Friday, December 27, 2013

Whenever I would go to the dentist - tooth pain or not - the dentist would want to take a set of xrays. Sometimes that was good as it helped find an underlying problem, but on other occasions - particular "annual xrays" - there seemed to be no purpose to them. Now an L.A. Times articles explores what really is the necessity of dental xrays.



Drilling down on the necessity of dental X-rays

Experts say new methods reduce radiation exposure, and X-rays should be taken when necessary but not as a matter of routine.

Dental x-rays
 An X-ray machine is lined up on a young patient. Doctors say children are more vulnerable to radiation exposure. (Rick Gomez / Getty Images/Blend Images)



By Emily Dwass
December 20, 2013, 2:08 p.m.

When my son and daughter were youngsters, once a year I'd have a disagreement with their pediatric dentist. He wanted to do routine annual X-rays, and I would protest because neither child ever had any cavities. His response: Dental X-rays are an important diagnostic tool, representing a small speck in the sea of radiation that we receive by inhabiting planet Earth.

It turns out we both were right. Dental X-rays are essential for detecting serious oral and systemic health problems, and generally the amount of radiation is very low. But new thinking on dental X-rays is that the "one size fits all" schedule is outdated.

"The notion of bite-wing X-rays every year and a full set of X-rays every three years for every patient should go in the garbage can," says Stuart White, a dentist and professor emeritus at the UCLA School of Dentistry. Instead, decisions should be made individually.

Emphasizing that "without dental X-rays we would go back 120 years, and disease detection would be primitive and awful," White says dentists must strive to minimize unnecessary exposure.
And this is where the discussion gets complicated because the amount of radiation you receive depends on how the dentist takes pictures of your teeth.

For example, if your dentist uses slow film and round collimation (the piece of equipment placed near your face during X-rays), you're going to get approximately double the dose that you would from digital imagery and rectangular collimation.

"All dentists should follow the ALARA principle (as low as reasonably achievable) when determining what X-rays to order. Adhering to this principle will minimize the patient's radiation exposure," says Dr. Mark Kirkland, an associate dean at the UC San Francisco School of Dentistry.
So why would any dentist favor equipment that ups the dose of radiation?

"They're used to one system and they don't want to change it," says Dr. Elham Radan, director of the radiology clinic at USC's dentistry school.

But even dentists who haven't switched to digital imagery can reduce patients' risk by opting for faster film, Radan says, adding that "another important factor is that the technician who is taking the images is well-trained and skilled, which reduces the amount of re-exposures."

As for round collimation, the problem is that it exposes more tissue, including the salivary glands, which are sensitive to radiation. Changing to rectangular collimation is not a big expense — systems can be converted for a few hundred dollars.

The ionizing radiation in X-rays is especially worrisome for children because their developing tissue is more vulnerable. There is concern about a new trend in orthodontics as popularity grows for cone-beam CT scanners, used to create 3-D images. Radiation doses from these machines can vary dramatically, depending on the manufacturer and settings.

Cone-beams are useful for oral surgeons, White says, but he criticizes routinely doing 3-D imaging when kids need braces.

Whenever any kind of dental X-ray is done, patients should wear protective lead aprons with thyroid collars. (However, the collar cannot be worn with all radiography, because sometimes it blocks the image.)

The aprons do not shield us from internal radiation "scattering," especially with sensitive tissue like the thyroid gland. That's why it's important to reduce the X-ray beam to the smallest size that provides necessary information, says Sharon Brooks, a dentist and an expert at the nonprofit Health Physics Society, devoted to radiation safety.

Dental X-rays made news in 2012 after the American Cancer Society journal Cancer published a widely criticized study saying that people with one type of brain tumor remembered having twice as many dental X-rays as individuals in the control group, who did not have brain tumors.

Such studies, which rely on participants' memories, can be problematic, says Dr. Otis Brawley, the society's chief medical officer. He adds that, ideally, the controversial research will be used "to justify doing a larger, more definitive study, actually trying to show causality."

But Brawley says the message of the study is valid: Dental X-rays should be done only when medically indicated, tailored to each patient's health needs.

Monday, December 23, 2013

Should the vitamin industry be better regulated? With a rise in liver damage, mislabeling, incorrect dosages listed, and counterfeit offshore products, a N.Y. Times article raises the question. Can all manufacturers be trusted to determine safety and efficacy, or will a few problem companies end up altering the 1994 Supplement Act to force FDA oversight?



Spike in Harm to Liver Is Tied to Dietary Aids




Michael Stravato for The New York Times
Christopher Herrera and his mother, Lordes Gonzalez, at home in Katy, Tex. A green tea extract nearly cost Christopher his liver.


When Christopher Herrera, 17, walked into the emergency room at Texas Children’s Hospital one morning last year, his chest, face and eyes were bright yellow — “almost highlighter yellow,” recalled Dr. Shreena S. Patel, the pediatric resident who treated him. 

Chester Higgins Jr./The New York Times 

About 55,000 dietary supplements, largely unregulated, are sold in the United States. 

Christopher, a high school student from Katy, Tex., suffered severe liver damage after using a concentrated green tea extract he bought at a nutrition store as a “fat burning” supplement. The damage was so extensive that he was put on the waiting list for a liver transplant

“It was terrifying,” he said in an interview. “They kept telling me they had the best surgeons, and they were trying to comfort me. But they were saying that I needed a new liver and that my body could reject it.” 

