2014 Monthly Doctor Walk Health Tips - Wheaton Franciscan Healthcare

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2014 Walk with a Wheaton Doc Health Tips

During each walk in 2014, our physicians shared health and wellness tips on specific topics. To view the tips, select a month below and then a topic.

January | February | March | April | July | August | September | November | December

Want more information? Learn about the Walk with a Wheaton Doc program and join us for our next walk.

December 2014 Tips from Mushir Hassan, MD

Middle-Aged Midriff Bulge an Independent Risk Factor for Sudden Cardiac Death

The association of general obesity with sudden cardiac death appears to be mediated through traditional cardiovascular risk factors, whereas abdominal obesity may pose an independent risk for sudden death, a recent heart study suggests.

Some 15,000 middle-aged adults in four areas of the U.S. were followed for roughly 13 years. Sudden cardiac death occurred more often among those with higher baseline measures of body mass index, waist circumference, and waist-to-hip ratio. However, after adjustment for hypertension, diabetes and coronary disease, only waist-to-hip ratio showed a direct association with sudden cardiac death (incidence rates among nonsmokers: 1.4 per 1000 person-years for highest waist-to-hip ratio vs. 0.37 per 1000 for normal waist-to-hip ratio).

The findings, according to editorialists, suggest that waist-to-hip ratio might be better than BMI for predicting sudden cardiac death. The mechanisms responsible for the association remain speculative, however.

Dr. Hassan’s Bottom Line: That pear shape may be a risk for cardiac arrhythmia on top of the risks for vascular disease.

2014-15 Flu Vaccine Not a Perfect Match to Circulating Viruses

Roughly half of the circulating influenza A (H3N2) viruses collected in the U.S. early this flu season are antigenically different from the H3N2 virus included in this year's vaccine, prompting CDC officials to remind healthcare providers about using neuraminidase inhibitors to treat and prevent influenza.

H3N2 has been present in about 90% of influenza-positive tests this flu season. Years with high H3N2 activity tend to see higher flu morbidity and mortality. The World Health Organization recommended components for the Northern Hemisphere vaccine in February. Antigenically drifted H3N2 viruses were detected in March and became more prevalent in September, too late to change the vaccine.

"They're different enough that we're concerned that protection from vaccination ... may be lower than we usually see," CDC Director Tom Frieden told reporters.

The CDC is still recommending that people get vaccinated against the flu because it provides partial protection and the B strains are well matched. But Frieden said that if clinicians suspect influenza in high-risk patients, they should start neuraminidase inhibitor treatment without waiting for confirmatory test results.

Dr. Hassan’s Bottom Line: Flu virus does mutate and change, especially with global travel patterns. Nonetheless, there is some help to the immune system having some parts of the virus covered.

No Evidence to Support Routine Use of Aspirin in Most Women for Primary Prevention

In most women, the benefits of regular aspirin use for primary prevention don't outweigh the risks, a heart study suggests.

In the Women's Health Study, nearly 28,000 women aged 45 and older were randomized to placebo or 100-mg aspirin every other day. Aspirin use led to small reductions in 15-year absolute risks for cardiovascular disease and colorectal cancer; 371 patients need to be treated to prevent one cardiovascular event, and 709 to prevent one colorectal cancer. This small benefit occurred at the expense of an increase in gastrointestinal bleeding — 133 needed to be treated to cause one event.

In women aged 65 or older, aspirin's cardiovascular benefits were more pronounced. Gastrointestinal bleeding was also increased in this older group, but the cardio vascular benefit appeared to outweigh the risk.

The authors conclude that aspirin "is ineffective or harmful in the majority of women with regard to the combined risk of cardio vascular disease, cancer, and major gastrointestinal bleeding." However, "selective treatment" in older women may be reasonable.

Dr. Hassan’s Bottom Line: Women may be risking GI bleeding taking a baby aspirin for prevention. Those who have known disease do have benefit and should stay on aspirin.

Benefits of Maintenance of Certification Unclear

The American Board of Internal Medicine's Maintenance of Certification (MOC) program has had unclear benefits in terms of patient care but might lead to lower healthcare costs, two JAMA studies suggest.

In the first study, researchers examined rates of potentially avoidable hospitalizations among 150,000 Medicare beneficiaries treated by internists who were either required to complete MOC recertification in 2001 or were grandfathered out of recertification. While the rate of such hospitalizations increased with time for both physician groups, there was no between-group difference. The MOC-recertified group did, however, have 3% lower mean total healthcare costs.

The second study included roughly 70 internists with time-limited certification and 30 with time-unlimited certification at four Veterans Affairs centers. Over 1 year, the two physician groups didn't differ in any of 10 primary care performance measures, including colorectal cancer screening rates and post-MI aspirin use.

An editorialist writes: "The medical profession may never fully understand the effect of MOC, but that does not mean that physicians should give up or stop trying to make it better. The MOC program is a work in progress, as are all good physicians."

Dr. Hassan’s Bottom Line: The MOC process has met resistance from practicing physicians who already complete CME for licensure as onerous and now not related to improved outcomes. My feeling is that there is some money grab and job security for bureaucrats tied into MOC.

High Adherence to Mediterranean Diet Linked to Marker of Healthy Aging

Women who closely follow a Mediterranean diet have longer telomeres, a key measure of healthy aging, a study finds.

The study included some 4700 Nurses' Health Study participants who completed food-frequency questionnaires and who also had their telomere length measured. Women who adhered closely to a Mediterranean diet (emphasizing vegetables, fruits, nuts, whole grains, legumes, fish, and monounsaturated fats, plus moderate alcohol intake) had longer telomeres after adjustment for characteristics likely to influence telomere length, including age, body mass index, smoking history and exercise.

The authors calculated that the difference in telomere length among women who were more adherent to the Mediterranean diet could translate into an average gain of about 4.5 years of life, roughly comparable to the difference between nonsmokers and smokers or being highly active and less active. "Our results," they conclude, "further support the benefits of adherence to the Mediterranean diet for promoting health and longevity."

Dr. Hassan’s Bottom Line: Eating healthy helps your heart and helps you age better. For a nice slideshow on the Mediterranean diet, please visit mayoclinic.org. Note that stopping smoking and being active are also nice ways to improve life expectancy.

Special thanks to NEJM Journal Watch and the British Medical Journal (BMJ).

November 2014 Tips from Mushir Hassan, MD

Newly Identified Mutations Act Like a Lifetime of Cholesterol Treatment

A large genetic study in the New England Journal of Medicine offers compelling evidence in support of a central role for LDL cholesterol in coronary heart disease.

Researchers identified 15 rare mutations that block the activity of a gene called Niemann-Pick C1-Like 1 (NPC1L1). The mean LDL level was 12 mg/dL lower in mutation carriers than non-carriers. Carriers of the mutations had a 53% risk reduction in CHD, compared with non-carriers.

