Monday, April 15, 2019

How to Understand Your Lab Results

A laboratory (lab) test is a procedure in which a health care provider takes a sample of your blood, urine, other bodily fluid, or body tissue to get information about your health. Some lab tests are used to help diagnose, screen, or monitor a specific disease or condition. Other tests provide more general information about your organs and body systems. Lab tests play an important role in your health care. But they don't provide a complete picture of your health. Your provider will likely include a physical exam, health history, and other tests and procedures to help guide diagnosis and treatment decisions.

Lab tests are used in many different ways. Your health care provider may order one or more lab tests to:
Diagnose or rule out a specific disease or condition

Screen - A screening test can show if you are at a higher risk for getting a specific disease. It can also find out if you have a disease, even if you have no symptoms.

Monitor a disease and/or treatment - If you've already been diagnosed with a disease, lab tests can show if your condition is getting better or worse. It can also show if your treatment is working.
Check your overall health - Lab tests are often included in a routine checkup.

Lab results are often shown as a set of numbers known as a reference range. A reference range may also be called "normal values." You may see something like this on your results: "normal: 77-99mg/dL". Reference ranges are based on the normal test results of a large group of healthy people. The range helps show what a typical normal result looks like. But not everyone is typical. Sometimes, healthy people get results outside the reference range, while people with health problems can have results in the normal range. If your results fall outside the reference range, or if you have symptoms despite a normal result, you will likely need more testing. Your lab results may also include one of these terms:
  • Negative or normal, which means the disease or substance being tested was not found
  • Positive or abnormal, which means the disease or substance was found
  • Inconclusive or uncertain, which means there wasn't enough information in the results to diagnose or rule out a disease. If you get an inconclusive result, you will probably get more tests. Tests that measure various organs and systems often give results as reference ranges, while tests that diagnose or rule out diseases often use the terms listed above.

Wednesday, April 10, 2019

Wisdom Wednesday: Metformin for Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis


Clinical Question
How effective is metformin in the treatment of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis?

Evidence-based Answer
Metformin does not seem to be an effective treatment for nonalcoholic steatohepatitis. There are no studies evaluating whether metformin improves long-term patient-oriented outcomes such as progression from NAFLD to nonalcoholic steatohepatitis, cirrhosis, hepatocellular carcinoma, or death from liver failure. Metformin does not improve anatomic outcomes (histologic or ultrasound features of the liver) or biochemical outcomes (alanine transaminase [ALT] and aspartate transaminase [AST] levels, or insulin resistance) in adults. Metformin does not improve liver histologic or biochemical outcomes, or body mass index (BMI) in adults with nonalcoholic steatohepatitis. (Strength of Recommendation: C, based on a meta-analysis of randomized, controlled trials [RCTs] evaluating laboratory parameters.) Similarly, metformin does not improve histologic or biochemical outcomes, or BMI in children and adolescents with NAFLD. (Strength of Recommendation: C, based on RCTs evaluating laboratory parameters.)

Evidence Summary
Adults With NAFLD
No studies have evaluated patient-oriented outcomes of metformin therapy for NAFLD or nonalcoholic steatohepatitis. An RCT found no improvement in liver histology on biopsy.[1,2] Two placebo-controlled RCTs (N = 113) evaluating the effect of metformin (850 to 1,700 mg per day) on ALT and AST levels, insulin resistance, and BMI found no differences. One RCT (n = 48) found a small decrease in BMI. Another RCT (n = 2,153) found no improvement in ALT levels after treatment with metformin (850 mg twice per day) vs. placebo.[2]

Adults With Nonalcoholic Steatohepatitis
Two RCTs (N = 52) evaluating metformin (500 to 1,000 mg per day) in patients with nonalcoholic steatohepatitis found that it did not improve liver histology, ALT and AST levels, BMI, or insulin resistance.[1,3]

Children With NAFLD
Two RCTs (N = 172) evaluating metformin (1,000 to 1,500 mg per day) vs. placebo in children with obesity and NAFLD found no improvement in liver histology on biopsy, ALT and AST levels, BMI, or insulin resistance.[4,5] A smaller RCT (n = 50; mean age: 15 years) found that metformin (850 mg twice per day) improved ultrasound scores for fatty liver but did not improve ALT and AST levels.[6]

Recommendations From Others
An evidence-based guideline from the American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the American Gastroenterological Association states that metformin has no significant effect on liver histology and is not recommended as a treatment for liver disease in adults with nonalcoholic steatohepatitis.[7]

Monday, April 8, 2019

How Sugary Drinks Fuel Cancer

Researchers acknowledge that obesity increases the risk of cancer, and some studies even consider the existence of a causal relationship between this metabolic condition and cancer.

One important factor that can lead to obesity is the high intake of sugar through the frequent consumption of processed foods and sugary beverages. However, so far, there has been limited research looking at the effects of sugar on tumor growth independently of obesity.
Now, a team of specialists from Baylor College of Medicine in Houston, TX and Weill Cornell Medicine in New York City, NY has collaborated with colleagues from other research institutions to identify a clear link between sugary drinks and the accelerated growth of tumors in colorectal cancer.

In the new study, the results of which appeared yesterday in the journal Science, the research team studied the effects of high-fructose corn syrup in mouse models of colorectal cancer.

The team opted for a solution of 25-percent high-fructose corn syrup because this is the type of sweetener that manufacturers most commonly used as an ingredient in popular soft drinks.

"The current thought is that sugar is harmful to our health mainly because consuming too much can lead to obesity," explains co-author Jihye Yun, who is an assistant professor of molecular and human genetics at Baylor College of Medicine. "We know that obesity increases the risk of many types of cancer, including colorectal cancer; however, we were uncertain whether a direct and causal link existed between sugar consumption and cancer."

The team conducted the research in mice with early-stage colorectal cancer in which they deleted a gene called "Apc." This gene encodes a protein with the same name, and its deletion simulated a mutation that characterizes fast-growing colon cancer in humans. "More than 90 percent of colorectal cancer patients have this type of Apc mutation," the researcher points out.

In the first stage of the study, the researchers allowed the mice to drink the sugary beverage freely. As a result, the rodents put on a lot of weight within just 1 month.

To determine whether or not the corn syrup would boost cancer growth independently of obesity, the team then decided to administer the sugary drink in a way that would allow the mice to ingest it without putting on weight. So, the researchers gave the mice the sugary drink orally through a specially designed syringe once a day for 2 months.

Following this 2-month intervention, the investigators observed that the rodents had not put on too much weight, but they had indeed developed larger, more advanced tumors than the rodents who had only received water.

Wednesday, April 3, 2019

Wisdom Wednesday: Continuing ARB Recalls Shake Up Hypertension, HF Care


Concerns over ongoing recalls of angiotensin II receptor blockers (ARBs) are forcing physicians and patients to choose between optimal treatments and rattling confidence in the safety of the generic drug supply itself.

"I see hypertension on a regular basis and on any given clinic day, four to five patients have either stopped their medicines or have considered stopping their medicines and a separate detailed conversation has to be put in place to try to convince them to continue," Keith Ferdinand, MD, Tulane University Heart and Vascular Institute, New Orleans, told theheart.org | Medscape Cardiology.

ARBs are recommended for the treatment of hypertension, heart failure, and chronic kidney disease, with more than 61 million prescriptions written for valsartan, losartan, and irbesartin in the United States in 2016, according to the federal ClinCalc DrugStats database.

Ongoing US Food and Drug Administration (FDA) recalls — all in generic ARB-containing products — began last July when the probable carcinogen N-nitrosodimethylamine (NDMA) was detected in the valsartan active pharmaceutical ingredient (API) supplied by Zhejiang Huahai Pharmaceuticals (ZHP), Linhai, China.

Within months, the rolling recalls had extended to irbesartan- and losartan-containing products. A second probable carcinogen, N-nitrosodiethylamine (NDEA), was identified last fall and a third, N-nitroso-N-methyl-4-aminobutyric acid (NMBA), only last month.