New data suggests that his is not an isolated case. Dietary supplements account for nearly 20 percent of drug-related liver injuries that turn up in hospitals, up from 7 percent a decade ago, according to an analysis by a national network of liver specialists. The research included only the most severe cases of liver damage referred to a representative group of hospitals around the country, and the investigators said they were undercounting the actual number of cases. 

While many patients recover once they stop taking the supplements and receive treatment, a few require liver transplants or die because of liver failure. Naïve teenagers are not the only consumers at risk, the researchers said. Many are middle-aged women who turn to dietary supplements that promise to burn fat or speed up weight loss. 

“It’s really the Wild West,” said Dr. Herbert L. Bonkovsky, the director of the liver, digestive and metabolic disorders laboratory at Carolinas HealthCare System in Charlotte, N.C. “When people buy these dietary supplements, it’s anybody’s guess as to what they’re getting.” 

Though doctors were able to save his liver, Christopher can no longer play sports, spend much time outdoors or exert himself, lest he strain the organ. He must make monthly visits to a doctor to assess his liver function. 

Americans spend an estimated $32 billion on dietary supplements every year, attracted by unproven claims that various pills and powders will help them lose weight, build muscle and fight off everything from colds to chronic illnesses. About half of Americans use dietary supplements, and most of them take more than one product at a time. 

Dr. Victor Navarro, the chairman of the hepatology division at Einstein Healthcare Network in Philadelphia, said that while liver injuries linked to supplements were alarming, he believed that a majority of supplements were generally safe. Most of the liver injuries tracked by a network of medical officials are caused by prescription drugs used to treat things like cancer, diabetes and heart disease, he said. 

But the supplement business is largely unregulated. In recent years, critics of the industry have called for measures that would force companies to prove that their products are safe, genuine and made in accordance with strict manufacturing standards before they reach the market. 

But a federal law enacted in 1994, the Dietary Supplement Health and Education Act, prevents the Food and Drug Administration from approving or evaluating most supplements before they are sold. Usually the agency must wait until consumers are harmed before officials can remove products from stores. Because the supplement industry operates on the honor system, studies show, the market has been flooded with products that are adulterated, mislabeled or packaged in dosages that have not been studied for safety. 

The new research found that many of the products implicated in liver injuries were bodybuilding supplements spiked with unlisted steroids, and herbal pills and powders promising to increase energy and help consumers lose weight. 

“There unfortunately are criminals that feel it’s a business opportunity to spike some products and sell them as dietary supplements,” said Duffy MacKay, a spokesman for the Council for Responsible Nutrition, a supplement industry trade group. “It’s the fringe of the industry, but as you can see, it is affecting some consumers.” More popular supplements like vitamins, minerals, probiotics and fish oil had not been linked to “patterns of adverse effects,” he said. 

The F.D.A. estimates that 70 percent of dietary supplement companies are not following basic quality control standards that would help prevent adulteration of their products. Of about 55,000 supplements that are sold in the United States, only 170 — about 0.3 percent — have been studied closely enough to determine their common side effects, said Dr. Paul A. Offit, the chief of infectious diseases at the Children’s Hospital of Philadelphia and an expert on dietary supplements. 

“When a product is regulated, you know the benefits and the risks and you can make an informed decision about whether or not to take it,” he said. “With supplements, you don’t have efficacy data and you don’t have safety data, so it’s just a black box.” 

Since 2008, the F.D.A. has been taking action against companies whose supplements are found to contain prescription drugs and controlled substances, said Daniel Fabricant, the director of the division of dietary supplement programs in the agency’s Center for Food Safety and Applied Nutrition. For example, the agency recently took steps to remove one “fat burning” product from shelves, OxyElite Pro, that was linked to one death and dozens of cases of hepatitis and liver injury in Hawaii and other states. 

The new research, presented last month at a conference in Washington, was produced by the Drug-Induced Liver Injury Network, which was established by the National Institutes of Health to track patients who suffer liver damage from certain drugs and alternative medicines. It includes doctors at eight major hospitals throughout the country. 

The investigators looked at 845 patients with severe, drug-induced liver damage who were treated at hospitals in the network from 2004 to 2012. It focused only on cases where the investigators ruled out other causes and blamed a drug or a supplement with a high degree of certainty. 

When the network began tracking liver injuries in 2004, supplements accounted for 7 percent of the 115 severe cases. But the percentage has steadily risen, reaching 20 percent of the 313 cases recorded from 2010 to 2012. 

Those patients included dozens of young men who were sickened by bodybuilding supplements. The patients all fit a similar profile, said Dr. Navarro, an investigator with the network. 

“They become very jaundiced for long periods of time,” he said. “They itch really badly, to the point where they can’t sleep. They lose weight. They lose work. I had one patient who was jaundiced for six months.” 

Tests showed that a third of the implicated products contained steroids not listed on their labels. 

A second trend emerged when Dr. Navarro and his colleagues studied 85 patients with liver injuries linked to herbal pills and powders. Two-thirds were middle-aged women, on average 48 years old, who often used the supplements to lose weight or increase energy. Nearly a dozen of those patients required liver transplants, and three died. 