NPC1L1 is the same gene that is blocked by the cholesterol-lowering drug ezetimibe. The mutations are thought to produce an effect that would be similar to a lifetime of drug treatment.

The author comments: "One of the key concepts here is that it may not be 'how you lower LDL' or 'how low you take LDL' but rather 'how long the LDL is lowered.' We should think about LDL like we do smoking. Smoking is typically quantified as 'pack-years,' a product of the number of years smoked times the number of packs per day. The concept to stress may be 'LDL-years.'"

Dr. Hassan’s Bottom Line: Neat research that shows a different perspective on LDL in terms of LDL years. Also shows, in my opinion, some lack of utility of the other less reliable testing.

Vitamin B Supplementation Doesn't Seem to Boost Cognitive Performance in Elderly

Long-term vitamin B supplementation does not appear to improve cognitive performance in elderly adults with elevated homocysteine levels, according to a recent study.

Dutch researchers studied some 3000 elderly people who were suspected to be at increased risk for cognitive decline because of elevated homocysteine levels. Participants were randomized to take either vitamin B12 plus folic acid or placebo every day.

After 2 years of supplementation, there were no significant differences between the groups in most measures of cognitive performance. Supplementation was associated with a slower rate of decline in global cognition, but the researchers note that the difference was not clinically significant and could still have been due to chance.

Dr. Hassan’s Bottom Line: Homocysteine is not a variable to track for cognition nor cardiovascular disease. B12 caused no harm but was not helpful either.

Popular Diets Achieve Only Modest Long-Term Weight Loss

Four popular weight-loss diets produce at best only modest long-term benefits, with few differences across the four, according to a study in Circulation: Cardiovascular Quality and Outcomes.

Researchers examined 12 randomized, controlled studies of the Atkins, South Beach, Zone, or Weight Watchers diets. Ten studies compared one of the diets with usual care. In these, Weight Watchers was the only diet to consistently outperform usual care, but the difference in weight loss at 1 year was modest at best. In the two head-to-head trials, the Atkins and Zone diets resulted in a similar but modest weight loss. Longer-term data out to 2 years, available only for Weight Watchers and Atkins, indicated that some of the lost weight was regained over time.

An editorialist argues passionately that the focus on individual diets or specific macronutrients is misguided and unhelpful. He proposes a simple formula: "wholesome foods in sensible combinations."

Dr. Hassan's Bottom Line:Eat smart, but if you need a plan with structure, then Weight Watchers still has value.

Medicare Proposes Reimbursing Lung Cancer Screening in High-Risk Groups

The Centers for Medicare and Medicaid Services has proposed covering annual, low-dose computed tomography screening for lung cancer in patients at high risk, the Associated Press reports.

To be eligible for screening, patients must meet the following criteria:

  • Current smoker or smoker who's quit in the past 15 years
  • 30 pack-year history or equivalent
  • Aged 55-74 (the U.S. Preventive Services Task Force recommends screening in those up to age 80).

Before being screened for the first time, patients would need to undergo counseling on the risks and benefits of screening and on smoking cessation.

Dr. Hassan’s Bottom Line: Stop smoking. If you cannot, between puffs, lobby your congressman to get CMS to approve this.

Non-Obstructive Coronary Artery Disease Linked to Elevated Risk

Non-obstructive coronary artery disease is associated with increased risk for myocardial infarction and death, according to a retrospective study in JAMA.

Researchers analyzed data from nearly 38,000 elective angiography patients in the Veterans Affairs health system; 55% were found to have obstructive CAD, while 22% were found to have non-obstructive CAD.

At 1 year, the risk for MI and death was elevated based on the severity and extent of the CAD. Compared to people with no CAD, the risk for MI was 2 to 4.5 times greater in patients with non-obstructive CAD. The risk continued to rise with obstructive disease, so that people with obstructive three-vessel or left main disease had nearly 20 times the risk for MI.

The findings, write the authors, "highlight a need to recognize that non-obstructive CAD is associated with significantly increased risk for MI, consistent with prior biologic studies indicating that a majority of MIs are related to non-obstructive stenoses."

Dr. Hassan’s Bottom Line: Even if you do not get a stent, some disease at cath is risky. Aspirin and risk factor control are key.

September 2014 Tips from Mushir Hassan, MD

FDA Advisers Recommend Restricting Use of Testosterone Products

An FDA advisory panel recommends physicians limit the use of testosterone replacement therapies to men with medically related low testosterone. If the FDA follows this advice, manufacturers could no longer market their products to treat age-related low testosterone, although clinicians could still prescribe it off-label for this indication. The panel also recommended additional safety studies be performed to evaluate cardiovascular risk in men using testosterone products for age-related low testosterone.

Bottom Line: As we have discussed before, “low T” is diagnosis created by marketing more than science. Beware of the potential cardiac and systemic effects of treating low testosterone.

Guidelines Issued for Nonsurgical Management of Urinary Incontinence

The American College of Physicians has issued guidelines on the nonsurgical management of urinary incontinence in women in the primary care setting.

The five main recommendations are:

  1. For women with stress incontinence, pelvic-floor muscle training (e.g., Kegel exercises) should be first-line treatment.
  2. For those with urgency incontinence, bladder training (e.g., lengthening the time between voids) is recommended; adding pelvic-floor muscle training does not offer additional benefit for these women.
  3. For mixed (stress and urgency) incontinence, both pelvic-floor muscle training and bladder training should be used.
  4. Systemic pharmacologic therapy is not recommended for stress incontinence; intravaginal estrogen therapies, however, may be helpful.
  5. If bladder training doesn't improve urgency incontinence, pharmacologic therapies are recommended. Adverse effects, including dry mouth and constipation, must be considered.

Bottom Line: Bladder training and Kegel training should be first line. Pills come after. None of this happens though if patients and doctors do not ask about this potentially embarrassing issue.

Cheaper Generic Statins Beat Brand-Name Statins in Adherence and Outcomes

People prescribed a generic statin were more likely to take their pills and had slightly better outcomes than people prescribed a brand-name statin, according to a large, industry-funded study in the Annals of Internal Medicine. The average prescription copayment for generics is $10 and $48 for brand-name.

Researchers found that adherence, as measured by the proportion of days covered up to 1 year, was significantly higher in a generic group than in the brand-name group. Patients in the generic group also had an 8% reduction in the incidence of death and hospitalization for an acute coronary syndrome or stroke.

Bottom Line: If drugs are affordable, patients will take them. Applying drug costs against a deductible may deter affordability.

Spinal Manipulation Associated with Short-Term Relief of Back-Related Leg Pain

Spinal manipulation (chiropractic) therapy plus home exercises is more effective than home exercises alone for treating back-related leg pain, according to a study in the Annals of Internal Medicine.

