Bisher AKIL, MD

Archive for the ‘General Health’ Category

Obesity: Myths and Facts

In General Health on February 25, 2013 at 7:03 am

Researchers identify a variety of myths about obesity and deliver sometimes-unpleasant countervailing facts in the New England Journal of Medicine. Among them:

Myth: Sexual activity is a good form of exercise.

Fact: It may be intense, but it’s not long-lasting enough to be much better than watching television, calorically speaking.

Myth: Breast-feeding infants protects them from obesity later in life.

Fact: Studies that controlled for confounding found no evidence of a protective effect.

Myth: Patients should set realistic goals for weight loss. Otherwise they might become frustrated and not lose as much.

Fact: Studies have shown that patients who set more ambitious goals are likely to lose more weight.

Citation:Myths, Presumptions, and Facts about Obesity, N Engl J Med 2013; 368:446-454; DOI: 10.1056/NEJMsa1208051

How effective is HPV vaccination?

In General Health, Immune System on February 25, 2013 at 12:18 am

The quadrivalent human papillomavirus (HPV) vaccine prevented genital wart acquisition among women in clinical trials , but its effect at the population level is just beginning to be evaluated. In Denmark, routine free HPV vaccination of 12-year-old girls was introduced in 2009, and the current estimated coverage is 80% for all three doses. Now, investigators have assessed the incidence of genital warts in 55% of the Danish population from 1996 to 2011. Annual incidence of genital warts rose in both women and men from 1996 to 2008, when a downward turn was noted among women but not men. This reduction was especially pronounced among 16- to 17-year-old women, in whom incidence fell 10-fold (from 382 per 100,000 to 40 per 100,000). During this period, prevalence of chlamydia and syphilis continued to rise.

Comment: The drop in prevalence of genital warts but not other sexually transmitted diseases suggests that the human papillomavirus vaccine — and not a behavioral change in the target population — was primarily responsible for this beneficial outcome. It also indicates the need to vaccinate both men and women. Such studies also demonstrate how countries with healthcare systems that allow for efficient delivery of preventive care as well as rapid assessment of the benefits at the national level. The U.S. would do well to learn from such successes.

CITATION: Baandrup L et al. Significant decrease in the incidence of genital warts in young Danish women after implementation of a national human papillomavirus vaccination program. Sex Transm Dis 2013 Feb; 40:130.

Published in Journal Watch Women’s Health

Eggs and CVD

In General Health, Heart on February 25, 2013 at 12:04 am

The American Heart Association (AHA) recommends consuming <300 mg of cholesterol daily (Circulation 2006; 114:82), to lower blood cholesterol and cardiovascular disease risk(CVD), and because chicken eggs are high in cholesterol (about 200 mg each), clinicians commonly advise patients with elevated blood cholesterol to avoid eating them. However, the association between egg consumption and cardiovascular disease is unclear. In a meta-analysis of 17 prospective cohort studies in which egg consumption was measured with food-frequency questionnaires, investigators assessed this association.The analysis included nine reports on coronary heart disease (CHD) and eight reports on stroke, with 10 to 20 years of follow-up in most studies. No associations between egg consumption and risk for CHD or stroke were observed. However, subgroup analyses of diabetic patients in which highest and lowest egg consumption were compared showed excess risk for CHD (relative risk, 1.5) and less risk for hemorrhagic stroke (RR, 0.8).

Comments: Another myth is challenged. This meta-analysis shows little association between egg consumption and coronary heart disease or stroke, and consumption was not associated with coronary heart disease or stroke except for excess CHD risk in diabetic patients, suggesting that most patients don’t need to avoid eggs. The findings are consistent with metabolic research showing that, in most people, dietary saturated and trans fatty acids influence serum LDL cholesterol more than dietary cholesterol does. As the authors note, chicken eggs are inexpensive and rich in protein and other nutrients.

CITATION: Rong Y et al. Egg consumption and risk of coronary heart disease and stroke: Dose-response meta-analysis of prospective cohort studies. BMJ 2013 Jan 7; 346:e8539. Appeared in Journal Watch General Medicine.