It was not always clear what the underlying causes of injury were in those cases, in part because patients frequently combined multiple supplements and used products with up to 30 ingredients, said Dr. Bonkovsky, an investigator with the network. 

But one product that patients used frequently was green tea extract, which contains catechins, a group of potent antioxidants that reputedly increase metabolism. The extracts are often marketed as fat burners, and catechins are often added to weight-loss products and energy boosters. Most green tea pills are highly concentrated, containing many times the amount of catechins found in a single cup of green tea, Dr. Bonkovsky said. In high doses, catechins can be toxic to the liver, he said, and a small percentage of people appear to be particularly susceptible. 

But liver injuries attributed to herbal supplements are more likely to be severe and to result in liver transplants, Dr. Navarro said. And unlike prescription drugs, which are tightly regulated, dietary supplements typically carry no information about side effects. Consumers assume they have been studied and tested, Dr. Bonkovsky said. But that is rarely the case. “There is this belief that if something is natural, then it must be safe and it must be good,” he said.

Wednesday, December 18, 2013

As a society we seem to take a pill for everything, not the least of which is idiopathic high blood pressure. But now according to a study reported in the Wall Street Journal, new guidelines say hold up on the drugs as lower blood pressure is not always better.



U.S. News: The Wall Street Journal

New Guidelines Say Lower Blood Pressure Not Always Better

Experts Raise Level at Which Older People Should Start Drugs


Updated Dec. 18, 2013 11:25 a.m. ET
 
New treatment guidelines for high blood pressure take a step back from the long-standing position that lower is always better when managing hypertension, easing the target range for people age 60 and over.

The recommendations from an expert panel say doctors should prescribe drugs to control blood pressure to these older patients whose levels are 150/90 or higher. The previous threshold for beginning treatment was 140/90.

The guidelines also raise the level to begin treatment to 140/90 for people between ages 20 and 59 who have diabetes or kidney disease. The target for those patients was previously 130/80.

For all other adults, 140/90 remains the trigger to consider taking drugs to lower the numbers.

The recommendations, being published online Wednesday by the Journal of the American Medical Association, come on the heels of new cholesterol guidelines released last month that also backed away from an aggressive lower-is-better stance that long had guided treatment policy. 

But at the same time, the cholesterol recommendations lowered the risk threshold for starting treatment with cholesterol-lowering drugs called statins and increased the number of people considered candidates for the medicines.

In both cases, the pullback reflects a lack of persuasive evidence from rigorous clinical trials that meeting the specific goals significantly reduced the risk of death, heart attacks and strokes. Experts also were concerned that any marginal benefits from achieving aggressive targets would be offset by side effects from the drugs or unnecessary use of unproven treatments.

But the new recommendations—especially raising the target to 150 for older people—drew concern in an editorial accompanying their publication in JAMA. Eric Peterson, a cardiologist at Duke Clinical Research Institute in Durham, N.C., and two other experts noted that one major study linked a five-year lowering of the top number to 143 from 155 resulted in a 32% reduction in heart attacks and other cardiovascular events. 

"Whether this change [to the higher target] will have adverse consequences for population health is unclear," they wrote. 

About 78 million Americans are diagnosed with high blood pressure, according to the American Heart Association, about half of whom have it controlled with medicine to levels below 140/90. The condition becomes more prevalent as people age. High blood pressure is a key risk factor for heart attacks, strokes, diabetes and kidney disease and keeping it under control is a mainstay of prevention efforts for those conditions.

Optimal blood pressure has long been regarded as below 120/80 and for natural or untreated levels, that is still the case, said Paul James, a family medicine doctor at University of Iowa Hospitals and Clinics and lead author of the new recommendations. "People with a blood pressure of 120 have lower health risks than people with 130 or 140," he said. But there isn't a clear association between drug treatment and health benefits, he added.

The first-line strategy for controlling blood pressure is healthy diet and exercise habits and can work for many patients. The new guidelines address only when intervention with drugs should begin.

Richard Krasuski, a cardiologist at the Cleveland Clinic, said the recommendations would give physicians and older patients more flexibility in managing hypertension. "If anything, 150 rather than 140 will make it a little easier for the clinician and the patient," he said.

Many older patients take two or three pills to control their blood pressure on top of other drugs to manage other illnesses, and the resulting side effects can cause people to stop taking the medicines.

"In some cases, we might have become overzealous" with the lower-is-better idea, Dr. Krasuski said. "When you start pushing those therapies up, people start feeling worse and the data suggest they don't do better clinically." And if they go off the drugs, they lose the benefit entirely.

The guidelines say four long-established classes of blood-pressure medicines—thiazide diuretics, calcium channel blockers, ACE inhibitors and angiotensin receptor blockers, or ARBs—all are appropriate for starting patients on medical therapy. The previous guidelines, published in 2003, recommended doctors start patients on diuretics.

In another difference from the previous guidelines, the expert panel didn't make any mention of "pre-hypertension," a category between 120/80 and 140/90 for which the earlier advice suggested medication could be considered. But clinical trials don't show a benefit from treating such patients.

The recommendations were based only on data from randomized clinical trials, considered the gold standard in guiding the use of drugs. But despite decades of research and hundreds of thousands of patients who have participated in trials of blood-pressure drugs, convincing data that links treatment to prevention of major events is limited.