Nearly 200 patients with subacute or chronic back-related leg pain were randomized to either spinal manipulation plus home exercises and advice or home exercises and advice alone for 12 weeks. For the spinal manipulation intervention, patients could receive as many as 20 sessions tailored to their individual needs and focused on manual techniques. The home exercise and advice intervention consisted of four one-on-one sessions that helped patients manage pain and prevent recurrence, with instructions to exercise daily.
At 12 weeks, the primary outcome — patient-rated leg pain during the past week — was 10 percentage points lower in the spinal manipulation group, a difference the researchers say was "clinically important." That advantage disappeared by 52 weeks.

Bottom Line: For subacute/chronic back pain, trying chiropractic therapy can get some temporary relief. This temporary relief may allow one to do back strengthening exercise to provide longer lasting pain relief. Chiropractors can have a role in back pain, as can acupuncturists.

No Endorsement for Routine ECG Screening of Young People

In a new scientific statement, the American Heart Association and the American College of Cardiology do not recommend the routine use of electrocardiograms (ECG) to screen young people for underlying congenital or genetic heart disease.

More aggressive screening for heart disease in young people is often advocated in response to pressure resulting from the rare but tragic cases of sudden death in young people. But a detailed examination of the evidence led the AHA/ACC to conclude that routine initial ECG screening in healthy young people (aged 12 to 25 years) without positive findings on history or physical examination does not appear to save lives.

Instead, they recommend that healthcare providers screen young people using a 14-point checklist that contains information taken from the patient's personal history, family history, and physical examination. A positive finding on any of the 14 points means that further testing, including a 12-lead ECG, may be indicated.

Bottom Line: A sports physical needs a good history and good physical with BPs in both arms. Wheaton Franciscan Healthcare offers these every summer. This is also a great way to keep your primary care physician updated on your high school star’s health status.

Screening All Women Up to Age 75 for Breast Cancer "May Lead to Overdiagnosis"

Increasing the upper limit for breast cancer screening from age 69 to 75 a recent study resulted in a slight decrease in diagnoses of advanced breast cancer, while early-stage cancer incidence increased.

Researchers assessed incident breast cancer rates among 25,000 women aged 70 to 75 before and after a mass screening program began to include women up to age 75. The incidence rates of early-stage tumors increased after the screening change. Meanwhile, incidence rates of advanced stage breast cancers slightly decreased.

Researchers say their results imply that "the effect of the screening program in older women is limited and may lead to overdiagnosis." They propose that routine breast cancer screening in women aged more than 70 years should not be performed on a large scale. Instead, the harms and benefits of screening should be weighed on a personalized basis, taking remaining life expectancy, breast cancer risk, functional status, and patients' preferences into account.

Bottom Line: My rule is that if we expect that you will live another 10 years, any cancer screening can make sense provided your health status could tolerate therapies.

Teen Cannabis Use Linked to Poor Educational Outcomes, Suicide Attempts

Cannabis (marijuana) use in the mid-teen years is associated with numerous poor outcomes by young adulthood, according to an analysis of data recently published.

The analysis included up to 3800 youths who reported on cannabis use before age 17 and then were followed until ages 27-30. The results showed that even using cannabis less than once a month was associated with lower educational attainment, suicide attempts, and use of other illicit drugs, relative to no use.

Outcomes worsened as cannabis use increased: daily use was associated with roughly a 60% reduced likelihood of graduating high school or earning a college degree, as well as nearly an 18x increased risk for later cannabis dependence, 8x risk for use of other drugs, and 7x risk for suicide attempt.

Bottom Line: It is important to ask if our teens are using pot and inform all teens of the risks above as well as the risks for sexual dysfunction and cognitive dysfunction.

Special thanks to NEJM Journal Watch and the British Medical Journal (BMJ).

August 2014 Tips from Mushir Hassan, MD

Higher BMI Linked to Increased Risk for Wide Array of Cancers

Higher body mass index (BMI) is associated with increased risk for many types of cancer, including those of the uterus, kidney, and liver, a recent study finds.
Researchers identified 5.2 million patients aged 16 or older with baseline BMI measurements and followed them for 71/2 years. During that time, 3% developed one of 22 cancers studied. Among the findings:

Each 5-unit increase in BMI was associated with large increases in risks for uterine, gallbladder, kidney, and liver cancer and smaller, albeit significant, increases in leukemia and colorectal, cervical, ovarian, pancreas, postmenopausal breast and thyroid cancers.
Among those who never smoked, higher BMI was also associated with increased risk for stomach and esophageal cancers.

Researchers estimate that 41% of uterine cancers and over 10% of gallbladder, kidney, liver, and colon cancers might be attributable to excess weight.

Bottom Line: That extra weight is not just bad for your heart, it can also adversely affect your cancer risk.

FDA Approves Novel Insomnia Drug

Suvorexant tablets (marketed as Belsomra) have been approved to treat insomnia by the FDA. The drug is the first approved orexin receptor antagonist — orexin helps regulate wakefulness.

Like other sleep aids, Suvorexant may lead to dependence. In addition, it carries a risk for certain activities such as driving while not fully awake. It will be available in 5-, 10-, 15- and 20-mg doses. The lower the dose, the lower the risk for common side effects like next day drowsiness. The approval is based on data from trials of 500 total patients. Those who took suvorexant fell asleep faster and woke up less during the night than those given placebo.

Bottom Line: Expect some mass marketing. Beware of the side effects and cost. Talk to your doctor about healthy sleep hygiene, simple remedies and trazodone or doxepin for sleep if you must use a pill.

Bevacizumab Approved for Late-Stage Cervical Cancer

The FDA has approved bevacizumab (Avastin) for metastatic, persistent, or recurrent cervical cancer to be used in combination with chemotherapy. In trial studies, overall survival increased by 16.8 months when bevacizumab was added to chemotherapy, compared with 12.9 months for chemotherapy alone. Treatment side effects may include decreased appetite, fatigue, headache, hyperglycemia, hypertension, urinary tract infection, and weight loss. Bevacizumab disrupts blood vessels that help cancerous cells grow.

Bottom Line: We have new uses for medicines that can strangle the blood flow to tumor cells.

Consumer Reports: Pregnant Women Should Avoid All Tuna

Pregnant women should avoid eating tuna altogether because of the risk for mercury exposure, says Consumer Reports. The recommendation is at odds with the FDA and EPA, which recently proposed that pregnant women eat 8-12 oz. of low-mercury seafood, including canned light tuna, weekly.

The agencies recommended limiting consumption of albacore tuna to 6 oz. per week. But Consumer Reports' analysis of FDA data found that a 125-pound woman could exceed the EPA's recommended mercury consumption limit by eating just 4 oz. weekly. Canned light tuna does, on average, contain less mercury than albacore, but FDA data indicate that 20% of canned light tuna samples contained double the average level of mercury.