Monday, April 1, 2019

When to Consume Protein

We all need protein as part of a balanced diet and to stay healthy. Some people consume protein for specific reasons, such as to help them lose weight or gain muscle mass. However, it is not yet clear when the best time is to have that protein. There is some evidence that consuming protein can help a person lose weight, and there is clear evidence that it can help people build muscle mass if they also exercise. However, research, as yet, does not make it unclear when is the best time to have protein. It is also unclear if there is any best time at all, why this is the case, or whether it is the case for everyone.

Most people in the United States get enough protein in their diet. Still, the United States Department of Agriculture (USDA) say many people should vary the types of food containing protein that they eat. If a person is trying to build muscle mass, they may also take protein in the form of supplements to help them build muscle tissue after exercise.

There is some evidence that eating protein can help a person lose weight. Evidence suggests protein does this in part by increasing satiety. Satiety is the feeling of being full. Currently, there is little solid evidence regarding when the best time to eat protein might be to encourage weight loss. For example, researchers published a study in the journal Advances in Nutrition suggesting that eating snacks that contain protein may reduce the number of calories a person consumes at their next meal. However, the research paper also points out that studies demonstrating this are scarce and sometimes conflicting. They suggest more studies are needed to confirm their findings.

Wednesday, March 27, 2019

Wisdom Wednesday: The 'London Patient' New HIV Remission Raises Hope


A London man has not had detectable HIV in his system for 18 months, despite not having received treatment during that period. The remission came after the patient underwent a stem cell transplant. This makes him the second man in history — after the Berlin patient — to have achieved HIV remission after such a transplant. And that has raised questions about whether he might be cured of HIV.

"The Berlin patient was not an anomaly," Ravindra Gupta, MD, from University College London, and his team write in their report published online today in Nature. But it is unlikely that this will lead to widespread stem cell transplants for people infected with HIV, said Gupta It is only "a small step in the right direction," he told Medscape Medical News. "But with enough small steps, we can get where we need to be."

As well as HIV, both Berlin patient Timothy Brown and the new patient — referred to as the London patient — had acute cancers that called for a stem cell transplant, a painful and invasive treatment used after other treatments have failed. For Brown, it was leukemia. For the London patient, it was stage 4 Hodgins’s lymphoma, a non-AIDS-related cancer more common among people with HIV. Both patients also had stem cell donors with two genetic mutations that remove the CCR5 receptor from the surface of the CD4 T-cell. Without that receptor, most HIV strains can't gain access to the cell and can't spread, and — bingo — that's the end of HIV.

Monday, March 25, 2019

Lifestyle Changes Do a Number on PSA Values

Simple, temporary lifestyle changes may be able to spare men with mildly increased prostate-specific antigen (PSA) levels from having to endure a prostate biopsy, results of a controlled study suggest.

Men who avoided eating spicy foods, drinking alcohol or coffee, and riding a bicycle had a repeat PSA reading approximately 1.5 ng/mL lower than their first reading a median of 8 weeks earlier.

Nearly half of men who adopted the lifestyle changes had a drop-in PSA below the minimum threshold for biopsy, reported Alexandre Zlotta, MD, director of Uro-Oncology at Mount Sinai Hospital and professor of surgery (urology) at the University of Toronto, Ontario, Canada.
In an interview with Medscape Medical News here at the European Association of Urology (EAU) 2019 Congress, Zlotta said that spicy food has something in common with alcohol, caffeine, and biking. "Spicy food induces inflammation, and inflammation directly translates into increase in PSA," he said.

Zlotta explained that repeat biopsy decisions are not based on a single PSA but that the new intervention might be a good idea before a repeat PSA test.

Friday, March 22, 2019

US adults do not consume enough protein, study warns

New research in the Journal of Nutrition, Health & Aging reveals that older people in the United States do not consume enough protein. Insufficient protein is a marker of poor diet and health overall, the study also suggests.

With age, the human body loses muscle mass. Sarcopenia, or the age-related gradual loss of muscle function, can slash muscle strength by around 50 percent. Also, loss of muscle mass and strength can lead to poor overall quality of life and increase the risk of falls and fractures in older age. So, as we age, intake of protein becomes increasingly important. However, few adults consume as much protein as they should, for a variety of reasons.

Older people often lose their appetite with age, have lower energy needs, or sometimes eat less due to financial and social difficulties. However, researchers do not know precisely how much protein older adults consume, so a new study aimed to fill this gap in research. Christopher A. Taylor, Ph.D. — a registered dietitian and associate professor at the Ohio State
University in Columbus — is the last and corresponding author of the new study.

Taylor and his team examined data from the 2005–2014 National Health and Nutrition Examination Survey to investigate the protein intake of 11,680 adults aged 51 and above. The scientists looked at the link between protein intake, dietary patterns, and physical function in these older adults. They stratified the study sample, used the Healthy Eating Index to assess the quality of the adults' diet, and weighted the data analyses "to create a nationally representative sample."

Wednesday, March 20, 2019

Wisdom Wednesday: Omega-3s and NLRP3 Inflammasom Signaling in Human Obesity


In a recent study in the Journal of Endocrinology, the relationship between fish oil derived long chain polyunsaturated fatty acids (n-3 PUFA) and the suppression of NLRP3 inflammasomes in human obesity through downregulation of inflammasome gene expression in adipocytes and macrophages was investigated. The NRLP3 inflammasome serves as a critical link between adipose inflammation and insulin resistance. This placebo-controlled clinical trial lasted 8 weeks, using 4 grams of EPA/DHA or placebo.

Results showed that “treatment of obese human subjects with fish oil supplements reduced expression of adipose inflammatory genes including inflammasome-associated IL-18 and IL-
1β and circulating IL-18 levels. Both EPA and DHA reduced inflammasome gene expression in obese human adipose and human adipocyte and macrophages.”

This study highlights the importance of N-3 PUFAs in reducing NLRP3 inflammasome in human adipose tissue, and its relevance in helping support healthy inflammatory pathways as they related to obesity.

My Take:
This all sounds pretty technical, but basically fish oil reduces the inflammatory compounds that are produced in fat cells of the human body. These inflammatory compounds are linked to insulin resistance and ultimately diabetes.

Monday, March 18, 2019

Tramadol Linked to Higher Mortality Risk in Osteoarthritis

New tramadol use among patients with osteoarthritis is associated with increased mortality risk, an observational study in JAMA suggests. Some guidelines recommend tramadol, a weak opioid agonist, to manage osteoarthritis pain.

Using U.K electronic medical records, researchers matched patients with hip, knee, or hand osteoarthritis who began taking tramadol to those who began naproxen, diclofenac, celecoxib, etoricoxib (not approved in U.S.), or codeine. Nearly 90,000 patients aged 50 and older were included.

Patients who started using tramadol had a higher mortality rate over the ensuing year than users of every other medication except codeine. For example, the mortality rate was 23.5 per 1000 person-years with tramadol versus 13.8 per 1000 with naproxen.
The authors caution that the findings "were susceptible to confounding by indication," given that tramadol users had greater comorbidity than NSAID users before propensity score matching.

My Take:
Some guidelines are recommending Tramadol as a replacement for Oxycodone in light of the skyrocketing death rate associated with its’ use. Tramadol is used in opioid agonist therapy (OAT), a treatment used to help addicts overcome opioid addiction. While it is an effective pain killer, it has addiction and overuse issues as well.

Friday, March 15, 2019

Napping may be as good as drugs for lowering blood pressure

A midday nap may be just what you need, not just to boost your energy levels but also to lower high blood pressure. This, at least, is what new research from Greece suggests.

A new study that investigators from the Asklepieion General Hospital in Voula, Greece conducted now suggests that taking a nap at midday can effectively help people lower their blood pressure levels.

In this study, the investigators worked with 212 participants who had a mean blood pressure of 129.9 mm Hg. The participants were, on average, 62 years old, and close to one in four of them smoked, had a diagnosis of type II diabetes, or both.

The team split the participants into two groups — one that practiced midday napping and one that did not take up this practice. Over 24 consecutive hours, the researchers took note of the participants' blood pressure measurements, the duration of their midday naps, their general lifestyle choices (such as alcohol consumption and physical activity), and their pulse wave velocity, which measures artery stiffness.

