Monday, December 31, 2018

2018 In Review

Traditionally, I use the last post of the year to review Bill’s Blog. I posted 143 blogs this past year bringing my total to 835 since fall of 2013. I’ve also started doing an occasional podcast with Kristen Bomas. There are currently only two that you can view on You tube – one on breast cancer and the other on medical marijuana.

The most common topic last year was various health conditions. This accounts for 20% of my blogs. I wrote about advances in MS, Parkinson’s disease and frequently about various aspect of metabolic syndrome. Much of the information was on environmental factors associated with these chronic diseases. Low grade viral infections and pervasive pesticides have both been implicated in a third of all autoimmune disease.

Tied for second at 17% were three topics – health care standards, supplementation and diet. The last two subjects have been popular topics of my blog since conception in 2013. Medical standards of care didn’t even make the top 10 last year. There is a dichotomy developing in health care. A large percentage of physicians stick by old standards of care that have been dropped and refuse to adopt the new evidence based research standards. The ongoing recommendation of aspirin for primary prevention of cardiovascular events is a prime example. Ongoing resistance against testing A1c to diagnosis diabetes is another.

In fifth place at 13% were blogs about various drugs. Recent research reveals less than 12% of Americans are considered healthy. By definition, that means free from all aspects of metabolic syndrome without taking any prescription drugs. The average U.S. adult takes four prescription drugs daily, one less than the definition of polypharmacy (taking 5 or more medications daily). To manage polypharmacy, a physician needs specialized training in drug interactions that few physicians have.

Environment was sixth accounting of 8% of last year’s blogs. Mounting pollution, global warming and easing of environmental protections in the United States were frequent topics. Here in South Florida the rising sea level during periods of high tides and the obvious death of our coral reefs are daily reminders for me as a member of the boating community.

Exercise came in seventh with only 2% of my blogs. Part of the reason I conduct this review is to make improvements the following year. In 2014, I increased my blog from one to three times a week. The next year, I added Wisdom Wednesday to focus aspects of daily practice. Two years ago, I shifted my emphasis toward more positive aspects of health as I felt I too often reported on negative aspects of health care. Next year, I promise to write more blogs about exercise.

Bottom Line:
I hope you enjoy reading my blogs as much as I enjoy writing them. My techie, Jarrod tells me that blogs are passĂ© – podcasts are the new thing. We’ll see how that develops. If you would to watch any of my podcasts, Kristen has invited me to be a returning guest on “Thursday at 12:45” every six weeks. Just go to “You Tube” and type in Kristen Bomas to view. Regardless, I will continue to write my blog as it keeps me abreast of the current research.

Friday, December 28, 2018

HDL: The "Good" Cholesterol

Cholesterol is a waxy, fat-like substance that's found in all the cells in your body. Your liver makes cholesterol, and it is also in some foods, such as meat and dairy products. Your body needs some cholesterol to work properly. But having too much cholesterol in your blood raises your risk of coronary artery disease.

There are two main types of cholesterol: HDL (good) cholesterol and LDL (bad) cholesterol:
HDL stands for high-density lipoproteins. It is called the "good" cholesterol because it carries cholesterol from other parts of your body back to your liver. Your liver then removes the cholesterol from your body. LDL stands for low-density lipoproteins. It is called the "bad" cholesterol because a high LDL level leads to a buildup of cholesterol in your arteries.

A blood test can measure your cholesterol levels, including HDL. When and how often you should get this test depends on your age, risk factors, and family history. With HDL cholesterol, higher numbers are better, because a high HDL level can lower your risk for coronary artery disease and stroke. How high your HDL should be depends on your age and sex:

Group Healthy HDL Level
Age 19 or younger More than 45mg/dl
Men age 20 or older More than 40mg/dl
Women age 20 or older More than 50mg/dl

If your HDL level is too low, lifestyle changes may help. These changes may also help prevent other diseases, and make you feel better overall: Eat a healthy diet, stay at a healthy weight, exercise, avoid cigarettes, and limit alcohol.