In addition, Consumer Reports recommends that young children, women of childbearing age and people who eat 24 oz. of fish per week or more should not eat yellowfin and big eye tuna in sushi since these are high-mercury fish.

Bottom Line: Keep sushi as a delicacy and avoid in pregnancy. It’s best to eat canned light tuna, 1-2 cans per week or less during pregnancy. Most women in my practice avoid seafood altogether. One can of tuna on occasion is not a big deal. For non-pregnant types, I push 3 servings of salmon or tuna per week. Avoid swordfish to once a month or less. Tilapia is cheap for a reason, it borders on garbage protein. Push for wild caught fish. For sustainable fish options, visit www.seafoodwatch.org.

Project Healthy Schools

The University of Michigan’s Project Healthy Schools, in collaboration with community partners, strives to improve the present and future health of middle school students through school-based education and environmental initiatives. Health behaviors are influenced and improved by these five program goals:

  • Eat more fruits and vegetables(5 servings per day)
  • Choose less sugary foods and beverages
  • Eat less fast and fatty foods
  • Spend less mindless time in front of a screen (less than 2 hours)
  • Be active every day (150 minutes per week)

Bottom line: A great idea that we should try to model here in Wisconsin.

July 2014 Tips from Mushir Hassan, MD

Niacin Proves Ineffective in Statin-Treated Patients with Vascular Disease

Niacin, when added to a statin, is associated with serious adverse effects and no cardiovascular benefit, according to a trial published in the New England Journal of Medicine.

Bottom Line: Niacin gives you pretty numbers that have little benefit. Ditch it to reduce pill burden.

For Patients at Risk for Alzheimer's, Multidisciplinary Intervention May Slow Decline

A multipronged intervention is associated with better cognitive performance than usual health advice in older adults at risk for Alzheimer's Disease, according to the results of a recent trial.

In the FINGER study (Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability), nearly 1300 adults aged 60 to 77 with modifiable risk factors for Alzheimer's were randomized to either usual medical advice or to an intervention that included modification of cardiovascular risk factors, nutritional advice, physical activity, cognitive training and social activities. After 2 years, patients in the intervention group performed better on a cognitive exam, including tests of memory, executive function, and cognitive processing speed.

Bottom Line: Having a multi-pronged approach to programming for Alzheimer’s helps. Demand this of care facilities. Make sure they are aware of this study.

Muscle Mass Predicts Longevity in Older Adults

All-cause mortality was significantly lower among older adults in the highest quartile of muscle mass relative to those in the lowest quartile, according to a study in the American Journal of Medicine. In contrast, BMI was not significantly associated with all-cause mortality.

Bottom Line: I push at least 2 days per week of weights at the gym and 4 days of cardio.

Organic Foods Contain More Antioxidants, Fewer Pesticides

Organically grown crops contain more antioxidants and fewer pesticides than nonorganic foods, according numerous studies. The findings run counter to previous research suggesting few differences between organic and conventional foods.

Among the findings:

  • The concentrations of many antioxidants were significantly higher in organic than nonorganic crops.
  • Pesticide residues were found more often in nonorganic crops, although they were still within safe ranges.

Bottom Line: We, as consumers, need to demand more from our food suppliers and be smarter shoppers. Note that the “organic dairy” section is often sold out. Shoppers are becoming more savvy and demanding to know where their food is coming from.

Insulin Pumps Linked to Improved Glycemic Control in Patients with Hard-to-Treat Type 2 Diabetes

Insulin pumps are associated with better glycemic control than insulin injections in patients with type 2 diabetes and high insulin requirements, according to recent trial.

Roughly 330 patients who had type 2 diabetes with insufficient glycemic control despite high doses of insulin (>0.7 units/kg/day) had a 2-month run-in phase to optimize their doses. They were then randomized to receive either an insulin pump or multiple daily insulin injections. At 6 months, the mean glycated hemoglobin level had decreased more the pump group than in the injection group (between-group difference, -0.7%). Severe side effects, like ketoacidosis and severe hypoglycemia and hyperglycemia, were rare and rates were not significantly different between groups.

This study "provides a compelling case for the clinical effectiveness of insulin pump treatment in type 2 diabetes, suggesting that it can help improve glycemic control in this difficult to treat group... However, cost effectiveness of pumps in different healthcare systems will need to be evaluated."

Bottom Line: An insulin pump can help even in type 2 diabetes (adult onset/insulin resistance). Key issue is coverage and compliance.

Only 27% of Kids Get Less Than 2 Hours of Screen Time a Day

Only a quarter of American boys aged 12 to 15 years old meet the American Academy of Pediatrics recommendation to limit daily screen time to 2 hours or less. American girls fare little better: only 29% met the suggested limit.

The estimates include watching television and playing video games and don't count usage during the school day. Patterns of TV watching and computer use varied according to race, Hispanic origin, and weight.

Bottom Line: Get out with the kids and get moving. Great idea from a patient “screen time will be equal to reading time” Read for 2 hours, then you can watch 2 hours of TV.

TAVI Explored To Treat Aortic Bioprosthesis Failure

With the increasing use of bioprosthetic aortic valves in aortic valve replacement surgery, more physicians will be faced with the dilemma of how best to treat degenerated valves. Although surgical reoperation is considered the best solution, many patients are too old and frail for surgery. Transcatheter aortic valve implantation (TAVI) has been proposed for use in this situation, though the risks and benefits have not as yet been well defined.

A new study in JAMA provides information on 460 patients with failed bioprosthetic valves who underwent TAVI. The investigators in the VIVID (Valve-in-Valve International Data) Registry report that the death rate was 7.6% at 1 month and 16.8% at 1 year. Nearly 40% of valve failures were due to stenosis, 30% were due to regurgitation, and 30% were due to a combination of the two. Survival was lowest in the stenosis group as well as in patients with small valves compared with patients with intermediate or large valves.

Bottom Line: This is almost science fiction. we are now putting valves in via someone’s leg artery. It is remarkable how technology has evolved here.

Special thanks to NEJM Journal Watch and the British Medical Journal (BMJ).

April 2014 Tips from Mushir Hassan, MD

FDA Approves Sublingual Ragweed Allergy Treatment

The FDA has approved Ragwitek to treat hay fever, with and without conjunctivitis, caused by short ragweed pollen. The pill, to be taken sublingually, contains an extract of short ragweed pollen.

Adults should take Ragwitek daily for 12 weeks before ragweed pollen season begins and should continue to do so during the season. It will contain a boxed warning alerting patients of the potential for severe allergic reactions.

Also, the FDA has approved Grastek, a second sublingual immunotherapy to treat grass pollen allergies. (The first sublingual immunotherapy for grass allergies, Oralair, was approved earlier this month.) The new tablet contains Timothy grass extracts and is indicated for patients aged 5 to 65 years.