Wednesday, March 13, 2019

Wisdom Wednesday: Alzheimer's: 'Holy herb' extracts shows promise as future treatment


Yerba santa, a plant with a long history of medicinal use in its native California, contains an active compound that could treat people with Alzheimer's disease one day. This was the conclusion that scientists at the Salk Institute for Biological Studies in La Jolla, CA came to after testing 400 plant extracts with known medicinal properties. Using a new drug-discovery screen, they tested the compounds for their ability to deter the effects of aging on the brain. The initial round of tests yielded several extracts that protected against a type of cell death that occurs in Alzheimer's and other aging-related diseases. Further tests revealed that sterubin, an extract of Eriodictyon californicum, or Yerba santa, was the most able to shield against inflammation and other triggers of brain cell death.

Native tribes of California have long valued Yerba santa, which is the Spanish for "holy herb," very highly as a medicine for respiratory illnesses, fever, infections, bruising, pain, and headaches.

According to a 2018 Alzheimer's Disease International report, dementia affects 50 million people worldwide, two-thirds of whom have Alzheimer's disease. In the U.S., the number of people living with Alzheimer's disease is set to rise from approximately 5.7 million people today to nearly 14 million by 2050.

Monday, March 11, 2019

Vitamin D and Brain Health

New research finds that vitamin D deficiency affects a type of brain "scaffolding" that supports the neurons. This finding could lead to new therapies for the neurological symptoms of mental health conditions such as schizophrenia.

Vitamin D, which people sometimes refer to as the "sunshine vitamin," is necessary for maintaining healthy bones. It also benefits the immune and cardiovascular systems, as well as endocrine function. For instance, research has suggested that insufficient vitamin D may compromise the immune system, raise the risk of hypertension, and negatively affect insulin secretion in people with type 2 diabetes.

Newer studies have focused on the potential link between vitamin D and brain health. For example, a recent study that Medical News Today reported on reinforced the notion that there may be an association between vitamin D deficiency and a higher risk of schizophrenia.

Other studies have shown that depriving middle-aged rodents of vitamin D led them to develop brain damage and perform less well on cognitive tests. Researchers have also found that people who survive sudden cardiac arrest are less likely to recover brain function if they have low levels of vitamin D.

Friday, March 8, 2019

Blueberries May Reduce Cardiovascular Risk By 20 Percent

The phytochemicals that give blueberries their blue color can significantly improve cardiovascular health, finds a new two part study. Dubbed "the silent killer" because it has no visible symptoms in its early stages, hypertension affects approximately 1 in 3 adults in the United States.

The condition puts a strain on the cardiovascular system, which in the long run may contribute to heart failure, stroke, and kidney failure. The National Institutes of Health (NIH) recommend that people with high blood pressure stay in control of the condition by eating healthfully, exercising, not smoking, and maintaining a healthy weight.

But should you eat anything in particular to keep your arteries healthy? In a previous Spotlight feature, we rounded up 16 foods that studies have suggested can improve cardiovascular health. Along with broccoli, spinach, pulses, and fish, berries may also reduce heart disease, due to their antioxidant polyphenols.

New research zooms in on the cardiovascular effects of blueberries and finds that anthocyanins — the phytochemicals that give blueberries their color — mediate the beneficial effects that this fruit has on the cardiovascular system. The lead author of the study is Ana Rodriguez Mateos, Ph.D., from the Department of Nutritional Sciences at King's College London, in the United Kingdom. The researchers published their findings in The Journals of Gerontology: Series A.

Wednesday, March 6, 2019

Wisdom Wednesday: DEXA


The dual-energy X-ray absorptiometry (DEXA) scan uses two low-energy X-ray beams that separates the images into two components, including soft tissue and bone. When determining whether a person has low bone density or whether the condition is getting worse, a DEXA scan tends to be more accurate than a typical X-ray because it can detect even small changes in bone loss. Doctors also consider it more reliable than other methods of calculating body fat percentage, including underwater weighing. Scan results may indicate the severity of bone loss and help doctors determine a person's risk of developing a fracture. When assessing body composition, the results may also help determine a person's level of visceral fat, which the body stores around certain internal organs.

The most common purpose of a DEXA scan is to assess whether a person's bones are weak and or at risk of fracture. It also helps a doctor diagnose osteoporosis. Osteoporosis causes the bones to lose density or become thin. When the bones get thin, they also become fragile, which makes them more susceptible to breaks. Determining whether a person has osteoporosis as early as possible is important to prevent the condition from becoming worse. It also reduces the risk of fractures. A DEXA scan is also a useful diagnostic tool to assess whether or not osteoporosis is getting worse. After the first DEXA scan, a doctor will usually order another scan in a couple of years to determine whether the bone density has changed.

Monday, March 4, 2019

Large Trials Cast Doubt on Low-Dose Aspirin's Benefits

Hello. I'm David Kerr, professor of cancer medicine at the University of Oxford. As many of you know—those who listen to my small rants on Medscape from time to time—I have been conducting a long-distance love affair with aspirin for some time in terms of its cancer-preventive properties.

I have to say that this love affair has been strained somewhat by the recent publication of two important pieces. One was published in the Lancet, written by Peter Rothwell and colleagues, and the other is a report of a combined Australian-US trial in the New England Journal of Medicine.

First, let's discuss Peter's study. Dr. Rothwell and his colleagues suggest that there is not a single dose of aspirin, a one-size fits-all dose, in terms of its cancer- or cardiovascular-preventive properties. They analyzed an enormous dataset from a large series of randomized trials, databases he has been successfully working on for some time. They investigated the benefits and disadvantages of aspirin according to height and weight, predominately weight. They found that the benefits of low-dose aspirin, 75-100 mg daily, in terms of cardiovascular prevention, were relatively confined to those who weigh less than 70 kg.

In the analyzed studies, the vast majority of men, 80% of whom were 70 kg or more, had no obvious benefits from aspirin at all. That's interesting. What was, for me, more worrisome was when they started to look at the disadvantages. They found that subjects taking low-dose aspirin who were under 70 kg had real possibility of harm—an increased incidence of early cancer. This is particularly pronounced in those patients who are more than 70 years old. They concluded that we should further explore the dose of aspirin. The clinical pharmacology of aspirin has been studied since the late 1960s. There is a relationship between pharmacokinetics, steady-state plasma concentrations, weight, and age. As we grow older, liver function deteriorates, and therefore we clear drugs less effectively. This could potentially underlie what is happening. We need more mechanistic work to understand this better.

Friday, March 1, 2019

Interval Training May Be Best for Weight Loss

Interval training may result in greater weight loss than continuous exercise, with sprint interval training (SIT) the most effective, say researchers, who say interval training also may be easier for obese and older individuals to perform.

The findings of Ricardo Borges Viana, MSc, a PhD student in the Faculty of Physical Education and Dance, Federal University of Goiás, Brazil, and colleagues were published online February 14 in the British Journal of Sports Medicine. Senior author Paulo Gentil, PhD, of the same institution, told Medscape Medical News that interval training "seems to promote many physiological changes that might favor long-term weight loss.

The team conducted a systematic review and meta-analysis and compared weight loss with interval training, including both high-intensity interval training (HIIT) and SIT with moderate-intensity continuous training (MOD).

After pooling results from over 1000 individuals, they found both interval training and MOD led to significant reductions in both total body fat percentage and total absolute fat mass.
However, interval training was associated with a reduction in total absolute fat mass that was more than 28% greater than that seen with MOD, with the greatest reductions seen with SIT.
Despite the positive results, the team cautions that "it is important to be aware of the possible risks and caveats associated with higher-intensity training."

For example, they warn that "it might increase the risk of injury and impose higher cardiovascular stress," and the potential discomfort associated with high-intensity training could affect adherence. They also highlight that the "methodological diversity" between protocols used in the studies "makes it difficult to generally recommend that one particular protocol is 'best' for modulating body adiposity."