Some cholesterol medicines, including certain statins, can raise your HDL level, in addition to lowering your LDL level. Health care providers don't usually prescribe medicines only to raise HDL. But if you have a low HDL and high LDL level, you might need medicine.

Monday, December 24, 2018

Thyroid Autoimmune Disease

Diagnosing and treating thyroid conditions in women is extremely important, concluded a group of practitioners in a recent round-table discussion, Thyroid Immune Testing – “Guidelines, Testing Platforms, and Clinical Impact on Women’s Health” and published in the Journal of Women’s Health.

The goal of the Expert Panel Discussion was to collect information from experts in the field so that clinicians could better identify the early signs and symptoms of autoimmune thyroid disease and to understand the role that thyroid-stimulating hormone (TSH) receptor antibodies, such as thyroid-stimulating immunoglobulins (TSI) and thyroid-blocking immunoglobulins (TBI), play in the disease states of Graves’ disease and autoimmune thyroid disease (AITD or Hashimoto’s thyroiditis), respectively.

Helena Rodbard, MD, a practicing endocrinologist, Past-President of the American College of Endocrinology, and Past President of the American Association of Clinical Endocrinologists served as moderator of the Roundtable.

The American Thyroid Association (ATA) has recently recommended thyroid antibody
testing. Dr. Rodbard emphasized that understanding the early signs and symptoms of hypo- and hyperthyroidism are so important for practitioners treating women, because the prevalence of these diseases is so much higher in women. Often, the early symptoms may be overlapping. She also opens the discussion with topics such as treating women who are pregnant and have Graves’ disease, the role of thyroid dysfunction and fertility, when to encourage physicians to look for clustering of other autoimmune diseases such as type 1 diabetes or rheumatoid arthritis, and how thyroid function test measurement is affected by women who use biotin.

Friday, December 21, 2018

Overuse of Cardiac Testing

Cardiovascular disease is the leading cause of death worldwide. More than 25% of individuals who experience acute myocardial infarction have no previous symptoms, making risk stratification essential to help target appropriate preventive interventions. Risk stratification should be performed using a clinical assessment of risk factors and exercise tolerance, as well as a validated risk tool. Inappropriate use of diagnostic tests to screen for cardiac disease in asymptomatic patients may lead to further testing and invasive procedures that are costly and potentially harmful, and have no clear benefits compared with clinical history and evaluation alone.

Routine screening of asymptomatic patients with ECG has a very low yield in detecting significant pathology and leads to many false-positive findings. Performing ECG as part of a health maintenance examination does not lower the risk of future cardiovascular events or cardiac death. The U.S. Preventive Services Task Force (USPSTF) recommends against screening with ECG to predict CAD in low-risk patients and found insufficient evidence to assess the benefits and harms of screening in individuals at intermediate or high risk.

Stress ECG (exercise stress tests), stress echocardiography, and myocardial perfusion imaging are commonly used to evaluate patients for CAD. However, it is unclear if these tests add any prognostic benefit beyond a careful evaluation of underlying cardiovascular risk factors in patients without cardiac symptoms. Inappropriate cardiac stress tests, particularly when done with imaging, are estimated to cost the U.S. health care system as much as half a billion dollars each year and expose many patients to unnecessary radiation.

It is important to understand that stress testing detects only significant coronary stenosis and does not identify nonobstructing plaques, which are a common cause of myocardial infarctions. In fact, because many patients who present with an acute myocardial infarction have no prior obstructive CAD, normal results on a stress test might be falsely reassuring. On the other hand, in a patient with a low pretest probability of CAD, a positive stress test is likely to be a false positive.

Many persons with a false-positive result on stress testing undergo subsequent testing and interventions such as cardiac catheterization and revascularization. Up to 3% of persons who get stress tests undergo cardiac catheterization, and 1.7% of catheterizations lead to severe adverse reactions, mostly in persons without CAD. Screening for CAD with stress tests has not been shown to affect clinical outcomes or further inform the use of risk-reducing therapies beyond a good clinical assessment.