In December 2013, FDA advisers called for postapproval studies to test Grastek's safety in children aged 5 to 11 years, citing side effects such as lip swelling and oral blistering.

Take home: Allergy shots may have oral competition in inducing the immune system to calm its allergic response.

Scoring System Reliably Predicts the Presence of Uncomplicated Ureteral Stones

A new scoring system based on five risk factors can predict which patients have uncomplicated ureteral stones and, ultimately, may reduce imaging use, a British Medical Journal (BMJ) study finds.

Using a retrospective cohort of some 1000 adults undergoing CT scans for flank pain in two emergency departments, researchers identified five factors most significantly associated with ureteral stones: male sex, acute onset of pain, non-black race, nausea or vomiting, and microscopic hematuria. These factors, considered together, formed the STONE score (range, 0-13 points).

The researchers then tested the score in a prospective cohort of some 500 patients: just 9% of those with low-probability scores had kidney stones, versus 51% with moderate scores and 89% with high scores. Only 1% of the high-score group had acutely important alternative findings on CT.

The authors write that the score may be used in certain situations — and particularly among younger patients — to avoid CT. For example, if the score is high, they write, "a CT might be avoided entirely or a reduced dose CT could be performed."

Take home: Another way to avoid having a CT scan done automatically, use this score above.

ACP Recommends Physicians Take Steps to Reduce Gun Violence

The American College of Physicians recommends counseling patients on the risks of keeping firearms in their homes, especially when minors or people with dementia, mental illness, or substance use disorders live there.

In a new position paper published in the Annals of Internal Medicine, the group says that physicians should also counsel patients on the best practices to reduce firearm-related injuries and deaths. The ACP also supports regulating the purchase of firearms to reduce injuries and deaths, including universal background checks, waiting periods, and banning assault weapons.

Take home: Asking about bike helmets, seat belts, and condom use is routine. So now should be gun presence in the home, especially for patients with dementia, mental health issues, or substance abuse.

Tamiflu, Relenza Data Show Little Clinical Benefit Against Flu

The neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) have only marginal benefits in the treatment and prevention of influenza, a series of BMJ articles concludes.

Investigators reviewed documents submitted to regulatory agencies concerning both drugs. Tamiflu data showed it reduced symptom duration by roughly 17 hours but made no difference in hospital admissions or rates of carefully defined pneumonia. Tamiflu increased nausea and vomiting. As prophylaxis, it greatly reduced symptomatic (but not asymptomatic) cases.

The Relenza analysis similarly showed a modest reduction in symptom duration (14 hours) and no effect on pneumonia. As prophylaxis, it acted like Tamiflu and had fewer side effects.

NEJM Journal Watch Infectious Diseases associate editor Stephen Baum wrote: "Clean out your medicine cabinet: these reviews call into question the drugs' efficacy and side effects, as well as the ways in which data were selectively used to promote them."

Take home: Flu management is best with rest and fluids and close follow up if secondary infections occur. Flu pills were oversold.

NSAID Use Associated with Atrial Fibrillation in Older People

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the elderly is associated with an increased risk for atrial fibrillation (AF), according to a prospective study in BMJ.

Using a Dutch cohort designed to investigate risk factors of disease onset in the aged, researchers followed some 8400 people for 13 years. None had AF at baseline (when their mean age was 69 years).

Current use of NSAIDs for 15 to 30 days was associated with a higher AF risk, relative to never use (adjusted hazard ratio, 1.76). Use in the recent past (within the past 30 days) also brought increased risk (HR 1.84). There was a suggestive dose-response relation, but it didn't reach statistical significance.

The authors speculate that, in addition to possible effects on blood pressure, NSAIDs could cause fluctuations in serum potassium, possibly contributing to the observed association.

Take home: NSAIDs are not without some risk, in particular, cardiac issues. Finding other methods of pain relief such as heat, massage, physical therapy, acetaminophen should be in our toolbox.

Paternal Obesity Seen as an Independent Risk Factor for Autism

A Pediatrics study finds the risk for autism spectrum disorder strongly associated with paternal obesity (that is, with a BMI of 30 or more).

Investigators examined the relationship in a Norwegian cohort of some 93,000 children, whose health was tracked in national databases. By the end of follow-up, at a mean age of 7 years, the odds ratio for autism spectrum disorder among children of obese fathers was 1.53, compared with those of normal-weight fathers. Maternal obesity was not significantly associated.

The authors express surprise at the findings, which suggest an unidentified genetic or epigenetic mechanism.

Take home: Look for research into obesity genes and a linkage to autism genes.

Special thanks again to our friends at NEJM Journal Watch and the British Medical Journal (BMJ).

March 2014 Tips from Mushir Hassan, MD

Anxiolytics & Hypnotics Associated with Long-Term Mortality Hazard

Use of anxiolytic and hypnotic drugs carries an increased mortality risk even after usage stops, according to a retrospective cohort study in BMJ.

Using the U.K.'s General Practice Research Database, researchers followed mortality in roughly 35,000 adults who'd received benzodiazepines; "Z" drugs such as Ambien and Sonata; other anxiolytics and hypnotics; or combinations of the three categories. Users were matched with some 70,000 other patients without such prescriptions.

During roughly 8 years of follow-up, there was an overall doubling of mortality risk among the users relative to controls. The risk remained significant after restricting the analysis to those who only received the drugs in the first year.

After excluding deaths in the first year of follow-up, the authors calculate that there were 4 excess deaths linked to drug use per 100 people followed over the 8-year period.

Take home: Try non-medicinal interventions such as relaxation breathing before asking for the Ambien.

Studies Provide Little Support for Guidelines on Dietary Fats & Supplements

Two new studies demonstrate the shaky underpinnings of guidelines that encourage the intake of omega-3 fatty acids. The first, a large meta-analysis in the Annals of Internal Medicine, examined dietary fatty acid consumption, fatty acid biomarkers, and fatty acid supplements. Among the chief findings:

  • Omega-3 and omega-6 fatty acids: There were trends for modest benefits associated with dietary intake or supplements, but these did not achieve statistical significance.
  • Saturated fatty acids: There was no discernible effect of total saturated fat as measured by either dietary intake or circulating biomarkers.
  • Monounsaturated fatty acids: No effect was found.
  • Trans-dietary fats: A harmful effect was confirmed.

In the second study, published in JAMA Internal Medicine, 4200 patients with age-related macular degeneration were randomized to omega-3 fatty acids; lutein/zeaxanthin (carotenoids found in the eye); both; or placebo. After roughly 5 years, there was no significant reduction in cardiovascular outcomes in the treatment groups.

Commentators say it's now clear that omega-3 supplements "with daily doses close to 1 g in patients with or without established CVD shows no clear, considerable benefit." They conclude that for now, Omega-3’s should be prescribed only for patients with severe hypertriglyceridemia, "an extreme minority of the general population."