The panel rated the evidence behind each recommendation, and only two of 11 were rated A—reflecting high confidence in the data. Six of the recommendations were rated E, meaning expert opinion—the weakest evidence.

The recommendations were developed by a group called the Eighth Joint National Committee on Prevention, Detection Evaluation and Treatment of High Blood Pressure.

Monday, December 16, 2013

This holiday season - with so many small toy parts, candies. nuts, and decorations around the house - it's important to remember the need to keep choking hazards away from children. It is easy to forget or think that something won't be a problem when indeed it can be. A new article. from the NYT, on the need to think about your child's safety is a good reminder while also featuring a CPR "How-To.".


Keeping Little Breaths Flowing

 

By JANE E. BRODY
A lifeguard practices CPR on an infant dummy. 
Maxine Hicks for The New York Times A lifeguard practices CPR on an infant dummy.
 
 
In October, Maja Djukic was rollerblading in Greenwich, Conn., when she heard a woman screaming for help. Ms. Djukic, an assistant professor at New York University College of Nursing, rushed to a nearby house to find 19-month-old Griffin Greene limp and blue. He had inhaled a Goldfish cracker, and his mother’s attempts to dislodge it by holding the toddler upside down and slapping his back had failed.

While the child’s father called 911, Ms. Djukic performed chest compressions, she recalled in an interview. By the time the ambulance arrived — about four minutes later — Griffin was breathing again and crying. Although he needed treatment to extract the cracker, which had become lodged in his lungs, Griffin is now fine thanks to the quick action of a passer-by.

Not every child who chokes is so lucky. Choking is the fourth-leading cause of unintentional deaths in children under age 5; every five days, at least one child dies after choking on food.

The trachea, or windpipe, of a young child is about the width of a drinking straw, and if food or a small object is inhaled instead of swallowed, it can block the airway. Even when something is swallowed and becomes lodged in a child’s throat or esophagus, it may compress the trachea enough to impair breathing. After just four minutes without oxygen, a child’s brain can be permanently damaged.

Even though both of Griffin’s parents were with him when this near-tragedy occurred, neither knew what to do to save him. Few parents of newborns are taught how to prevent choking and what to do if it occurs. Yet infants and toddlers routinely explore the world with their mouths, and anything they may find lying about can become a choking hazard.

Nearly every day, I see a statistic in the making among small children in my neighborhood. Under the care of a parent, grandparent or nanny, they are routinely given all manner of snacks and allowed to run back to their activities — while still chewing. It is a disaster waiting to happen, and sometimes I can’t resist saying aloud that the child should not get up until his food has been thoroughly chewed and his mouth is empty.

A child should not eat in a moving vehicle, either. If the driver stops short or the vehicle is bumped from behind, the sudden lurch may cause a child to inhale food or to swallow it unchewed. Food accounts for 60 percent of pediatric choking cases, according to the Centers for Disease Control and Prevention. Any food can become a choking hazard. The American Academy of Pediatrics cites hot dogs, meats, sausages, fish with bones, cheese cubes, popcorn, chips, pretzel nuggets, hard candy, gum, lollipops, jelly beans, marshmallows, whole grapes, raw vegetables, cherry tomatoes, nuts, peanut butter (especially eaten from a spoon or on soft bread) and even ice cubes.

Many parents now know that grapes should be halved for a young child, but fewer realize that a hot dog should be cut lengthwise for a child until at least age 4. (Better yet, skip nutritionally questionable hot dogs altogether.) Parents should wait to introduce puréed food until after 4 months of age, when motor skills for swallowing are better developed. Always supervise meals and snacks when babies and children feed themselves.

But nearly a third of choking cases in children are caused by objects. The pediatrics society lists these among the most common offenders: coins, buttons, marbles, small balls, deflated balloons, watch batteries, jewelry, pen caps, paper clips, arts and crafts supplies, small toys and detachable toy parts.

Toys and games that are safe for an older sibling may not be for a younger brother or sister. Always check packaging for age recommendations, and keep toys meant for older children away from younger ones. And while it may be hard to believe, some infants have choked on pacifiers.

It is critical to know what to do if a child appears to be choking. If the child can cough, speak or cry, the airway is not completely blocked. Encourage the child to cough, and if that fails to dislodge the object, call 911. Caregivers should always have a cellphone on hand.

If a choking baby can make little or no sound, ask someone to call 911 (if you are alone, attempt a rescue for two minutes before calling 911). Place the baby face down over your arm with the head lower than the chest and support the baby’s head with your hand. Then give five quick blows between the shoulder blades with the heel of the other hand. If no object is dislodged, turn the baby faceup on a firm surface, place two fingers in the middle of the breastbone just below the nipples and give five quick thrusts. Repeat this sequence until the baby begins breathing or help arrives. If breathing is not restored within a few minutes, begin CPR (see box).

For a child over 1 who is choking, stand or kneel behind the child and wrap your arms around her. Make a fist and place it just above the navel. Grasp the fist with the other hand, and make quick upward thrusts with it. Repeat until the object is dislodged or the child begins breathing.
Any child who required a choking rescue should be examined by a physician afterward.