Wednesday, December 19, 2018

Wisdom Wednesday: Tension Headaches

Tension-type headache is very common, with a lifetime prevalence in the general population ranging in different studies between 30% and 78%. It has a high socio-economic impact.
While it was previously considered to be primarily psychogenic, a number of studies since ICHD-I strongly suggest a neurobiological basis.

The division of 2. Tension-type headache into episodic and chronic types, introduced in ICHD-I, has proved extremely useful. In ICHD-II, the episodic type was further divided into an infrequent type, with headache episodes less than once per month, and a frequent type. 2.2 Frequent episodic tension-type headache can be associated with considerable disability, and sometimes warrants treatment with expensive drugs. In contrast, 2.1 Infrequent episodic tension-type headache, which occurs in almost the entire population, usually has very little impact on the individual and, in most instances, requires no attention from the medical profession. The distinction of 2.1 Infrequent episodic tension-type headache from 2.2 Frequent episodic tension-type headache thus separates individuals who typically do not require medical management, and avoids categorizing almost the entire population as having a significant headache disorder, yet allows their headaches to be classified. 2.3 Chronic tension-type headache is a serious disease, causing greatly decreased quality of life and high disability.

The exact mechanisms of 2. Tension-type headache are not known. Peripheral pain mechanisms are most likely to play a role in 2.1 Infrequent episodic tension-type headache and 2.2 Frequent episodic tension-type headache, whereas central pain mechanisms play a more important role in 2.3 Chronic tension-type headache. Increased pericranial tenderness is the most significant abnormal finding in patients with any type of 2. Tension-type headache: it is typically present interracially, is exacerbated during actual headache and increases with the intensity and frequency of headaches. Increased tenderness is very probably of pathophysiological importance. ICHD-II therefore distinguished patients with and without such disorder of the pericranial muscles, a subdivision maintained in ICHD-3 to stimulate further research in this area.

Tuesday, December 18, 2018

Parkinson’s: Dietary compound moves toxic protein from gut to brain

A recent study in rats reveals that a now-banned herbicide and a common food-derived chemical can work together to produce symptoms similar to those present in Parkinson’s disease.

Parkinson’s disease is a neurodegenerative condition. Brain cells in the substantia nigra – a region vital for motor control – slowly break down. The most common Parkinson’s symptoms are rigidity and tremor. The condition is most common in older adults. To date, there is no cure and no way to prevent the disease from progressing.

A protein called alpha-synuclein plays a pivotal role in Parkinson’s; it clumps together to form part of larger structures called Lewy bodies. These appear to kill the brain cells. A potential risk factor that has sparked debate is exposure to an herbicide called paraquat. Once widely used, the United States banned it in 2007.

Experiments have demonstrated that administering paraquat can cause Parkinson’s-like symptoms, or Parkinsonism, in rodents. However, the levels of pesticide the scientists used in those experiments are way above what a human would ever experience.

Recently, researchers at Penn State College of Medicine wanted to understand exactly how paraquat could travel from the stomach to impart protein buildup in the brain. They have now published their results in the journal NPJ Parkinson’s Disease.

To investigate, the researchers fed rats small doses of paraquat for 7 days. They also fed them lectins, which are sugar-binding proteins present in foods such as raw vegetables, eggs, and grains.

Friday, December 14, 2018

What causes a lateral collateral ligament sprain?

A lateral collateral ligament sprain occurs when the ligament on the outer side of the knee tears. This type of sprain is most common in people who play contact sports, such as football.

While knee injuries represent up to 39 percent of all injuries in athletes, lateral ligament injuries are less common. Many lateral collateral ligament (LCL) injuries occur alongside other knee damage.

The LCL connects the thigh bone to the smaller calf bone. It controls the sideways movement of the knee, and, alongside the medial collateral ligament on the inner knee, it contributes to knee stability. An LCL sprain usually occurs when the knee pushes out beyond the usual range of motion. This overstretches and tears the ligament.