Wednesday, February 27, 2019

Wisdom Wednesday: Fecal Immunochemical Tests


Performance Characteristics of Fecal Immunochemical Tests for Colorectal Cancer and Advanced Adenomatous Polyps: A Systematic Review and Meta-analysis

Purpose:
To summarize performance characteristics of FITs for CRC and advanced adenomas in average-risk persons undergoing screening colonoscopy (reference standard) and to identify factors affecting these characteristics.

Data Sources:
Ovid MEDLINE, PubMed, Embase, and the Cochrane Library from inception through October 2018; reference lists of studies and reviews.

Study Selection:
Two reviewers independently screened records to identify published English-language prospective or retrospective observational studies that evaluated FIT sensitivity and specificity for colonoscopic findings in asymptomatic, average-risk adults.

Data Extraction:
Two authors independently extracted data and evaluated study quality.

Data Synthesis:
Thirty-one studies (120 255 participants; 18 FITs) were included; all were judged to have low to moderate risk of bias. Performance characteristics depended on the threshold for a positive result. A threshold of 10 µg/g resulted in sensitivity of 0.91 (95% CI, 0.84 to 0.95) and a negative likelihood ratio of 0.10 (CI, 0.06 to 0.19) for CRC, whereas a threshold of greater than 20 µg/g resulted in specificity of 0.95 (CI, 0.94 to 0.96) and a positive likelihood ratio of 15.49 (CI, 9.82 to 22.39). For advanced adenomas, sensitivity was 0.40 (CI, 0.33 to 0.47) and the negative likelihood ratio was 0.67 (CI, 0.57 to 0.78) at 10 µg/g, and specificity was 0.95 (CI, 0.94 to 0.96) and the positive likelihood ratio was 5.86 (CI, 3.77 to 8.97) at greater than 20 µg/g. Studies had low to high heterogeneity, depending on the threshold. Although several FITs had adequate performance, sensitivity and specificity for CRC for 1 qualitative FIT were 0.90 and 0.91, respectively, at its single threshold of 10 µg/g; positive and negative likelihood ratios were 10.13 and 0.11, respectively. Comparison of 3 FITs at 3 thresholds was inconclusive: CIs overlapped, and the comparisons were across rather than within studies.

Limitations:
Only English-language studies were included. Incomplete reporting limited quality assessment of some evidence. Performance characteristics are for 1-time rather than serial testing.

Conclusion:
Single-application FITs have moderate to high sensitivity and specificity for CRC, depending on the positivity threshold. Sensitivity of 1-time testing for advanced adenomas is low, regardless of the threshold.

Primary Funding Source:
Department of Medicine, Indiana University School of Medicine.

My Take:
This is an abstract taken directly from the Annals of Internal Medicine, February 26, 2019. Typically I “dummy it down” a little, but I thought you might find the original abstract interesting. It’s a retrospective study using two independent authors as noted above. Please note how they not only present the data, but also the limitations prior to any conclusions. Finally, they also list the funding. In this case, it appears to be independent of bias.

Bottom Line:
Cologuard is the most popular trade name for this home test. It is available by prescription only but is covered by most insurance. Despite the limitation in testing for advanced adenomas, it is quite accurate in testing for colorectal cancer. I highly recommend you ask your primary care provider to add this test to your annual physical.

Monday, February 25, 2019

Colorectal Cancer: Scientists halt growth with cannabinoid compounds

Scientists have identified several cannabinoid compounds that could potentially treat colorectal cancer. A team at Pennsylvania State University College of Medicine in Hershey tested hundreds of cannabinoids on various types of human colorectal cancer cells in the laboratory. Of these, 10 synthetic cannabinoids showed the ability to stop cancer cell growth. The well-known cannabis compounds tetrahydrocannabinol (THC) and cannabidiol (CBD) showed negligible ability to do the same.

The researchers see their findings as a starting point for further studies to better understand the anticancer effects that they observed, and to evaluate the compounds' potential for drug development. They report their results in a paper that features in the journal Cannabis and Cannabinoid Research. "Now that we've identified the compounds that we think have this activity," says senior study author Prof. Kent E. Vrana, who is chair of the Department of Pharmacology, "we can take these compounds and start trying to alter them to make them more potent against cancer cells." "And then, eventually, we can explore the potential for using these compounds to develop drugs for treating cancer," he adds.

According to the World Cancer Research Fund, colorectal cancer is the "third most common cancer worldwide." This is also the case in the United States, where a national surveillance program has estimated that colorectal cancer accounted for 8.1 percent of all new cancer incidences in 2018.

For several decades, overall rates of colorectal cancer diagnoses and deaths have been falling steadily in the U.S. Experts attribute this largely to changes in risk factors, more widespread screening, and better treatments. However, this overall decline masks an opposite trend in that rates and deaths to colorectal cancer are rising among those of 50 years of age and under. The reasons for this remain unclear, although some suggest that obesity, changes in diet, and an increase in sedentary lifestyles may be involved.

Friday, February 22, 2019

Researchers Discover Almost 2,000 New Gut Bacteria

According to numerous recent studies, human gut bacterial populations are capable of influencing various aspects of our physical and mental health. Despite this, many bacteria remain "unmapped" by scientists. A new study has now uncovered approximately 2,000 previously unknown gut bacteria.

Recent studies covered by Medical News Today have shown that the gut microbiota could have a role in Parkinson's disease and dementia, and they may explain why type 2 diabetes medication works well for some but not for others.

New research — appearing yesterday in the journal Nature — has now identified almost 2,000 new gut bacterial species that scientists have never cultured in a lab before.

"In this study," Almeida explains, "we leveraged the most comprehensive public databases of gastrointestinal bacteria to identify bacterial species that have not been seen before. The analysis methods we used are highly reproducible and can be applied to larger, more diverse datasets in the future, enabling further discovery."

In the future, the researchers hope that this and similar studies will further aid their understanding of the human gut, which, in turn, will contribute to developing better treatments of a variety of conditions.

Research such as this is helping us create a so-called blueprint of the human gut, which, in the future, could help us understand human health and disease better and could even guide diagnosis and treatment of gastrointestinal diseases."

Wednesday, February 20, 2019

Wisdom Wednesday: Zinc and Hypertension


New research links zinc deficiency to hypertension. Zinc is involved with hundreds of enzyme systems and has other health implications. Zinc has been shown to be beneficial for learning and cognition  and is also recommended for people with a genetic predisposition to heart disease. It may even mitigate certain degenerative effects of aging. Some research indicates zinc deficiency may be a component of dementia.

The link to zinc deficiency and hypertension has been shown in an earlier cohort study, and a new animal study suggests a possible mechanism. Zinc deficient mice were compared to those with normal zinc levels. The researchers found that the zinc deficient mice had decreased sodium excretion and, therefore, higher blood pressure when compared to healthy controls. Zinc deficiency increases blood pressure by causing an upregulation of sodium chloride cotransporter (NCC) and a decrease in sodium excretion.

The researchers stated, “This study links dysregulated renal sodium handling to zinc deficiency induced hypertension. Furthermore, NCC is identified as a novel mechanism by which zinc regulates blood pressure. Understanding the mechanisms of zinc deficiency induced BP dysregulation may have important therapeutic impact on hypertension.”

My Take:
For years, what little attention to diet and hypertension has focused on limiting sodium intake. Unfortunately, conventional health care does not differentiate between organically bound sodium (think celery) and inorganic sodium (added to processed meats). The latter is associated with hypertension, not the former.

Monday, February 18, 2019

Just 8 weeks of Yoga Benefit Rheumatoid Arthritis

New research, published in the journal Restorative Neurology and Neuroscience, finds that an 8-week regimen of intensive yoga eases both the physical symptoms of rheumatoid arthritis and the psychological distress that usually accompanies the condition.

Dr. Rima Dada, Ph.D., who is a professor in the Department of Anatomy at the All India Institute of Medical Sciences in New Delhi, led the new research.

Rheumatoid arthritis (RA) is a chronic inflammatory condition that affects approximately 1.3 million people in the United States. The disease is most likely autoimmune, which means that the immune system mistakes the body's own tissues and cartilage as foreign and attacks them. While there is no cure for RA, there are a variety of medications available. However, as Dr. Dada and her colleagues explain in their paper, recovery depends on various factors, some of which are psychological. Depression, for instance, often occurs alongside RA, and it can negatively affect a person's outcome.