Take home: Fish Oil has been oversold. All it really adds is pill burden. Best to eat fish 2-3 servings per week.

Apixaban Gains Indication for DVT Prophylaxis After Knee & Hip Replacement

The FDA has approved the anticoagulant apixaban (Eliquis) for the prophylaxis of deep vein thrombosis (DVT) in patients who have undergone hip or knee replacement surgery. The DVT indication joins the previously approved indication of stroke prevention in patients who have non-valvular atrial fibrillation.

The new indication is based on results of the ADVANCE clinical trial program in which apixaban was compared with enoxaparin in more than 11,000 patients.

Take home: We now have pills instead of shots to reduce risk for clot after joint replacement.

Caregivers Often Absorbed in Mobile Devices During Meals Out with Kids

Caregivers frequently use their mobile devices when eating out with children and often become absorbed in the devices, researchers observed in a study in Pediatrics.

Acting like anthropologists, the researchers sat in fast food restaurants and observed 55 anonymous caregivers with children (aged 0 to 10 years). During the course of the meal, 40 caregivers used a mobile device, 16 of whom used it almost continuously.

While the adults were absorbed in their devices, children often engaged in limit-testing behavior. Adults who were paying attention to their devices often responded by first ignoring the behavior and then scolding the child, giving robotic instructions without looking at the child, not addressing the child's needs, or responding physically.

Take home: Meal time should be screen free time.

Delaying Antibiotics Doesn't Worsen Respiratory Infection Symptoms

Delayed antibiotic prescription is not associated with increased symptom severity in patients with respiratory tract infections, according to a BMJ study.

Clinicians in the U.K. assessed nearly 900 patients aged 3 years and older presenting with respiratory tract infections. A third were deemed to require immediate antibiotics. The remainder were randomized to one of five strategies: They were asked to recontact the clinic for an antibiotic prescription if needed; received a post-dated prescription; were instructed to wait but allowed to collect the prescription from the front desk; received a prescription but were asked to wait to use it; or did not receive a prescription.

The primary outcome — patient-reported symptom severity on days 2 to 4 — did not differ significantly among the groups, including the group prescribed antibiotics immediately. Antibiotic use was also not significantly different across the randomized groups.

Take home: It is not the end of the world if your doctor tells you “this is probably a virus” and to call back if worse next week.

Requiring Flu Vaccination for Child Care Programs Might Reduce Serious Illness

Requiring influenza vaccination for children to attend child care programs in Connecticut was associated with a 12% reduction in flu-related hospitalizations, according to an MMWR article.

In September 2010, the state required that children aged 6 to 59 months in licensed child care programs receive at least one dose of influenza vaccine every year. Researchers found that for children aged 4 years and younger in Connecticut:

  • The influenza vaccination rate increased from 68% during the 2009–2010 flu season to 84% during 2012–2013.
  • The rate of influenza-associated hospitalizations dropped 12% between the 2007–2008 and the 2012–2013 seasons.
  • The drop in hospitalizations was greater than at 10 other sites studied (New Jersey and New York City were not among those studied).

Take home: Another blow to the anti-vaccine crowd. Flu shots work and really should be more widely adopted. Child care programs are a logical place to start.

See also:

Special thanks again to our friends at NEJM Journal Watch.

February 2014 Tips from Mushir Hassan, MD

Annual Screening Mammography Produces Over-diagnoses, No Mortality Benefit

Annual mammography screening in women under age 60 does not confer a breast cancer mortality advantage, and it results in more than 20% over-diagnosis among the lesions found, according to a follow-up of the Canadian National Breast Screening Study.

As reported in BMJ, between 1980 and 1985, some 90,000 women aged 40 to 59 were randomized to 5 years of annual mammography or no mammography (women aged 40-49 in the mammography group and all women aged 50-59 received annual physical breast examinations). After up to 25 years' follow-up, there was no discernible difference between groups in breast cancer mortality. Of the screen-detected tumors, 22% were over-diagnoses — one for every 424 women in the mammography arm.

The NEJM Journal Watch comments: "This important Canadian report documents the failure of screening mammography to impact mortality from breast cancer, as well as breast cancer over-diagnosis. Based on these and other recently published data, clinicians and women should move away from starting screens among women in their 40s and from screening annually. While we reevaluate the practice of screening mammography, adopting the U.S. Preventive Services Task Force 2009 recommendations (beginning screening in average-risk women at age 50 and screening biennially) would appear prudent."

Take home: Yearly Mammogram at 40 may not help you live any longer and may result in unnecessary testing. Test with evidence not fears.

Kids' (Very Low) Rate of Accidental Exposure to Marijuana Increases with Decriminalization

Accidental exposures to marijuana among children under age 10 have increased in states that have liberalized access, according to an Annals of Emergency Medicine study. The absolute risk remains low, however.

Researchers examined records of calls to poison centers from 2005 to 2011. States that eased access before 2005 showed a roughly 30% annual increase in calls; those states with more recent laws easing access had a roughly 10% annual increase that was not statistically significant; and those where marijuana remained illegal showed less than a 2% annual increase, which was also insignificant. The absolute rates in the states with easiest access stood at roughly 15 calls per million residents under age 10 in 2011.

The NEJM Journal Watch comments: "These results suggest that neither patients nor the healthcare system are likely to be substantially affected by marijuana legalization, by showing that spontaneous reports of unintentional ingestion are rare despite legal availability of the drug."

Take home: Legalizing marijuana does not cause an increase in accidental ingestion that ends up in Emergency Departments.

Screening for Asymptomatic Carotid Artery Stenosis

The U.S. Preventive Services Task Force is once again recommending against screening for asymptomatic carotid artery stenosis in the general population. Following are some of the task force's reasons for recommending against screening:

  • The "most feasible" method, ultrasonography, has a high false-positive rate in the general population.
  • There's no reliable way to determine who with carotid stenosis is at increased risk for stroke.
  • There's no evidence that adding cardiovascular medications or increasing current dosages to manage asymptomatic stenosis yields any benefit.
  • Adequate evidence shows that treatment with carotid endarterectomy can cause harm.

The USPSTF concludes "with moderate certainty" that the harms of screening outweigh the benefits.

Take home: Maybe that LifeLine Screening is not needed yearly after all. Finding disease and finding disease that will cause mortality or morbidity are two different things.

Trial Offers Little Support for Early Use of Radiofrequency Ablation in Atrial Fibrillation

A new, industry-supported trial offers little support for early use of radiofrequency ablation to treat atrial fibrillation. The findings appear in JAMA.