The most obvious symptom is pain, which may be mild or severe, on the outer side of the knee. People sometimes hear a snapping or tearing sound when the injury occurs. Other symptoms include: bruising to the skin, general weakness in the knee joint and a feeling that it may give way, numbness in the knee, which may occur due to damage to nerves, stiffness, swelling along the outside of the knee, tenderness around the ligament, especially if with pressure, the sensation that the knee is locking during movement

The severity of symptoms depends on the seriousness of the sprain. Doctors categorize LCL sprains as:

Grade 1: The ligament overstretches but does not tear. It can result in mild pain or swelling. A grade 1 sprain does not usually affect joint stability.

Grade 2: The knee ligament partially tears. Symptoms can include moderate pain, swelling, knee instability, and difficulty using the joint. The skin around the LCL ligament may bruise.

Grade 3: This involves a complete ligament tear. Symptoms include swelling, significant bruising, joint instability, and difficulty putting weight on the leg. A grade 3 sprain increases the risk of injury to other parts of the knee and leg.

Wednesday, December 12, 2018

Wisdom Wednesday: Migraine Headaches (Part 1)

Migraine is a common disabling primary headache disorder. Many epidemiological studies have documented its high prevalence and socio-economic and personal impacts. In the Global Burden of Disease Study2010 (GBD2010), it was ranked as the third most prevalent disorder in the world. In GBD2015, it was ranked third–highest cause of disability worldwide in both males and females under the age of 50 years.

Migraine has two major types: Migraine without aura is a clinical syndrome characterized by headache with specific features and associated symptoms. Migraine with aura is primarily characterized by the transient focal neurological symptoms that usually precede or sometimes accompany the headache.

This week we will focus on migraine without aura. Previously, called a common migraine, it is a recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or sensitivity to light and sound.

Diagnosis requires a history of at least 5 attacks, lasting 4-72 hours with a least two of the following: unilateral location, pulsating quality, moderate or severe pain, or aggravation by routine physical activity. During the headaches the patient must exhibit nausea and/or vomiting or light and sound sensitivity.

Migraine headache in children and adolescents (aged under 18 years) is more often bilateral than is the case in adults; unilateral pain usually emerges in late adolescence or early adult life. Migraine without aura often has a menstrual relationship. Very frequent migraine attacks are now distinguished as a Chronic migraine. When there is associated medication overuse, both diagnoses, Chronic migraine and Medication-overuse headache, should be applied. Migraine without aura is the disease most prone to accelerate with frequent use of symptomatic medication.

Monday, December 10, 2018

A Sunny Workout is Best

Want to get fit? Check your vitamin D levels. Cardiorespiratory fitness (CRF) may well be linked to serum vitamin D levels. A study, published in the European Journal of Preventive Cardiology (October 2018), looked at data from nearly 2,000 participants in the National Health and Nutrition Survey. Subjects were between the ages of 20 and 49.

Researchers used VO2 max as an indicator of cardiorespiratory fitness. Used to establish the aerobic endurance of an athlete, VO2 max is the amount of oxygen a person can utilize during intense exercise. By putting a face mask on the subject, the volume and gas concentrations of inspired and expired air can be directly measured.

Of the 1995 participants, 45.2% were women, 49.1% were white, 13% were hypertensive and 4% had diabetes. Vitamin D levels did not vary between matched subjects with confounding variables like diabetes, high blood pressure, age, sex, race, CRP levels, BMI, etc. The one variable that did make a difference between matched subjects was serum vitamin D levels. The researchers found that serum vitamin D levels had a significant effect on cardiorespiratory fitness (VO2 max). Those in the highest quadrille had a VO2 max 2.9 higher on average than those in the lowest quadrille.

According to the authors, “We found a strong independent association between vitamin D levels and CRF, which was robust to potential confounding variables. Future studies are needed to explore the underlying biological mechanisms of the observed association. Clinical trials of vitamin D supplementation are required to validate the relationship.” 

Vitamin D levels have been associated with other cardiovascular issues. Low levels are linked to a higher risk of hypertension, poor outcomes for congestive heart failure patients and overall cardiac mortality. Now we can add cardiorespiratory fitness to that list. Because CRP status may be an indicator of cardiovascular risk, the American Heart Association has recommended that CRP be measured in routine clinical practice.