In this context, Dr. Dada and team wondered if a yoga-based mind-body intervention could ease depressive symptoms in RA and help achieve remission of this chronic disease. To find out, Dr. Dada and colleagues examined the effects of practicing yoga intensively in 72 people with RA.

The scientists divided the study participants into two groups. Both groups continued to take disease-modifying antirheumatic drugs (DMARDs), which are the drugs doctors typically prescribe for this condition. Also, one group engaged in 120-minute sessions of yoga five times a week, for 8 weeks. The two main outcomes the researchers assessed were disease activity and depression severity. After the intervention, improvements in markers of neuroplasticity, inflammation, cellular health, and cellular aging — such as oxidative stress — showed that yoga had a positive effect on those who practiced it.

Dr. Dada and colleagues conclude, "Yoga, a mind-body intervention reestablished immunological tolerance by aiding remission at molecular and cellular level along with significant reduction in depression." "Thus in this inflammatory arthritis with a major psychosomatic component, yoga can be used as a complementary/adjunct therapy." The study's lead author reports, "Our findings show measurable improvements for the patients in the test group, suggesting an immune-regulatory role of yoga practice in the treatment of RA."

"An intensive yoga regimen," she continued, "concurrent with routine drug therapy induced molecular remission and re-established immunological tolerance. In addition, it reduced the severity of depression by promoting neuroplasticity."


Friday, February 15, 2019

PROBIOTICS MAY DIRECTLY AFFECT BREAST MILK CARBOHYDRATE COMPOSITION

New research has revealed a possible two-way connection between maternal dietary microbes and the makeup of the oligosaccharide sugar molecules found in human breast milk.

Until recently, it was thought that oligosaccharides affected the microbial communities within an infant’s gut, acting as prebiotics that then decreased their risk of certain infections, conditions and diseases. Studies showed that a woman’s genetics could determine the presence of between 23 and 130 oligosaccharides in her breast milk, and that the range of sugars was related to her blood type.

However, a new Finish study has shown that the probiotics that enter a woman’s digestive body orally may further affect her breast milk, changing which sugars occur within it. The study analyzed the breast milk 81 pregnant women, some of whom were administered probiotics, and others that were not, and found distinct oligosaccharide compositions in the milk of the two groups.

This study is important on a number of levels. It is the first time that a causal relationship has been discovered between friendly bacteria and human breast milk carbohydrate polymers. This breakthrough could have great consequences for infant as well as general human health.

Breast milk oligosaccharides play a key role in the healthy development of an infant’s immune system and directly affect the child’s ability to fight ill health. For example, some of the sugars in question have been associated many benefits, including a reduced incidence of diarrhea, gastroenteritis, respiratory tract infections and other immune-mediated and infectious diseases during the first few years of life, as well as the promotion of immune development and inflammatory response regulation.

Wednesday, February 13, 2019

Wisdom Wednesday: Statins Lower Risk for CV Events in Elders, But Benefits for Primary Prevention Still in Question


Statin therapy lowers the risk for vascular events in adults over age 70, according to a meta-analysis in The Lancet. However, the benefit seems apparent only in those with a history of vascular disease.

Researchers examined data from 28 randomized trials that either compared statin use with nonuse or compared intensive statin regimens with standard treatment. Over 185,000 participants were included, of whom 15% were age 71–75 and 8% were older than 75.

During roughly 5 years' follow-up, statin use or intensive treatment was associated with a significant reduction in major vascular events across all age groups — overall, a 21% reduction in risk with each 1-mmol/L (39-mg/dL) decrease in LDL cholesterol. However, when stratified by history of vascular disease, a significant benefit among those aged 71 and older was limited to those with prior vascular disease.

My Take:
The full article is available online from The Lancet. These findings are strikingly similar to those found with aspirin – it’s best used for patients with a history of cardiovascular disease than for prevention.

Monday, February 11, 2019

Hip Arthroscopy Outperforms PT for Femoroacetabular Impingement

Arthroscopic surgery may be superior to physical therapy for patients with femoroacetabular impingement (FAI), according to a U.K.-based study in The BMJ. FAI, which affects roughly one-fifth of the general population, is characterized by adverse morphology causing the femoral neck to impact against the acetabular rim; this predisposes patients to premature degeneration of the joint.

Over 200 adults with symptomatic, confirmed FAI were randomized to either physical therapy plus activity modification or arthroscopic surgery to remove the impinging femoral and acetabular bone. The primary outcome — a 100-point score on an activities of daily living measure at 8 months post-randomization — favored the surgery group by 10 points. Secondary outcomes, including sports and depression scores, also favored the surgery group.

The researchers caution: "Although arthroscopic hip surgery seems superior to physiotherapy and activity modification, patients must be informed of the potential risks and benefits of surgery, including the risk of no improvement. Up to a half of patients may not achieve a clinically important improvement after surgery; hence accurate patient selection is critical to optimizing treatment outcomes." They note, for example, that osteoarthritis may negatively affect the surgery's outcomes.

My Take:
The full article is available for free from The BMJ (The British Medical Journal) CLICK HERE.

Manipulation of the femoral head is an excellent alternative to the arthroscopic surgery and can be combined with physical therapy for much improved outcomes. Clinically, I find that manipulation will also provide good temporary relief for a torn labrum as well, but ultimately a labral tear will require surgery.

The conservative approach is to try manipulation and physical therapy for up to three months. If significant improvement is not achieved then arthroscopic surgery can be performed before osteoarthritis becomes a factor. Most surgeons agree that the window for successful surgery closes around six months after symptoms appear.

It is interesting to note that the results of this study on hip surgery are the opposite of similar studies on knee and shoulder surgery. Please review my blog “No Surgery for Subacromial Pain Syndrome” posted last Friday. Outcomes for hip surgery traditionally are better than surgery on the knee or shoulder. Just look at the recovery times for people you know having a hip replacement versus those having a knee replacement.

Bottom Line:
Whenever possible take the conservative route first to rehabilitate a joint rather than operate. In the worst case scenario, the rehabilitation prior to surgery will improve outcomes even if the therapy fails and surgery is still required. Obviously, the better outcome is to avoid the surgery altogether.


Source: February 12, 2019 New England Journal of Medicine

Friday, February 8, 2019

No Surgery for Subacromial Pain Syndrome

Subacromial decompression surgery should not be offered to patients with subacromial pain syndrome, according to a new guideline from The BMJ's Rapid Recommendations panel. The guidance — considered a strong recommendation — applies to patients with atraumatic shoulder pain, including rotator cuff disease, lasting longer than 3 months.

The recommendation was based on findings from seven randomized trials among roughly 1000 patients that compared decompression surgery with either sham surgery or exercise alone. Overall, decompression surgery did not provide a meaningful benefit over nonsurgical treatment in terms of pain, function, or quality-of-life. However, surgery was associated with more cases of frozen shoulder (12 more cases per 1000 patients undergoing surgery) and could cause more serious adverse events like major bleeding.

The panel, which included patients, clinicians, and researchers, concluded: "Almost all informed patients would choose to avoid surgery.... However, there is substantial uncertainty in what alternative treatment is best."

My Take:
The full article is available for free online from the New England Journal of Medicine.

Atraumatic shoulder pain can mean an insidious onset or from a chronic injury (more than six months, but often several years old). Much like the recent recommendations on knee surgery, shoulder decompression surgery should be reserved for acute injuries.

Wednesday, February 6, 2019

Wisdom Wednesday: Heavy Metals Found in Popular Fruit Juices



Nearly half of 45 fruit juices tested had elevated levels of heavy metals, which can pose health risks for children and adults, Consumer Reports has found.

The report, released Wednesday, says that even small amounts of juice might hold risks.
"In some cases, drinking just 4 ounces a day — or half a cup — is enough to raise concern," James Dickerson, PhD, chief scientific officer for CR, says in the report.