Elevated Serum Uric Acid Predicts Metabolic Syndrome in Adolescents

In General Health, Heart on June 20, 2012 at 8:59 pm

Elevated uric acid (UA) is one of a number of clinical abnormalities associated with the metabolic syndrome in adults and children. To examine this association in adolescents, researchers followed 613 randomly selected male adolescents (age range, 10–15 years) from a health screening center in Taiwan for a mean of 2.7 years. Baseline UA, waist circumference, blood pressure (BP), body-mass index (BMI), fasting plasma glucose, and cholesterol levels were measured at baseline and follow-up. Adolescents with metabolic syndrome, type 1 diabetes, hypertension, or hyperlipidemia at baseline were excluded. Adolescents were divided into quartiles according to UA levels, ranging from lowest (mean, 5.2 mg/dL) to highest (mean, 8.9 mg/dL). Nineteen adolescents (3.1%) developed metabolic syndrome as defined by the International Diabetes Federation consensus criteria (>3 of the following: abdominal obesity, triglycerides 150 mg/dL, high-density lipoprotein cholesterol <40 mg/dL, hypertension, and fasting plasma glucose 100 mg/dL). Age, waist circumference, BMI, BP, high-density lipoprotein cholesterol, and triglycerides were significantly associated with baseline UA. Risk for developing metabolic syndrome was significantly greater in adolescents in the highest UA quartile than in those in the lowest quartile (odds ratio, 6.39). The positive predictive value of a baseline UA value of 7.6 mg/dL for developing metabolic syndrome was 79% and the negative predictive value was 94%. Higher UA, waste circumference, and BP were independently predictive of metabolic syndrome at follow-up. Conclusion: Male adolescents with the highest uric acid levels at baseline were 6 times more likely to develop metabolic syndrome after 3 years

 Comments: small but interesting data. The positive predictive value is somewhat low but was strong. This is another marker in this disease _ BA

CITATION(S):

  1. Wang J-Y et al. Predictive value of serum uric acid levels for the diagnosis of metabolic syndrome in adolescents. J Pediatr 2012 May 11
  2. Journal Watch

Metabolic Syndrome: Metabolic syndrome is a name for a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes.

For more info: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004546/

low dose aspirin and risk of bleeding

In General Health, Heart on June 20, 2012 at 5:09 pm

Low-dose aspirin use lowers risk for recurrent adverse cardiovascular (CV) events in patients with known CV disease. Its benefit for primary prevention of CV events, especially in low-risk patients (those with 10-year risk <10%), is less clear given the risk for complications, particularly major bleeding. In this Italian study, researchers used a population-based database to identify 186,425 patients (mean age, 69) who took low-dose aspirin (81-83 mg) daily for at least 75 days and matched them to the same number of control patients who had the same bleeding propensity and did not use aspirin. During median follow-up of 5.7 years, 6907 episodes of major bleeding requiring hospitalization in aspirin and control patients occurred; about two thirds of bleeds were gastrointestinal, and one third were intracranial. The incidence rate was 5.58 events per 1000 person-years in aspirin users and 3.60 for nonusers, an excess of 2 per 1000 person-years.

Editorial: This is an observational study, and other factors could not be accounted for, these factors could change the outcome / conclusion of this study. Nevertheless, these are important data. An editorial that accompanied this study in JAMA,  puts these risks into perspective with the calculation that, for 10,000 patients without known cardiovascular (CV) disease followed for 1 year, aspirin would prevent about seven (7) major CV events and would cause four (4) major bleeding events. Not a big benefit! Other data have shown different results, , in 10,000 patients with known CV disease, aspirin use would prevent about 250 major CV events and would cause about 40 major bleeding events.

CITATION(S): 1. De Berardis G et al. Association of aspirin use with major bleeding in patients with and without diabetes. JAMA 2012 Jun 6; 307:2286.

2. Siller-Matula JM. Hemorrhagic complications associated with aspirin: An underestimated hazard in clinical practice? JAMA2012 Jun 6; 307:2318.

3. Journal Watch & Thomas L. Schwenk, MD

 

Let them eat choclate.