Friday, December 7, 2018

Higher Risk Thresholds May Be Needed for Starting Statins for Primary CVD Prevention, Study Suggests

The guideline-recommended risk thresholds for initiating statins for primary prevention of cardiovascular disease may be too low, a modeling study in the Annals of Internal Medicine suggests.

Researchers performed a network meta-analysis of studies comparing four low- or moderate-dose statins with no statins in patients aged 40 to 75 with no CVD history. They balanced statins' potential benefit of CVD event prevention with potential harms, like myopathy, hepatic or renal dysfunction, cataracts, hemorrhagic stroke, type 2 diabetes, and cancer.

Most current guidelines recommend statin initiation when a person's 10-year CVD risk is 7.5%–10%. In this study, the benefits only began to outweigh the risks when CVD risk was 14% for men aged 40 to 49. For men 70 to 75 years, the threshold was 21%. For women, thresholds ranged from 17% to 22%.

The authors conclude: "Our results suggest that guidelines should use higher 10-year risk thresholds when recommending statins for primary prevention of CVD and should consider different recommendations based on sex, age group, and statin type."

Of note, guidelines released last month by the American College of Cardiology and American Heart Association consider a 10-year risk score of 7.5%–19.9% to denote "intermediate risk."

Wednesday, December 5, 2018

Wisdom Wednesday: U.S. Life Expectancy Down, Overdose and Suicide Rates Up

U.S. life expectancy at birth has declined for the second year in a row, from 78.7 years in 2015 to 78.6 years in 2016, according to the latest CDC data.

Notable increases were observed in drug overdose deaths and suicides. The overdose rate nearly doubled from 2006 to 2016, hitting 19.8 deaths per 100,000. Meanwhile, suicide rates rose steadily among adults aged 25–44 years, reaching 16.9 deaths per 100,000 — higher than the heart disease death rate. Among those aged 15–24 years, suicide became the second leading cause of death in 2016, and among children aged 1–14 years, the rate reached 0.8 per 100,000.

CDC Director Dr. Robert Redfield said in a statement, "These sobering statistics are a wakeup call that we are losing too many Americans, too early and too often, to conditions that are preventable. ... we must all work together to reverse this trend and help ensure that all Americans live longer and healthier lives."

My Take:
In 2016, the top 10 leading causes of death were heart disease, cancer, unintentional injuries, chronic lower respiratory diseases, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide. Metabolic syndrome, a preventable condition is a direct cause in half of the top causes of death.

Monday, December 3, 2018

Strength Training Bests Aerobics for Cardioprotection

Static exercise, such as strength training, might be superior to dynamic exercise, such as walking or cycling, for conferring protection against cardiovascular disease (CVD), new research suggests.

Using data for the 2005/06 National Health and Nutrition Examination Survey (NHANES), Maia P. Smith, PhD, assistant professor, Department of Public Health and Preventive Medicine, St. George’s University, West Indies, found that 36% of adults 21 to 44 years of age and 25% of adults older than 45 years engaged in static activity, compared with 28% and 21%, respectively, of adults engaging in dynamic activity.

Although both activities were associated with 30% to 70% lower rates of CVD risk factors, the associations were strongest in the static activity group. “In over 4000 American adults from a representative sample, I found that static activity – strength training – appeared more cardioprotective than dynamic activity – in this case walking and biking,” Smith told Medscape Cardiology.

“The odds of having a given risk factor – hypertension, overweight/obesity, diabetes, or high cholesterol – were between one-third and two-thirds lower for those who engaged in static activity that for those who engaged in no activity, but although dynamic activity wasn’t as good as static, it still had some benefits, especially for [those who were] overweight,” she said.

Commenting on the study, Richard C. Becker, MD, professor of medicine, University of Cincinnati College of Medicine, noted that the Physical Activity Guidelines for Americans, highlight moderate-intensity aerobic activity of at least 150 minutes per week and muscle-strengthening activity 2 days per week.