If anything, the results simply reinforce existing concerns about fruit juices. "I don't think we need to say you can't give your kids any juice," says Steven Abrams, MD, a professor of pediatrics at Dell Medical School, University of Texas at Austin. But, he says, "juice is not a product that is intrinsically healthy for children." He coauthored the American Academy of Pediatrics' guidelines on juice, which set limits by age. Meanwhile, juice producers say the report needlessly alarms consumers.

Consumer Reports experts tested 45 juices made by 24 brands, including well-known and lesser-known brands such as Gerber, Minute Maid, Mott's, Great Value from Walmart, Clover Valley from Dollar General, and Big Win from Rite Aid. Those tested included organic products, too, as well as store brands from Whole Foods and Trader Joe's.

They focused on levels of cadmium, lead, mercury, and inorganic arsenic, saying that these elements pose some of the greatest risks and that research has found they are common in food and drink. The juices tested were apple, fruit blends, grape, and pear.

The new testing was done as a follow-up to a study in 2011, when CR found elevated levels of inorganic arsenic and lead in apple and grape juices. The new evaluation was done to see if there's been improvement, to test other juices, and to test for other heavy metals.

Overall, CR says, heavy metal levels in fruit juices have declined since their last testing. But in the new report, every juice contained at least one of the four metals tested, and 47%, or 21, had concerning levels of cadmium, inorganic arsenic, and/or lead. None had concerning levels of mercury. Other major conclusions: Seven of the 21 had enough heavy metals to potentially harm children who drink a half-cup or more a day, and nine of the 21 held risks for kids drinking a cup or more a day. Ten of the juices posed a risk to adults, too: Five were potentially hazardous at a half-cup or more a day, and five at a cup or more a day. The highest heavy metal levels were in grape juice and juice blends. Organic juices did not have lower heavy metal levels than non-organic.

Monday, February 4, 2019

Antibiotics disrupt gut bacteria, impact bone health

A new study about the side effects of antibiotic treatment reveals that it may dysregulate post pubertal skeletal development by interfering with gut bacteria.

The trillions of bacteria living in our bodies are crucial for our health. They support the gastrointestinal and immune systems. They also help the body absorb nutrients from foods and supplements. People often call the "good" bacteria within us "commensal," because they live together in harmony without causing any harm. However, we often treat the "bad" microbes that cause disease using antibiotics.

Some researchers from the Medical University of South Carolina (MUSC) in Charleston specialize in osteoimmunology, the "interface of the skeletal and immune systems." The scientists analyzed the impact of antibiotics on post pubertal skeletal development and published their results in The American Journal of Pathology. The study demonstrated that antibiotic disruption of the gut microbiota causes a proinflammatory response that may lead to less bone resorption, a process by which osteoclasts, or large bone cells, release the minerals and transfer them to the blood.

According to Chad M. Novince, Ph.D. — who studies the link between microbiome and skeletal health — the study "introduces antibiotics as a critical exogenous modulator of gut microbiota osteoimmune response during post pubertal skeletal development."

The post pubertal phase of development supports the accumulation of about 40 percent of peak bone mass. Previous research by Novince and team had already shown that the gut
microbiota contributes to skeletal health.

Friday, February 1, 2019

Don’t Succumb to the Common Cold

The winter season may be a time of comfort: a slower pace, inner focus, and reflection, but it is also the time of year that many people will battle against cold and flu season. The viruses that cause cold and flu symptoms, technically respiratory infections, reliably spring to life between November and March in the Northern Hemisphere, with most American adults getting an average of between two to four colds per year. 

While being exposed to cold winter weather won’t necessarily mean you’ll “catch a cold,” transmission rates are highest in cold, dry air. Cold and flu viruses thrive when the temperatures plunge. Research suggests that these viruses are most virulent at temperatures near 40 degrees Fahrenheit or colder, and they do not transmit at all at temperatures around 85 degrees. This may be due to the virus’ outer lipid membrane, which is fortified by cold weather, forming a rubbery gel-like consistency that enables the virus to survive longer outside a host. Once the virus enters the respiratory tract, the outer membrane melts, and the virus is able to infect host cells and replicate.

However, in warmer temperatures, that membrane is more likely to have a liquidly consistency, effectively weakening the virus so that it loses the ability to spread readily between hosts. 

Luckily, there are many ways to reduce the risk for the common cold and flu, as well as strategies to shorten the duration and lessen the severity of any cold or flu infection that does take hold. Time-honored lifestyle strategies that help keep the immune system robust and resilient include: Eating a healthful diet that includes a wide variety of colorful fruits, vegetables, herbs, and spices to help bolster the immune system, getting adequate sleep, exercising daily, managing stress, maintaining healthy vitamin D levels, washing hands often and supplementing with appropriate vitamins, herbs, and other medicinal plants.

Wednesday, January 30, 2019

Wisdom Wednesday: Gut Microbiota and the Neuroendocrine System


The gut-brain axis is undeniable, but specific mechanisms of influence continue to be investigated. Specifically, the gut microbiota is now considered the body’s major neuroendocrine system, controlling body processes including the stress response and the hypothalamic-pituitary-adrenal (HPA) axis.

Back in the early 20th century, Nobel laureate, Ilya Metchnikoff, observed that the growth of cholera could be reduced by some microbes and enhanced by others. He proposed that commensal bacteria within the intestine could contribute to protection against this pathogen and alteration of the gut bacteria could prevent disease. In 2001, Nobel Prize winner Joshua Lederberg coined the term “microbiome”. The microbiome is the “ecological community of commensal, symbiotic and pathogenic microorganisms” that can be found on mucosal surfaces, including the eye, mouth, lungs, and the gut. Recent research reviews the connection between the microbiota and the neuroendocrine system.

The article is a review of the literature showing the connection of the microbiome to remyelination, microglia function, diseases like multiple sclerosis (MS), recovery from spinal cord injury and even behavior. The article cites research that links MS with intestinal permeability. Other research shows a link between the microbiome and pediatric MS, suggesting a connection between myelin production and metabolites produced by gut microbes (particularly p-cresol). Short chain fatty acids from the bowel flora (especially butyrate) affect remyelination, microglia function, and also oligodendrocyte differentiation. In the autoimmune disease, neuromyelitis optica, research shows there may be a connection to bowel ecology. Another study showed the connection between CNS inflammation and the gut microbiome in mice.

Monday, January 28, 2019

Quercetin

Quercetin is a pigment found in many plants, fruits, and vegetables. It may have some health benefits and help prevent a range of conditions. People can get quercetin through a balanced diet or by taking a supplement. Quercetin is a flavonol, which is a sub-category of flavonoids. Flavonoids are a particular chemical in plants, called phytonutrients, and have a wide range of health benefits. Humans cannot make quercetin in their body, but many fruits, vegetables, and drinks contain it. Foods and drinks that contain quercetin include: grapes, berries, cherries, apples, citrus fruits, onions, buckwheat, broccoli, kale, tomatoes, red wine and black tea.

Quercetin is also present in herbal remedies, such as ginkgo biloba and St John's wort. People can also take quercetin as a supplement. Quercetin is a more powerful antioxidant than vitamin C, vitamin E, or beta carotene. Quercetin might help reduce inflammation. One study on animals found that quercetin prevented both acute and chronic inflammation, in addition to showing anti-arthritis properties. Quercetin may contain anticancer properties that might help prevent the spread of cancerous cells and tumor growth. Quercetin may help to prevent neurodegenerative diseases, such as Alzheimer's or Parkinson’s disease.

Research suggests that quercetin might be an effective antihistamine, as it restricts histamine from being released from cells. These anti-allergy properties indicate that quercetin might help treat bronchitis and asthma. Quercetin has antibacterial properties, which are effective against almost all types of bacteria. Quercetin may improve blood vessel cell health and blood flow through arteries in people with heart disease. According to a 2016 study by the American Heart and Stroke Association, taking quercetin supplements could be an effective way to reduce blood pressure.

Friday, January 25, 2019

Climate Change — A Health Emergency

In this issue of the Journal, Haines and Ebi summarize the devastating effects that the global burning of fossil fuels is having on our planet (pages 263–273). Disruption of our climate system, once a theoretical concern, is now occurring in plain view — with a growing human toll brought by powerful storms, flooding, droughts, wildfires, and rising numbers of insectborne diseases. Psychological stress, political instability, forced migration, and conflict are other unsettling consequences. In addition, particulate air pollutants released by burning fossil fuels are shortening human life in many regions of the world. These effects of climate disruption are fundamentally health issues, and they pose existential risks to all of us. People who are sick or poor will suffer the most.