Some 130 patients with paroxysmal AF were randomized to antiarrhythmic therapy or radiofrequency ablation as initial treatment. After 2 years, a documented atrial arrhythmia had occurred more often in the drug group than in the ablation group (72% vs. 55%). However, the difference in symptomatic arrhythmias alone, while statistically significant, was much smaller (59% vs. 47%). Four cases of cardiac tamponade occurred with ablation.

The authors note that the high rate of cardiac tamponade indicates that ablation "carries considerable risks that need to be discussed with the patient" when offering it as first-line therapy.

A JAMA editorialist says the overall findings serve as "a powerful endorsement" of the current guidelines, which recommend radiofrequency ablation only after drug therapy has failed.

Take home: Try drugs first before zapping for Atrial Fibrillation.

Endocrine Society Offers Statement on Testosterone Therapy After Recent Reports

In the wake of recent studies pointing to increased risks for cardiovascular events after testosterone therapy, the Endocrine Society has issued a statement that concludes: "Large scale, prospective, randomized controlled trials are needed to determine the risks and benefits of testosterone therapy in older men with age-related decline in testosterone levels."

Until that evidence is available, the Society says, "Patients should be made aware of the potential risk of cardiovascular events in middle-aged and older men who are taking or considering testosterone therapy. ... Physicians and patients should have a conversation about the risks and benefits ... especially in patients who have pre-existing heart disease."

The statement recommends that any prescriptions for testosterone be given in accordance with the Society's practice guidelines.

Take home: As we have discussed previously, treating “low T” is not without risk.

First-Ever Guidelines Issued on Stroke Prevention in Women

The American Heart Association and American Stroke Association have issued the first stroke-prevention guidelines that focus on women's unique risks. Among the recommendations:

  • Pregnant women with chronic hypertension or a history of pregnancy-related hypertension should take low-dose aspirin, beginning at 12 weeks' gestation, to reduce preeclampsia risk.
  • Preeclampsia is a risk factor for stroke later in life, and other risk factors in such women should be treated early.
  • Pregnant women with severe hypertension should receive antihypertensive therapy (e.g., methyldopa, labetalol); those with moderate hypertension (150–159 mm Hg/100–109 mm Hg) may be considered for treatment.
  • Suspicion of cerebral venous thrombosis, more common in women, should warrant routine blood studies: complete blood count, chemistry panel, prothrombin time, and activated partial thromboplastin time.

Take Home: If blood pressure was an issue for you in the past during pregnancy, a discussion on vascular risk factor reduction during the annual physical is a good idea for women.

Program Linked to Professional Soccer Teams Helps Men Lose Weight

Weight loss was significant among overweight soccer fans enrolled in this team-based intervention.

Men are poorly represented in commercial weight-loss programs and clinical trials of weight-loss interventions. Now, researchers report results of a study in which 747 overweight and obese men were recruited through Scottish professional football (soccer) league clubs to participate in a program of dietary advice and physical activity, with context, content, and delivery style tailored specifically to men. The program consisted of 12 weekly sessions conducted by team-employed community coaches in home-team stadiums using team-branded materials and peer-support activities that encouraged male banter, followed by a 9-month weight-loss maintenance phase that involved e-mails and group reunions at team clubs. Participants were randomized to receive the intervention immediately (intervention group) or after a 12-month waiting period (comparison group).

At 12 weeks, mean weight loss was significantly greater in the intervention group than in the comparison group, and the difference was largely unchanged at 12 months. Other 12-month between-group differences that significantly favored intervention participants were waist circumference; percent body fat; blood pressure; and self-reported physical activity, dietary behaviors, psychological health, and physical health–related quality of life.

Take home: Men may not do Weight Watchers but they may respond better to the Manchester United diet program. Male bonding and teaching during bonding are key.

Is the Stethoscope Going to Join Your Typewriter in the Storage Closet?

Point-of-care ultrasound devices, available on eBay for roughly the price of a fancy digital camera, seem poised to be "the stethoscope of the 21st century," according to a review and commentary in Global Heart.

The review's authors praise ultrasound's advantages, especially in the emergency department and the ICU, where treatment decisions have often had to rely on other imaging devices that need to be scheduled and require radiation shielding. They argue for the earlier introduction of the technology into medical school curricula.

Editorialists echo those sentiments, reminding readers that ultrasound has been called a "disruptive technology," in that it's simpler, cheaper, more convenient, and more accessible than those other devices, which rely on highly trained subspecialists to interpret the images

Take home: Ultrasound is cheap, has no radiation, and can be done at the bedside or in an exam room. The key will be ensuring broad consensus on image interpretation.

Special thanks again to our friends at NEJM Journal Watch.Special thanks again to our friends at NEJM Journal Watch.

January 2014 Tips from Mushir Hassan, MD

Heavy Drinking in Middle-Aged Men Found to Speed Cognitive Decline

Middle-aged men drinking 36 g or more of alcohol per day (roughly equivalent to three 12-oz. bottles of beer, or three glasses of wine, or three shots of liquor) experience more rapid cognitive decline than those drinking moderately or less, according to a Neurology study.

Some 5000 men and 2000 women — all British civil servants — self-reported their alcohol consumption levels three times over a 10-year period. Then, over the ensuing 10 years, beginning at roughly age 56, they underwent cognitive testing on three occasions to measure age-related declines.

Declines were steeper among men who were heavy drinkers. In women, an effect was seen starting at the 19-g/day consumption level, but it did not reach statistical significance. The authors say the decline among heavy-drinking men showed an effect size ranging from 2 to 6 extra years of cognitive decline over the 10 years of observation.

Take home: Heavy alcohol use speeds up cognitive decline. Moderation is key.

Melanoma Mortality Has Tripled in Older Men

By NEJM Journal Watch Editors

Since 1950, melanoma incidence has increased more than 20-fold in older men, and the rate of associated mortality in men has tripled, according to a study of Connecticut Tumor Registry data in the Journal of Clinical Oncology.

Take home: Consider a full skin exam with a dermatologist every 2 years, especially those of Caucasian descent.

FDA Warns of Risks from Overdose of OTC Sodium Phosphate for Constipation

The FDA is warning that the over-the-counter constipation drug sodium phosphate (marketed as Fleet, and generics) has been tied to heart and kidney damage and even death when patients exceed the recommended dose.

The agency has identified over 50 serious adverse events related to dehydration and electrolyte disturbances (sodium, calcium, and phosphate) with both the oral and rectal formulations. Most cases occurred in older adults and children younger than 5 years.

The FDA warns:

  • Rectal sodium phosphate should never be used in children under age 2 years.
  • In children 5 years and younger, caution should be used in recommending the oral version.
  • Patients should stay below the maximum recommended dose; they should not take another dose within 24 hours.
  • Patients at higher risk include those older than 55; those with decreased intravascular volume, baseline kidney disease, decreased bowel transit time, or active colitis; and those taking diuretics, ACE inhibitors, angiotensin receptor blockers, or NSAIDs.
  • Patients should be advised to stay well hydrated during use. Electrolytes and renal function should be assessed in high-risk patients.