Tips for CPR on the Very Young
A baby or child who cannot breathe and loses consciousness — because of choking, an accident or any other reason — will need CPR modified for the young. If you are alone, perform CPR for two minutes before stopping to call 911.
    Place an infant face up on a firm surface. Place two or three fingers at the center of the baby’s chest, just below the level of the nipples. Give 30 gentle chest compressions at the rate of at least 100 a minute. Each should depress the chest about an inch and a half.
    Then tilt the baby’s head by lifting the chin; cover the baby’s nose and mouth with your mouth and give two gentle breaths, each for one second. Look to see that the chest rises with each breath.
    Repeat this sequence until the baby starts breathing or help arrives.
    For an unconscious older child, place the heel of one hand on the breastbone, just below the level of the nipples. Administer 30 fast and hard chest compressions, depressing the chest about two inches each time
    Then lift the chin with one hand, place the other hand on the forehead to tilt the head back, and put your mouth tightly over the child’s mouth. Give two breaths, each for one second, to make the chest rise.
    Repeat this sequence until the child resumes breathing or help arrives.

Friday, December 13, 2013

You can eat well, exercise regularly, and participate in all forms of preventive care but still you are subject to disease from the environment. Daily, you and your children are exposed to one of the most harmful toxins that mounting evidence demonstrates is harmful. A Washington Post article discusses our exposure to the toxin BPA and how it is found everywhere.

The Washington Post -

BPA is still everywhere, and mounting evidence suggests harmful effects

 

iStockphoto - BPA is found in such common items as receipts from ATM machines.

These days the baby aisle shelves are lined with products proudly announcing: “BPA-free.” As a mom and a consumer, this is reassuring. BPA (bisphenol A), a chemical used in the production of plastics and many other products, has been linked to a variety of health problems such as reproductive disorders, diabetes and cardiovascular disease. A 2003-2004 national health survey by the Centers for Disease Control and Prevention found BPA in more than 93 percent of 2,517 urine samples from people age 6 and older.

In 2008, the Food and Drug Administration stated that BPA was safe for use in food-related materials such as plastic food containers and the linings of food and beverage cans, including containers for liquid infant formula. Last year, the FDA ruled that BPA could no longer be used in the manufacturing of baby bottles and sippy cups; this action came after the chemical industry and major manufacturers had abandoned the use of BPA in those products.

But the chemical is found in many other common items: medical devices, dental sealants and compact discs, to name a few. Even paper receipts from the grocery store and ATM machines often contain BPA. In short, it’s pretty hard to avoid the chemical.

In the past few years, the FDA has expressed greater concern about BPA. In 2009, the National Institutes of Health launched a $30 million, five-year program in collaboration with the FDA and the CDC to examine long-term health outcomes associated with developmental exposure to BPA. Research from this effort will be pouring out over the next few years. But the studies already emerging continue to add to the evidence that the safety of BPA is highly uncertain.

These and many other studies have converged on a central message: Even at low levels and particularly during prenatal development and early childhood, exposure to BPA — known to mimic the hormone estrogen — can have subtle but detrimental effects.

When chemicals such as BPA mimic hormones, it leads to what’s called endocrine disruption. “The effect is not necessarily toxic in the traditional sense,” says Sarah Vogel, director of the health program at the Environmental Defense Fund and author of “Is it Safe? BPA and the Struggle to Define the Safety of Chemicals,” but it is a disruption.

Hormonal signals work the way a lock and key work. We have receptors (the locks) that receive signals from hormones (the keys). “[BPA] is almost like a little master key because it can fit into many of these little locks that are in your body and in your cells,” says Emilie Rissman, a behavioral neuroendocrinologist at the University of Virginia.

Rissman and other researchers are finding that when humans and other animals are exposed to BPA during critical developmental windows such as in the womb and in infancy, the chemical can scramble cellular signals and leave lasting biological effects.

For instance, a 2012 study found that when female rhesus monkeys were exposed to low doses of BPA during their second or third trimesters of pregnancy, the chemical caused defects in egg formation in the offspring. In other studies of the same rhesus monkeys, researchers found abnormalities in the development of other organ systems including the brain, lungs and reproductive tract following prenatal BPA exposure.

BPA has also been linked to obesity and Type 2 diabetes.

Researchers have also found that newborn rats that were exposed to low doses of BPA for a short period had a significantly higher risk of prostate cancer (an estrogen-induced cancer) later in life.

“It’s as if early life exposure [to BPA] programmed a memory in the prostate gland,” says Gail Prins, a physiologist at the University of Illinois in Chicago who led that research. In soon-to-be published studies, Prins’s group has found nearly identical results with human prostates created from stem cells and exposed to BPA during development.

Prins’s work and that of others is finding that BPA is causing alterations at the level of the epigenome — the modifications, or tags, that tell genes when to turn on and off. For instance, a study published this year found that BPA disturbs the epigenetic programming of gene expression in the brains of mice.

Most concerning, recent studies suggest that these epigenetic changes may be heritable between generations. Rissman and her colleagues have found that low-level exposure to BPA in pregnant mice suppresses gene expression of two proteins that are important in regulating social behavior — oxytocin and vasopressin — and alters social behaviors in the fourth generation (the great-great grandchildren) of the exposed mice. The implications of Rissman’s work are “profoundly disturbing,” says Pete Myers, chief scientist at Environmental Health Sciences, a nonprofit research organization in Charlottesville. The levels of BPA that Rissman is experimenting with, he notes, are in the same range as those found in most people.