As physicians, we have a special responsibility to safeguard health and alleviate suffering. Working to rapidly curtail greenhouse gas emissions is now essential to our healing mission. The United Nations Intergovernmental Panel on Climate Change concluded that we need to cut global greenhouse gas emissions in half by 2030 and entirely by 2040 to avoid the most catastrophic effects of climate change. Yet these emissions hit a record high in 2018. Rapid but equitable changes in energy, transportation, and other economic sectors are needed if we are even to begin to meet the requisite emissions-reduction targets. Tackling this challenge may feel overwhelming, but physicians are well placed and, we believe, morally bound to take a lead role in confronting climate change with the urgency that it demands.

Individual lifestyle actions (e.g., walking or cycling rather than driving, eating less meat, reducing food waste, and conserving energy) are the easiest for us to undertake, offer many benefits for personal wellness, and allow us to model health-promoting behaviors as we reduce our environmental footprint. But individual actions are far from enough to address the challenge we collectively face. The financial interests of organizations vested in the fossil fuel industry, a federal administration that disavows climate science and its own responsibility to act, and inertia are powerful countervailing forces. Changing our institutions and society will therefore require concerted, organized, and forceful efforts.

Wednesday, January 23, 2019

25% of Antibiotic Prescriptions Could Be Inappropriate


At least a quarter of outpatient antibiotic prescriptions filled in 2016 may have been unnecessary, researchers conclude in The BMJ.

Using a national U.S. claims database, the researchers identified over 15 million outpatient antibiotic prescriptions filled in 2016 by privately insured children and adults under age 65. The most common antibiotics used were azithromycin, amoxicillin, and amoxicillin-clavulanate, accounting for roughly half of prescriptions.

On the basis of ICD-10-CM diagnosis codes:
23% of prescriptions were classified as inappropriate, usually for acute bronchitis, acute upper respiratory tract infection, or respiratory symptoms.

36% were potentially appropriate, most frequently for acute sinusitis, acute suppurative otitis media, or acute pharyngitis.

13% were considered appropriate, most often for urinary tract infections, streptococcal pharyngitis or tonsillitis, and bacterial pneumonia.

Some 29% of antibiotic prescriptions did not have an associated diagnosis code.

Monday, January 21, 2019

CDC Offers Update on Flu Activity This Season

The CDC on Friday offered its weekly snapshot of influenza activity so far this season. Among the findings for the week ending January 12:
Influenza A(H1N1)pdm09 viruses have predominated in most regions, although influenza A(H3) viruses have been most common in the Southeast.
Most circulating viruses are genetically similar to the reference viruses used for this year's flu vaccines.

All tested viruses have been susceptible to neuraminidase inhibitors (oseltamivir, zanamivir, and peramivir). Information on susceptibility to the newly approved flu drug, baloxavir, will be available later in the season.

New York City and 22 states had either high or moderate influenza activity.

The CDC also estimated that between 6.2 and 7.3 million people in the U.S. had symptomatic influenza from October 1, 2018, through January 5, 2019. This led to some 2.9 to 3.5 million medical visits and 69,300 to 83,500 hospitalizations. The agency noted that this is the first time it's reported in-season estimates, so the numbers can't be used to evaluate how this season compares with prior seasons.

My Take:
There was no data on the estimated number of related deaths given by the CDC. All the vaccines noted are administered through a shot. There was no data on the nasal vaccine.

Friday, January 18, 2019

Key West Sunscreen Ban?

The Key West City Commission on Tuesday unanimously voted to ban the sale of sunscreens that contain two ingredients — oxybenzone and octinoxate — that a growing body of scientific evidence says harm coral reefs. “This ordinance is just one other thing we can do to help improve and protect our water quality,” said Mill McCleary, of the nonprofit environmental protection group Reef Relief.

The measure, which passed 7-0, isn’t law yet, though. The commission must review it a second time and pass the measure again before it would become law. The second vote is scheduled for Feb. 5.

Environmental researchers have published studies showing how these two ingredients, which accumulate in the water from bathers or from wastewater discharges, can damage coral reefs through bleaching and harming the corals’ DNA. In some instances, the corals can die.
Last year, Hawaii banned the sale or distribution of any sunscreens containing oxybenzone and octinoxate, a measure that will go into effect on Jan. 1, 2021. It was the first state in the nation to implement such a ban.

In Florida, the website for the South Florida Reef Ambassador Initiative, which falls under the state’s Department of Environmental Protection, tells divers to “Avoid sunscreens with Oxybenzone and Avobenzone. The benzones are compounds that are lethal to coral reproduction in very small amounts.”

Wednesday, January 16, 2019

Wisdom Wednesday: Chronic Pain Syndrome


Chronic pain syndrome (CPS) is a common problem that presents a major challenge to health-care providers because of its complex natural history, unclear etiology, and poor response to therapy. CPS is a poorly defined condition. Most authors consider ongoing pain lasting longer than 6 months as diagnostic, and others have used 3 months as the minimum criterion. In chronic pain, the duration parameter is used arbitrarily. Some authors suggest that any pain that persists longer than the reasonably expected healing time for the involved tissues should be considered chronic pain. Approximately 35% of Americans have some element of chronic pain, and approximately 50 million Americans are disabled partially or totally due to chronic pain. Chronic pain is reported more commonly in women.

CPS can affect patients in various ways. Major effects in the patient's life are depressed mood, poor-quality or nonrestorative sleep, fatigue, reduced activity and libido, excessive use of drugs and alcohol, dependent behavior, and disability out of proportion with impairment. Chronic pain may lead to prolonged physical suffering, marital or family problems, loss of employment, and various adverse medical reactions from long-term therapy. Parental chronic pain increases the risk of internalizing symptoms, including anxiety and depression, in adolescents.

The pathophysiology of chronic pain syndrome (CPS) is multifactorial and complex and still is poorly understood. Some authors have suggested that CPS might be a learned behavioral syndrome that begins with a noxious stimulus that causes pain. This pain behavior then is rewarded externally or internally. Thus, this pain behavior is reinforced, and then it occurs without any noxious stimulus.

A literature review by Gupta et al indicated that in chronic pain patients, primary sensorimotor structural and functional changes are more prominent in females than in males. Males and females differed with regard to the nature and degree of insula changes (with males showing greater insula reactivity), as well as in the extent of anterior cingulate structural changes and in reactivity to emotional arousal.

Monday, January 14, 2019

Can Exercise Lower High Blood Pressure as Effectively as Drugs?

According to the Centers for Disease Control and Prevention (CDC), approximately 75 million adults in the United States have to manage high blood pressure, where it exceeds the threshold of 140 millimeters of mercury (mm Hg). The condition can increase their risk of developing heart disease or experiencing a stroke, both of which are leading causes of death in the U.S. Moreover, high blood pressure drives an expense of around $48.6 billion per year nationally, including the cost of medication, accessed health care, and absence from work.

People with high blood pressure typically follow an antihypertensive or blood pressure-lowering treatment, which includes special medication. At the same time, specialists sometimes advise that people make lifestyle changes to help them manage their blood pressure. One such change is to take regular, structured exercise.

However, no studies have yet compared the effectiveness of physical activity in lowering blood pressure with that of antihypertensive medication. A new study in the British Journal of Sports Medicine — a BMJ publication — aims to address this gap in the literature.
In the current study, they looked at the data from 194 clinical trials that focused on antihypertensive drugs and their impact on systolic blood pressure, and another 197 clinical trials, looking at the effect of structured exercise on blood pressure measurements. In total, these trials collected information from 39,742 participants.

They found that antihypertensive drugs were more effective in lowering blood pressure than structured exercise in the case of the general population. However, when they looked specifically at people with high blood pressure, they saw that exercise was as effective as most blood-lowering medication. Moreover, the study authors concluded that there is "compelling evidence that combining endurance and dynamic resistance training was effective in reducing [systolic blood pressure]."

