakthrough of Science or Marketing?

Shoppers in the United States are about to encounter something new in the dairy aisle. A2 milk, a substitute for conventional milk successfully launched in New Zealand two decades ago, is hoping the win over American consumers with an expansive pitch of health claims.

Advocates of A2 mild don’t just see it as the next almond or soy milk. Instead, they’re positioning it as an alternative to one of Western society’s foundational food sources, which they believe has had an outsized role in causing maladies ranging from simple indigestion to cardiovascular disease, autism, and schizophrenia.

These claims have been met in equal measure by critics who have identified A2 milk as something more conventional – a hype-driven product building a profitable foundation on limited science.

Beta-casein is the major source of protein in mild. Around 8000 year ago however, the characteristics of beta-casein began to change, with a lone mutation occurring at one of the 209 amino acids in its genetic profile. Breeding practices and random acts of history made A1-production cows the norm in Europe and, subsequently, the majority of the Western world.

The difference is potentially important because digesting A1, but not A2, beta-casein can cause the release of the opioid beta-casomorphin (BCM-7) in the small intestine. BCM-7 has been linked to impaired gastrointestinal function, such as decreased intestinal contractions and suppressed lymphocyte proliferation.

Many studies on the risks of A1 milk are from animal study data and causal associations showing higher rates of chronic disease in countries primarily reliant on A1 milk. Researchers have used both to establish a link between A1 milk consumption and an elevated risk for gastrointestinal impairment, type 1 diabetes, coronary heart disease, and perhaps further afield, autism and schizophrenia.

Many of these studies have been knocked for being funded by the A2 Milk Company, the main producer of this product. In a turnaround befitting the tit-for-tat nature of this debate, the author of a 2006 critical review that found “no convincing or even probable evidence” of A1’s harmful effects in humans was later found to have been a consultant for a New Zealand dairy company producing A1 milk.

Wednesday, August 22, 2018

Wisdom Wednesday: Homocysteine

A homocysteine test measures the amount of homocysteine in your blood. Homocysteine is a type of amino acid, a chemical your body uses to make proteins. Normally, vitamin B12, vitamin B6 and folic acid break down homocysteine and change it into other substances your body needs. There should be very little homocysteine left in the bloodstream. If you have high levels of homocysteine in your blood, it may be a sign of a vitamin deficiency, heart disease, or a rare inherited disorder.

If your health care provider thinks a vitamin deficiency is the reason for your high homocysteine levels, he of she may recommend dietary changes to address the problem. Eating a balanced diet should ensure you get the right amount of vitamins.

If your health care provider thinks your homocysteine levels put you at risk for heart disease, he or she will monitor your condition and may order more tests.

My Take:
Another “dummied down” press release from NIH. Again, the information is fairly accurate, although misleading. I write about homocysteine frequently. Please review my blog “Cardiovascular Disease: Risk Assessment with Nontraditional Risk Factors” posted on July 13, 2018. This will familiarize you with the cardiac risks associated with homocysteine.

Homocysteine is an intermediate metabolite in the sulfur amino acid pathway. We consume sulfur attached to amino acids, most commonly in cruciferous vegetables like broccoli, cauliflower, arugula, and kale. Methionine (a sulfur bearing amino acid) is converted to SAM-e, a popular nutritional supplement used to calm the brain. SAM-e is then converted to homocysteine.

Monday, August 20, 2018

After Doctors Cut Their Opioids, Patients Turn to a Risky Treatment for Back Pain

An injectable drug that the manufacturer says is too dangerous to use along the spine is growing in popularity for back pain as doctors turn away from opioids.

The anti-inflammatory drug, called Depo-Medrol and made by Pfizer, is approved for the injection into muscles and joints. Once a drug is approved, however, doctors may legally prescribe it however they see fit.

What few doctors or patients know is that Pfizer, faced with hundreds of complaints about injuries and complications related to the shots, asked the Food and Drug Administration to ban that type of treatment five years ago. The company cited the risk of blindness, stroke, paralysis and death – a request that neither the agency nor Pfizer made public.

The FDA declined to issue a ban but toughened the label warning. Other countries – among them Australia, Brazil, Canada, France, Italy, New Zealand and Switzerland – heeded Pfizer’s request.

After concerns were raised about the off-label treatments, use of the injections declined. But the opioid epidemic appears to be spurring their popularity despite risks known to public health officials and doctors.

According the FDA, back problems are the most common cause of disabling, chronic pain. Weekend classes to train physicians in the procedure are flourishing. Critics like Dr. Terri A. Lewis, a rehabilitation specialist and lecturer at the Southern Illinois University, say they are responsible for transforming pain clinics into “drill mills.”

And in June, as part of legislation to tackle the opioid crisis, the House of Representatives approved an increase in Medicare reimbursement for the procedure.

Friday, August 17, 2018

ORIVO Certification

ORIVO provides laboratory services for testing the authenticity of marine ingredients, both oil and meal. The testing technology, initially developed by the Norwegian research organization SINTEF, is based on proven species and region of origin via quality assured sampling protocols. Based in Molde, Norway, ORIVO serves the global markets independent third party verification to meet the consumer demand for non-adulterated and sustainable marine ingredients.

Biotics Research Corporation is the first supplement brand in the United States to provide certification of authenticity to their fish oil products, verified by ORIVO through an independent third-party authenticity test. They use an anchovy source from the cold waters of the South Pacific Ocean off the South American coast.

Customers now can be certain they are getting the highest quality omega-3s available. The certification also shows the fish oil is coming from sustainable sources.

My Take:
SINFEF developed this technology in response to concerns about the quality of omega-3 fatty acids products, most of which come from Norway. In the past, most supplement companies depended on the wholesale manufacturers to provide good quality fish oil.

Reputable supplement companies, like Carlson and Metagenics, would pay the manufacturer to remove any mercury from the raw material. That is how their labels claimed that their products were “mercury free”. Brands that offered low cost fish oil, like Costco, didn’t pay for mercury removal and made no such claims.

However, in 2004, 74 supplement companies were indicted by a judge in California for mercury contamination in products that claimed to be mercury free. The common source was a Norwegian manufacturer who was charging for mercury removal but skipping the high density molecular extraction process needed to remove the mercury.

Wednesday, August 15, 2018

Wisdom 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.