We can reduce our BPA exposure by making choices such as opting for electronic receipts, using fresh and frozen vegetables rather than canned, choosing glass and stainless steel containers and not microwaving food in polycarbonate plastic containers. (The heat in a microwave can cause plastic to break down, allowing BPA to leach into food or liquids.) Still, the chemical is all around us, and there is controversy around whether current replacements are any safer.

Wednesday, December 11, 2013

Could we be moving into an age of greater enlightenment about healthcare when an excellent new study concludes that exercise may well be more potent then medication for certain conditions? A N.Y. Times article asks if maybe its time science considers diet and exercise as a first option in the treatment of conditions rather than discussing it only in terms of prevention or weight loss.


 

Exercise as Potent Medicine

Johner Images/Getty Images
 
 
Gretchen Reynolds on the science of fitness.


Exercise can be as effective as many frequently prescribed drugs in treating some of the leading causes of death, according to a new report. The study raises important questions about whether our health care system focuses too much on medications and too little on activity to combat physical ailments.

For the study, which was published in October in BMJ, researchers compared how well various drugs and exercise succeed in reducing deaths among people who have been diagnosed with several common and serious conditions, including heart disease and diabetes.

Comparative effectiveness studies are a staple of science, of course, especially in pharmaceutical research. Scientists often track how well one drug treats a condition compared with the outcome if they use a different drug. But few studies have directly compared drugs with exercise, and even fewer have compared outcomes in terms of mortality or whether the intervention significantly lessens the chance that someone with a disease will die from it, despite treatment.

So Huseyin Naci, a graduate student at the London School of Economics and Political Science, and Dr. John Ioannidis, the director of the Stanford Prevention Research Center at the Stanford University School of Medicine, decided to create a comprehensive comparison of the effectiveness of drugs and exercise in lessening mortality among people who had been diagnosed with one of four diseases: heart disease, chronic heart failure, stroke or diabetes. They chose these particular conditions because those were the only ones for which they could find studies that had examined whether exercise lessened the risk of death among patients with that disease, Mr. Naci said.

He and Dr. Ioannidis then gathered all of the recent randomized controlled trials, as well as previous reviews and meta-analyses of older experiments relating to mortality among patients with those diseases, whether they had been treated with drugs or exercise.

They ended up with data covering 305 past experiments that, collectively, involved almost 340,000 participants, which is an impressive total. But most of the volunteers had received drugs. Only 57 of the experiments, involving 14,716 volunteers, had examined the impact of exercise as a treatment.
Still, the numbers were large enough that Mr. Naci and Dr. Ioannidis could create an elaborate network of cross-references, comparing the outcomes when people received certain drugs, followed exercise regimens or, occasionally, both. The exercise routines, typically part of rehabilitation programs, usually involved walking or other aerobic routines but sometimes consisted of weight training or other exercises.

The researchers compared mortality risks for people following any of the treatment options.
The results consistently showed that drugs and exercise produced almost exactly the same results. People with heart disease, for instance, who exercised but did not use commonly prescribed medications, including statins, angiotensin-converting-enzyme inhibitors or antiplatelet drugs, had the same risk of dying from — or surviving — heart disease as patients taking those drugs.

Similarly, people with diabetes who exercised had the same relative risk of dying from the condition as those taking the most commonly prescribed drugs. Or as the researchers wrote in statistics-speak, “When compared head to head in network meta-analyses, all interventions were not different beyond chance.”

On the other hand, people who once had suffered a stroke had significantly less risk of dying from that condition if they exercised than if they used medications — although the study authors note that stroke patients who can exercise may have been unusually healthy to start with.

Only in chronic heart failure were drugs noticeably more effective than exercise. Diuretics staved off mortality better than did exercise.

Over all, Dr. Ioannidis said, “our results suggest that exercise can be quite potent” in treating heart disease and the other conditions, equaling the lifesaving benefits available from most of the commonly prescribed drugs, including statins. Statins are at the center of a debate about new treatment guidelines that could vastly expand the number of people taking the drugs.

The results also underscore how infrequently exercise is considered or studied as a medical intervention, Dr. Ioannidis said. “Only 5 percent” of the available and relevant experiments in his new analysis involved exercise. “We need far more information” about how exercise compares, head to head, with drugs in the treatment of many conditions, he said, as well as what types and amounts of exercise confer the most benefit and whether there are side effects, such as injuries. Ideally, he said, pharmaceutical companies would set aside a tiny fraction of their profits for such studies.
But he is not optimistic that such funding will materialize, without widespread public pressure.

For now, Mr. Naci said, he hopes that this new study will prompt smaller-scale negotiations. “We are not suggesting that anyone stop taking their medications,” he said. “But maybe people could think long and hard about their lifestyles and talk to their doctors” about whether exercise could and should be incorporated into their care.

Monday, December 9, 2013

Ahhh, nuts. I make a nut & fruit treat as a holiday snack every year. With its sweet, salty and spicy taste, I could eat a pound of it if I weren't worried about the fat and calories nuts possess. However, it turns out that not only does it taste terrific, but according to a report published in the N.Y. Times, nuts are a great snack to improve your health.