Friday, January 11, 2019

Are Infectious Complications Following Probiotics an Underestimated Problem?

Probiotics seem to be everywhere. From dietary supplements to chocolate bars, these products are designed to improve one’s microbiome. Yet, there have been few serious evaluations of complications related to probiotic ingestion. This study presents a synthesis and critical evaluation of the reports and series of cases on the infectious complications related to the ingestion of probiotics, which can raise awareness for the prescribing and use of probiotics for certain groups of patients. The researchers emphasize that this study is not meant to discourage the use of probiotics, but to instead better understand that certain high-risk patients may not benefit from the introduction of probiotics in a clinical setting.

In this study, published in BMC Complementary and Alternative Medicine, researchers culled and systematically reviewed the data from PubMed, SciELO and Scopus databases published until August 2018. They found 60 case reports and 7 case series, making up a total of 93 patients. Among those studies, they found certain strains of probiotics were responsible for the most complications. They also found common factors associated with mortality, including infants and the elderly with compromised immunity and the prevalence of C. dificile, colitis and antibiotic use.

The authors note “to assume that probiotic intake is completely risk-free is not true. The proportion of cases of infectious complications is small when the total number of people who use probiotics is considered. However, the cases described here are infections with high mortality rates such as endocarditis and sepsis. So, although on one hand there is the possibility of publication bias, with more serious cases having been published, on the other, due to the mentioned limitation for the publication of case reports, several other serious cases may not have reached public knowledge.”

The use of probiotics cannot be considered risk-free and should be carefully evaluated for some patient groups. The most frequent probiotic-related infectious complications were fungemia and sepsis and the most frequent probiotic microorganisms were of the genus Saccharomyces, a fungus. Mortality was associated with age > 60 years, C. dificile colitis, current antimicrobial use and Saccharomyces infection. Probiotics were often used in the context of excessive antibiotic use, and a more judicious use of antibiotics is critical, as the use of probiotics cannot be considered risk free and should be carefully evaluated for high-risk groups of patients.

Wednesday, January 9, 2019

Wisdom Wednesday: Headaches Attributed to Trauma to the Head or Neck


Headache attributed to trauma or injury to the head and/or neck are among the most common secondary headache disorders. During the first 3 months from onset they are considered acute; if they continue beyond that period they are designated persistent. This time period is consistent with ICHD-II diagnostic criteria, although the term persistent has been adopted in place of chronic.

There are no specific headache features known to distinguish the Headache attributed to trauma or injury to the head and/or neck from other headache disorders; most often these resemble Tension-type headache or Migraine. Consequently their diagnosis is largely dependent upon the close temporal relation between the trauma or injury and headache onset. Consistently the diagnostic criteria of ICHD-3 for all types of Headache attributed to trauma or injury to the head and/or neck require that headache must be reported to have developed within 7 days following trauma or injury, or within 7 days after regaining consciousness and/or within 7 days after recovering the ability to sense and report pain. Although this 7-day interval is somewhat arbitrary, and some experts argue that headache may develop after a longer interval in a minority of patients, there is not enough evidence at this time to change this requirement.

Headache may occur as an isolated symptom following trauma or injury or as one of a constellation of symptoms, commonly including dizziness, fatigue, reduced ability to concentrate, psychomotor slowing, mild memory problems, insomnia, anxiety, personality changes and irritability. When several of these symptoms follow head injury, the patient may be considered to have a post-concussion syndrome.

The pathogenesis of Headache attributed to trauma or injury to the head and/or neck is often unclear. Numerous factors that may contribute to its development include, but are not limited to, axonal injury, alterations in cerebral metabolism, neuroinflammation, alterations in cerebral haemodynamics, underlying genetic predisposition, psychopathology and a patient’s expectations of developing headache after head injury. Recent research, using advanced neuroimaging modalities, suggests a potential for detecting brain structural, functional and metabolic abnormalities following minor trauma that are not detectable through conventional diagnostic tests. Post-traumatic sleep disturbances, mood disturbances and psychosocial and other stressors can plausibly influence the development and perpetuation of headache. The overuse of abortive headache medications may contribute to the persistence of headache after head injury through the development of Medication-overuse headache. Clinicians must consider this possibility whenever a post-traumatic headache persists beyond the initial post-trauma phase.

Monday, January 7, 2019

Artificial Sweetners

Objective:
To assess the association between intake of non-sugar sweeteners (NSS) and important health outcomes in generally healthy or overweight/obese adults and children.

Design:
Systematic review following standard Cochrane review methodology.
Data sources Medline (Ovid), Embase, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and reference lists of relevant publications.

Eligibility criteria for selecting studies:
Studies including generally healthy adults or children with or without overweight or obesity were eligible. Included study designs allowed for a direct comparison of no intake or lower intake of NSS with higher NSS intake. NSSs had to be clearly named, the dose had to be within the acceptable daily intake, and the intervention duration had to be at least seven days.

Main outcome measures:
Body weight or body mass index, glycaemic control, oral health, eating behaviour, preference for sweet taste, cancer, cardiovascular disease, kidney disease, mood, behaviour, neurocognition, and adverse effects.

Results:
The search resulted in 13 941 unique records. Of 56 individual studies that provided data for this review, 35 were observational studies. In adults, evidence of very low and low certainty from a limited number of small studies indicated a small beneficial effect of NSSs on body mass index (mean difference −0.6, 95% confidence interval −1.19 to −0.01; two studies, n=174) and fasting blood glucose (−0.16 mmol/L, −0.26 to −0.06; two, n=52). Lower doses of NSSs were associated with lower weight gain (−0.09 kg, −0.13 to −0.05; one, n=17 934) compared with higher doses of NSSs (very low certainty of evidence). For all other outcomes, no differences were detected between the use and non-use of NSSs, or between different doses of NSSs. No evidence of any effect of NSSs was seen on overweight or obese adults or children actively trying to lose weight (very low to moderate certainty). In children, a smaller increase in body mass index z score was observed with NSS intake compared with sugar intake (−0.15, −0.17 to −0.12; two, n=528, moderate certainty of evidence), but no significant differences were observed in body weight (−0.60 kg, −1.33 to 0.14; two, n=467, low certainty of evidence), or between different doses of NSSs (very low to moderate certainty).

Conclusions:
Most health outcomes did not seem to have differences between the NSS exposed and unexposed groups. Of the few studies identified for each outcome, most had few participants, were of short duration, and their methodological and reporting quality was limited; therefore, confidence in the reported results is limited. Future studies should assess the effects of NSSs with an appropriate intervention duration. Detailed descriptions of interventions, comparators, and outcomes should be included in all reports.

Friday, January 4, 2019

Does magnesium hold the key to vitamin D benefits?

Vitamin D, also known as the sunshine vitamin, has enjoyed something of a celebrity status, receiving praise for a multitude of health benefits. Yet, in the complex web of biological processes that govern our health, few players ever work in isolation. New evidence shifts the focus onto magnesium, implicating it in playing a central role in determining how much vitamin D our bodies can make.

In a study that features in the December issue of The American Journal of Clinical Nutrition, a research team from Vanderbilt University Medical Center in Nashville, TN concludes that optimal levels of magnesium may play an important role in the vitamin D status of an individual.

Dr. Qi Dai, a professor of medicine at Vanderbilt University Medical Center and the lead study author, previously reported on the relationship between magnesium intake and vitamin D levels in over 12,000 individuals taking part in the National Health and Nutrition Examination Survey (NHANES) 2001–2006 study.

Here, Dr. Dai and team found that individuals with high levels of magnesium intake, whether from dietary sources or taking supplements, were less likely to have low levels of vitamin D. Importantly, the researchers also found a possible association between magnesium intake and a reduction in mortality, particularly when they looked at mortality due to cardiovascular disease and bowel cancer.

So, how does magnesium affect vitamin D biology in the body? It is a cofactor in the synthesis of vitamin D from both exposure to sunlight and dietary sources. "Magnesium deficiency shuts down the vitamin D synthesis and metabolism pathway," Dr. Dai explains.