In General Health on June 1, 2012 at 6:28 pm

Dark chocolate may be a cost effective — and palatable — option to reduce cardiovascular risk in high-risk patients, according to a new study.
To construct their model, Australian researchers used data from meta-analyses that showed dark chocolate consumption reduced systolic blood pressure by 3.2 mm Hg and LDL cholesterol by 0.15 mmol/L (roughly 6 mg/dL). The model included 2000 people with hypertension and metabolic syndrome who were free of cardiovascular disease.They calculated that over a decade, regular dark chocolate consumption could prevent 70 nonfatal cardiovascular events and 15 cardiovascular-related deaths per 10,000 population treated. The strategy would be cost effective if $42 was spent per person per year on a dark chocolate prevention strategy (e.g., advertising, educational campaigns, or chocolate subsidies). The strategy would still be cost effective with only 80% compliance. The authors conclude: “Chocolate benefits from being by and large a pleasant, and hence sustainable, treatment option. Evidence to date suggests that the chocolate would need to be dark and of at least 60-70% cocoa, or formulated to be enriched with polyphenols.” This paper published in British Medical Journal (  BMJ 2012;344:e3657   ) comes after another study showing the benefit of dark chocolate in blood pressure control. In a randomized, investigator-blinded trial, German researchers evaluated whether low doses of polyphenol-rich dark chocolate offer benefits. Forty-four adults (mean age, 64) with untreated pre- or stage 1 hypertension (mean blood pressure [BP], 147/87) received daily supplements of either dark chocolate (6.3 g — about the weight of 1.5 Hershey’s Kisses) or polyphenol-free white chocolate. Participants had no other cardiovascular or metabolic disease and maintained their usual diet and physical activity. At 18 weeks, mean systolic BP declined by 2.9 mm Hg and diastolic BP by 1.9 mm Hg in the intervention subjects, with no change in control subjects. The BP reductions were associated with a significant increase in S-nitrosoglutathione, a marker of nitric oxide activity. No significant changes were noted in weight, cholesterol profile, or other metabolic parameters.( Taubert D et al. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide: A randomized controlled trial. JAMA 2007 Jul 4; 298:49-60.)

Comments: these remain small studies and large trials might be needed; in the meantime a little dark chocolate might be healthy treat_BA

Appeared in Physician’s First Watch

Just get up!

In General Health on May 31, 2012 at 11:40 pm

According to epidemiologic data, just a few minutes of physical activity hourly can confer metabolic benefit in otherwise sedentary people. To explore this possibility further, researchers conducted a randomized crossover trial that involved 19 sedentary, nondiabetic, overweight adult volunteers. On 3 separate days, each person received a liquid test meal (containing carbohydrates and fats) followed by five hourly measurements of blood glucose and insulin. On one study day, participants remained seated throughout the 5 hours; on a second day, they interrupted sitting with 2-minute light-intensity walks (2 miles/hour) every 20 minutes; and on a third day, they interrupted sitting with 2-minute moderate-intensity walks (3.5–4.0 miles/hour) every 20 minutes. The mean areas under the 5-hour curves for insulin and glucose were significantly lower (by about 25%) during both the light-activity day and the moderate-activity day, compared with the completely sedentary day. In other words, brief periods of activity blunted serum glucose and insulin responses to meals.

Comments: this is intriguing and needs further testing; however, at least your back will thank you if you get up every hour; I am told there are computer programs that puts your computer in a suspended mode for few minutes every hour. BA

CITATION(S):

Dunstan DW et al. Breaking up prolonged sitting reduces postprandial glucose and insulin responses. Diabetes Care 2012 May; 35:976