Snacking Your Way to Better Health

 
Lou Beach
 
Personal Health
Jane Brody on health and aging. 
 

Nuts to you! No, that’s not an insult. It’s a recommendation to add nuts to your diet for the sake of your health and longevity.

Consistent evidence for the health benefits of nuts has been accumulating since the early 1990s. Frequent nut consumption has been linked to a reduced risk of major chronic diseases, including heart and blood vessel disorders and Type 2 diabetes.

The newest and most convincing findings, reported last month in The New England Journal of Medicine, come from the Nurses’ Health Study and the Health Professionals Follow-Up Study, which together have followed nearly 119,000 women and men for decades. Both studies repeatedly recorded what the participants ate (among many other characteristics) and analyzed their diets in relation to the causes of death among the 27,429 people who died since the studies began.

The more often nuts were consumed, the less likely participants were to die of cancer, heart disease and respiratory disease, and not because nut eaters succumbed to other diseases. Their death rate from any cause was lower during the years they were followed. (The nuts in question were pistachios, almonds, Brazil nuts, cashews, hazelnuts, macadamias, pecans, pine nuts, peanuts and walnuts.)

Those who ate nuts seven or more times a week were 20 percent less likely to die from 1980 to 2010; even among those who consumed nuts less often than once a week, the death rate was 11 percent lower than for those who did not eat them.

I know what you’re thinking: Aren’t nuts fattening? Yes, an ounce of nuts has 160 to 200 calories, nearly 80 percent from fat.

But in study after study, the more often people ate nuts, the leaner they tended to be.

For example, in a Mediterranean study that tracked the effect of nut consumption on weight gain over the course of 28 months, frequent nut consumers gained less weight than those who never ate nuts, and were 43 percent less likely to become overweight or obese.

How is that possible? First, nuts may be taking the place of other high-calorie snacks, like chips, cookies and candy. And nut eaters may be less likely to snack, period; the fat, fiber and protein in nuts suppresses hunger between meals.

Second, the body may treat calories from nuts differently from those in other high-carbohydrate foods. Third, nut eaters may pursue a healthier lifestyle and burn more calories through exercise.
Whatever the reasons, every study has indicated that nuts make an independent contribution to health and longevity, even after taking other factors into account.

And not just tree nuts. The new study found that peanuts were also linked to a reduced death rate and lower risk of chronic disease. Peanuts are legumes that grow underground, but they share constituents with tree nuts that are believed to protect against a wide range of diseases.

Botanically speaking, nuts are fruits, but most of the nuts we consume are the fruits’ seeds — able to produce a new plant when raw. Like the yolk of an egg, seeds must contain nutrients that support healthy tissues.

Thus, all nuts are powerhouses of biologically active substances, most of which are known to protect and promote health. Penny M. Kris-Etherton, a professor of nutrition at Penn State who has studied the effects of nuts on heart disease, describes them as “complex plant foods that are not only rich sources of unsaturated fat but also contain several nonfat constituents,” including protein, fiber, plant sterols that can lower cholesterol, and micronutrients like copper and magnesium.

Every one of these substances has been shown to ward off one disease or another. The fat content of nuts alone could account for their ability to support heart health. Nuts have less cholesterol-raising saturated fat than olive oil. On average, 62 percent of the fat in nuts is monounsaturated, the kind that supports healthy levels of protective HDL cholesterol and does not raise blood levels of harmful LDL cholesterol.

Nuts contain omega-3 fatty acids that can lower triglycerides and blood pressure, slow the buildup of arterial plaque and prevent abnormal heart rhythms. Walnuts are especially rich sources of alpha-linolenic acid, some of which is converted to heart-protective omega-3 fatty acids.

Most nuts, and especially almonds, are good sources of vitamin E, an antioxidant. Joan Sabaté, a nutritionist at Loma Linda University who has studied the health effects of nuts among Seventh-day Adventists, lists folic acid, selenium, magnesium and several phytochemicals among the compounds in nuts that have antioxidant, anti-inflammatory or anticancer properties.

The nurses’ study has linked tree nuts to a reduced risk of pancreatic cancer. A Taiwanese study of about 24,000 people found a 58 percent lower risk of colorectal cancer among women who ate peanuts, although a similar effect was not found among men.

In both the nurses’ and health professionals’ studies, eating nuts more than five times a week was associated with a 25 percent to 30 percent lower risk of needing gallbladder surgery.

Nuts also contain dietary fiber, about a quarter of which is the type that reduces cholesterol and improves blood sugar and weight control. The nurses’ study and a study of about 64,000 women in Shanghai found strong evidence that frequent consumption of tree nuts, peanuts and peanut butter reduced the risk of developing Type 2 diabetes.

Peanuts and especially pistachios are rich in resveratrol, which is being investigated for possible anti-aging effects. Pistachios are also rich in arginine, which gives rise to nitric oxide, a substance that improves blood flow and can help counter erectile dysfunction.

Including a serving or two of nuts in your daily diet is not challenging. Dr. Kris-Etherton suggests using peanut butter as the protein source in a sandwich, and replacing a cookie snack with a one-ounce serving of mixed nuts. Nuts can also be added to hot or cold cereals, salads, stir fries and desserts.