Take home: Fleets is old school, use Miralax; much safer.

Mediterranean Diet Protects Against Diabetes, Regardless of Weight Loss

Even if it doesn't lead to weight loss, a Mediterranean diet could help prevent type 2 diabetes, according to a subanalysis of the PREDIMED study published in the Annals of Internal Medicine.

Some 3500 adults without diabetes but at high cardiovascular risk were randomized to a Mediterranean diet supplemented by either extra-virgin olive oil or nuts or to a low-fat diet (control). Calorie restriction or increased physical activity was not advised.

After 4 years, diabetes had developed in 6.9% of the olive oil group, 7.4% of the nuts group, and 8.8% of controls. After multivariable adjustment, there was a significant, 40% reduction in diabetes risk in the olive oil group, but no such reduction in the nuts group. The differences in outcome appeared unrelated to weight loss.

The authors conclude that PREDIMED "provides strong evidence that long-term adherence to a Mediterranean diet supplemented with [olive oil] without energy restrictions ... results in a substantial reduction in the risk for type 2 diabetes among older persons with high cardiovascular risk."

Take Home: Everyone should really be using extra virgin olive oil in their cooking.

Shingles an Independent Predictor of Vascular Disease

People who experience herpes zoster (HZ), especially in young adulthood, face increased risks for transient ischemic attack (TIA), stroke, and myocardial infarction (MI), according to a retrospective study in Neurology.

Using a U.K. general practice database, researchers matched some 105,000 zoster cases with 210,000 controls. Vascular events were recorded for up to 24 years after zoster occurrence.

After adjustment for vascular risk factors, herpes zoster was associated with significantly increased risks for TIA and MI but not stroke. In analyses limited to zoster before age 40, risk increases were significant for TIA (hazard ratio, 2.4), MI (HR, 1.5), and stroke (HR, 1.7).

The researchers suggest that the herpes zoster vaccine be offered to adults with risk factors for vascular disease, "irrespective of age, to reduce the associated risk of HZ." They also advocate screening for vascular risk factors in patients with zoster, particularly younger adults "in whom intervention may have the most impact."

Take home: We do not know exactly why, but shingles may be an indicator of the wrong type of inflammation in the body that is harmful for the heart. More reason yet to spend 215 bucks on the shingles shot if you are over 60.

Lung Cancer Screening Recommendations Finalized

The U.S. Preventive Services Task Force has issued its final recommendation on screening for lung cancer in the Annals of Internal Medicine, but not to universal acclaim.

The group recommends annual screening with low-dose computed tomography for adults aged 55 to 80 with a 30-pack-year smoking history who currently smoke or have quit within the past 15 years. Screening is discouraged for those who quit 15 or more years ago or who've developed health problems that substantially limit their life expectancy.

Two editorials accompany the recommendations: One is critical of the USPSTF's use of modeling data to fill gaps in evidence — expressing dismay that the "B" rating (moderate certainty of moderate benefit) will, in effect, mandate coverage for the procedure under the Affordable Care Act. The other editorial asks whether primary care clinicians currently have enough information to advise their patients on screening's benefits and harms.

Take home: Stop smoking. If you do not, get ready for semi regular CT scans which may carry their own inherent risks. Stop Smoking is still best.

Eating Nuts While Pregnant May Protect Offspring Against Allergies

Frequent nut consumption during pregnancy could protect offspring against nut allergies, according to a JAMA Pediatrics study.

Researchers studied physician-confirmed tree nut and peanut allergies among roughly 8200 children (ages 10 to 14 years) whose mothers had completed food-frequency questionnaires around the time they were pregnant.

Mothers who ate five or more servings of nuts per week had reduced risk for nut allergy among their offspring (adjusted odds ratio, 0.58), compared with those who ate less than one serving per month. Risk reductions were observed with just one to four weekly servings. For mothers with existing allergies to tree nuts, high consumption of peanuts (or vice versa) was associated with a nonsignificantly increased allergy risk in their children.

An editorialist concludes: "Pregnant women should not eliminate nuts from their diet as peanuts are a good source of protein and also provide folic acid, which could potentially prevent both neural tube defects and nut sensitization."

Tree nuts include, but are not limited to, walnut, almond, hazelnut, cashew, pistachio, and Brazil nuts. These are not to be confused or grouped together with peanut, which is a legume, or seeds, such as sunflower or sesame.

Take home: Peanuts in pregnancy might actually be helpful. Offspring have less nut allergies if Mom has nuts in pregnancy.

Dietary Supplements Blamed for Sharp Rise in Drug-Related Liver Injuries

Dietary supplements, including many marketed for muscle-building and weight loss, account for a spike in drug-related liver injuries over the past decade, according to a front-page story in Sunday's New York Times. Many patients ultimately recover, but some end up requiring transplants or dying from liver failure.

Supplements accounted for nearly 20 percent of drug-related liver injuries that led to hospitalization in 2010-2012, the Times reports, up from 7 percent in 2004. The data, from the NIH's National Liver Network, showed that many of the products were bodybuilding supplements that contained steroids not listed on the label. Use of green tea extract was also frequently reported. The extract contains catechins, which are said to increase metabolism; in high doses, they can cause liver toxicity.
Of over 50,000 supplements sold in the U.S., less than 1% have been examined well enough to determine their adverse effect profile, one expert told the Times.

Take home: Supplements that are “Natural” may not always be safe. There is less FDA monitoring of this arena, instead market forces tend to control what is desired. This means that customers are guinea pigs in many cases. No thanks.

2000 Steps a Day May Keep the Doctor Away

Walking 2000 steps a day — about 20 minutes of moderate-intensity walking — can lower the odds of cardiovascular events among high-risk adults, according to an analysis from the NAVIGATOR trial published in the Lancet.

Researchers studied some 9300 adults aged 50 and older with existing cardiovascular disease or impaired glucose tolerance and at least one additional cardiovascular risk factor. Ambulatory activity was measured with a pedometer for 7 days at baseline and 1 year.

During roughly 6 years' follow-up, 531 cardiovascular events occurred. Each 2000-step/day increment in ambulatory activity at baseline was associated with a roughly 10% lower risk for cardiovascular events. Similarly, each 2000-step increase in activity from baseline to 1 year was associated with an 8% lower risk, while each 2000-step decrease conferred an 8% higher risk.

Commentators say the trial "adds compelling and reassuring evidence for the benefits of physical activity on cardiovascular health."

Take home: Get a pedometer, get your 2000 steps a day in and then keep adding more in. Walk with A Wheaton Doc is a nice way to get these in too.

Thanks to our friends at NEJM Journal Watch/First Watch for their helpful links and summaries cited above.

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