Journal Watch 5/31/2012

Resistant Gonorrhea

In General Health on July 21, 2011 at 12:22 am

Recent reports from the West Coast and from Japan described a new strains gonococci (gonorrhea, GC) and that is a concern. Here is a summary and update. The current recommendations for treating Neisseria gonorrhoeaeinfection involve the use of a cephalosporin plus either azithromycin or doxycycline. In May 2011, the CDC reported the isolation of azithromycin-resistant gonococci from five male patients at a sexually transmitted disease (STD) clinic in California. Then earlier this month, a report presented at a meeting of the International Society for Sexually Transmitted Diseases Research in Quebec City, described a
strain of N. gonorrhoeae highly resistant to ceftriaxone . The organism was discovered in samples from Kyoto, Japan[ Ohnishi M et al. The new superbug Neisseria gonorrhoeaemakes gonorrhoea untreatable? — First high-level ceftriaxone resistance worldwide and public health importance. 19th Biennial Conference of the International Society for Sexually Transmitted Diseases Research, Quebec City, Canada, July 2011. Abstract O3-S4.01] The strain shows four- to eightfold higher levels of resistance to ceftriaxone than any previously described isolate, according to the meeting abstract. The organism is also resistant to “all other cephalosporins, as well as most other antimicrobials tested.”The strain’s resistance to ceftriaxone, the last line of defense against treatment failures in the disease, represents “a large public health problem,” the abstract says. It continues: “The era of untreatable gonorrhea may now have been initiated.” – Now, the CDC urges confirmation of treatment success, especially in MSM in the western U.S., by having patients return for testing (preferably with culture) 1 week after treatment. Patients with cefixime treatment failure should be retreated with 250 mg of ceftriaxone intramuscularly and 2 g of azithromycin orally. In cases involving ceftriaxone treatment failure, an infectious diseases expert and the CDC should be consulted. All isolates with decreased cefixime or ceftriaxone should be reported to local or state health departments and, ultimately, to the CDC (gipsinfo@cdc.gov). Source: [Centers for Disease Control and Prevention (CDC). Cephalosporin susceptibility among Neisseria gonorrhoeaeisolates — United States, 2000–2010. MMWR Morb Mortal Wkly Rep 2011 Jul 8; 60:873.] _ Comments: Confirmation of the infection (cultures) should be obtained when GC is suspected, then proper treatment as described above need be given, then a repeat of the culture, now that we have this serious threat. Treaters should not cut-corners .BA


Exercises to help Sleep Apnea

In General Health on May 20, 2009 at 5:13 pm

Continuous positive airway pressure (CPAP) is tolerated poorly by many patients with obstructive sleep apnea (OSA). Certain patients have experienced positive outcomes with less-obtrusive interventions (e.g., mandibular advancement devices, weight reduction), and, now, Brazilian researchers introduce yet another alternative — oropharyngeal exercises. A study that published in May 2009 looked at oropharyngeal exercises to help OSA. Thirty-one patients with moderate OSA (apnea-hypopnea index, 15–30 events hourly) were randomized to weekly sessions that involved instruction in either oropharyngeal exercises (intervention group) or deep-breathing exercises (control group); patients repeated the exercises at home daily. A speech pathologist taught the intervention program, which involved repetitive exercises of the soft palate, tongue, and facial muscles, as well as breathing, speech, swallowing, and chewing exercises (video). At 3 months, mean apnea-hypopnea indexes were unchanged in the control group but had decreased significantly in the intervention group (from about 22 to about 13 events hourly). Sleepiness and sleep-quality scores also improved significantly only in the intervention group. Source: Published in Journal Watch. Guimarães KC et al. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2009 May 15; 179:962. Comments: although no diet, weight loss or improvement in over health has been studied in combination with these exercises, it seems that simply  reducing the size of the neck would help reduce sleep apnea._BA


Can we predict dementia?

In General Health on May 14, 2009 at 7:44 pm

The goal is too develop a late-life dementia risk index that can accurately stratify older adults into those with a low, moderate, or high risk of developing dementia within 6 year. The authors of this paper developed a 15-point risk index can identify older adults at low, intermediate, and high risk for dementia. Researchers studied nearly 3375 adults aged 65 or older,without evidence of dementia at baseline. We used logistic regression to identify those factors most predictive of developing incident dementia within 6 years and developed a point system based on the logistic regression coefficients.14% of whom developed dementia over 6 years’ follow-up. The researchers then identified independent predictors of dementia — including older age, poor cognitive test scores, history of coronary bypass, slow physical performance, and lack of alcohol consumption — and incorporated them into a risk prediction tool. Each factor was assigned 1 to 2 points, for a maximum score of 15. The tool accurately predicted which participants were likely to develop dementia. For example, dementia developed in 56% of subjects with high risk scores but only 4% of those with low scores. The authors say their prediction tool “could be used clinically to identify older adults who do not currently have overt dementia symptoms but who should be monitored more closely for signs of cognitive impairment.”. Published  online before print on May 13, 2009 (Neurology 2009)