Wednesday, December 4, 2013

After a motorcycle accident with an SUV left me on the side of the road a few years ago (the SUV won), my first thought was to pick up my bike and ride home. Shock, a foot with broken bones dangling from my ankle, and the inability to pick up a 750 pound bike from a ditch prevented me from doing so. But after a visit to the local hospital, I was ordered to wear a boot for almost 12 weeks, during which time I thought I should be able to drive my car. No one said when that would be safe and, as discussed in this N.Y. Times "Well" article, there seems to be no standards when anyone in a boot, cast or sling should be allowed to drive.


When Is It Safe to Drive After Breaking a Bone?

 
iStock

Hands on the steering wheel, one foot toggling between brake and pedal, head twisting to check mirrors. Consider the many bones and joints you must engage before you even turn on a car’s ignition, among them the fingers, wrist, forearm, elbow, shoulder, neck, heel, ankle and leg.
If you’ve recently had an injury to any of them, when is it safe to resume driving?

It turns out there are no widely accepted return-to-driving timelines for patients who must wear casts, slings, neck collars or controlled ankle-motion boots. Whether someone is recovering from a sprain, fracture, bunion surgery, knee or hip replacement or neck fusion, the ability to steer, glance at mirrors and brake safely can be seriously, if temporarily, impaired.

Several recent articles have attempted to summarize the disparate findings of a relative handful of postoperative driving studies. Among their conclusions: most studies say that braking function returns to normal four weeks after right knee arthroscopy, nine weeks after surgery for an ankle fracture, and six weeks after the patient can walk unencumbered after a fracture of a major lower-body bone. After a total right hip or knee replacement, the recommended time before driving is generally four to six weeks.

One absolute: patients should not drive with a cast or brace on the right leg, or if a cast or sling immobilizes the wrist or elbow.

The goal of such studies, which typically measure how long it takes a recovering patient to make an emergency stop, was to encourage surgeons to have conversations with their patients about factors to weigh before getting behind the wheel — something many surgeons are loath to do because of a misperception that they could be sued if the patient got into an auto accident or if driving somehow aggravated the injury. And even when surgeons do have that conversation, some of the research showed, many patients dismiss the advice.

“As surgeons, we can’t clear someone for driving, but we can educate them,” said Dr. Geoffrey S. Marecek, a co-author of one review, recently published in The Journal of the American Academy of Orthopaedic Surgeons. “I tell patients, ‘No immobilization, full range of motion without pain, and then we’ll talk about it.’”

“But that’s common sense and not science,” added Dr. Marecek, an assistant professor of clinical orthopedic surgery at the University of Southern California Keck School of Medicine.

Still, there is great variation among studies in terms of timelines and precautions, with one concluding that patients who were pain free could drive as soon as one week after a simple right knee arthroscopy. Experts therefore urge surgeons to tailor their advice to the individual patient and procedure, weighing such factors as the patient’s pain tolerance, medications, postoperative mobility and mental acuity.

One reason formal guidelines have not been endorsed by associations of orthopedic surgeons is that gold-standard data is scarce. Typically, the few studies used computerized driving simulators or obstacle courses and healthy volunteers (police recruits, in one), whom they fettered with mobility-restricting casts, splints and slings.

These are not representative recreations of the typical patient after surgery, but they do show that even pain-free, unmedicated, highly competent drivers experience lag time in braking when wearing such post-surgical supports.

Another limitation of the studies is that the vast majority were done on automatic transmission vehicles, and looked at impairments to right arms for steering and right legs and feet for braking and accelerating. Almost none looked at stick-shift drivers, who typically use both feet.

Dr. Kenneth A. Egol, vice chairman of the department of orthopedic surgery at N.Y.U. Langone Medical Center, who has conducted driving-impairment studies but was not involved in the recent review articles, noted that even on automatic transmissions, some people drive or steer with their left arm, or use their left foot because of an amputation or other medical challenges. Some drive cars with adapted hand controls.

“It’s all about what you’re used to,” he said. “The message should be, ‘if there is any impairment to your normal mode of operating a vehicle, you shouldn’t do it.’ ”

He said that normal braking function usually follows the patient’s return to walking, though other factors may play a role. If, for example, a patient is sleeping poorly because of pain, alertness may be a compromising factor.

Dr. David Goodwin, a resident physician in the department of orthopedic surgery at Georgetown University Hospital, and a co-author of a review recently published in the journal Orthopedics (PDF), typically instructs patients, “It’s best that you practice in a parking lot or another large open space.” But, he added, “Legally, I would never put down in writing that ‘you’re cleared to drive.’”

Many doctors remain skittish about even broaching the subject, with one study showing that 35 percent of surgeons never discussed safe postoperative driving with their patients.

But the doctors’ fear of litigation may be overblown. Dr. Marecek noted that many insurance companies and law-enforcement officials place the responsibility for the decision to drive squarely on the patient.

According to Julian L. Rivera, a partner at the law firm Husch Blackwell and a member of the American Bar Association’s health law section, “I know of nothing definitive in the law that establishes a standard for physicians in clearing patents for driving after orthopedic surgery.”

“Given that reality,” he said, “it is wise for physicians and patients to have a conversation about when it would be safe for the patient to drive.”