Menopausal Hormone Therapy: Clear as Mud (Part 2)

So what did you think of yesterday's post regarding the latest analysis of the Women's Health Initiative?  Confusing, right?  Some benefit, but definitely some risk, too.  Of course, it appears that starting earlier is better than taking it later on.  Well, coincidentally, a population-based case-control study was published at the beginning of this week in JAMA Internal Medicine in which the authors concluded that oral conjugated equine estrogen (CEE) use was linked to greater risk for clotting & heart attack compared to plain estradiol (E2).

If you compare the above findings to the Global Consensus Statement on Menopausal Hormone Therapy published in March as well as the American College of Obstetricians and Gynecologists' Committee Opinion #556 published in April, you'll find that transdermal estradiol has an even lower risk of clots compared to any oral estrogen, but especially when mixed w/medroxyprogesterone acetate (MPA) as compared to plain progesterone.

For now, if you need MHT for unbearable menopausal symptoms, and not just for disease prevention, it would appear that you should try some form of transdermal E2 first.  And only if that doesn't work should you try an oral E2, leaving oral CEE as your hormone of last resort.  And if you have your female parts still in place (in other words, you haven't had a hysterectomy), ask for progesterone while avoiding medroxyprogesterone acetate.  I'm sure there'll be more updates to come in the future.  The final nail hasn't been hammered in yet!

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Mirror, Mirror, On the Wall . . . Part 4

Wouldn't it be great if we had a mirror on the wall which could tell us who's the fairest of all?  But then there'd be no need for television shows like America's Next Top Model.  Personally, I'd prefer the crystal ball that could tell me which stock to buy or sell, and more importantly, when!  Of course, neither of these prediction devices exists, at least not where I live.  But we continue to be enamored as a society about developing models (no, not those kinds) to predict the future.  Case in point was yesterday's look at diabetics' risk for developing dementia.

Well, one of the bigger risks for falling is living long enough, right?  If it's a simple slip & trip w/o injury, then no big deal.  But for our elderly, we worry about serious injuries especially conditions like hip fractures which portend tremendous disability.  But there are those who recover amazingly quick to their premorbid condition.  So of course, we want to know what sets them apart, right?

Well, in a prospective observational study published earlier this week in JAMA Internal Medicine, the authors concluded that post-fall recovery was linked to pre-fall function.  No fecal matter, Sherlock!  In other words, as if you couldn't already have guessed, the less disabled & therefore more functional you were prior to your fall, the better your chances of recovering quickly.  To arrive at their conclusions, the authors followed for 14yrs 754 community-dwelling participants avg 86yo, all of whom were not disabled in their activities of daily living at baseline, and of whom 130 sustained a serious fall.

But as one can imagine, there's a tremendous variation even among those who can perform their basic ADLs.  So the authors scored each participant according to 4 ADLs, 5 instrumental ADLs & 4 mobility tasks.  Those with least disability were most likely to recover quickly & totally.  Those with greatest disability were most likely not to recover.  Mortality also appears to be associated w/disability.

One other point: aside from those with gradual disability over the year preceding the fall, most elderly are relatively stable in their functional status.  But I would recommend that we should encourage them to exercise regularly, focusing not just on endurance (aerobics) but also strength, balance & flexibility.  Better to prevent the fall than have to recover afterwards.

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Does Your Back Hurt? Don't Go See Your Doctor Unless . . .

A very interesting study was published yesterday in JAMA Internal Medicine in which the authors noted that despite numerous guidelines to the contrary, simple uncomplicated back pain is being overtreated here in the States. Most recently, a number of specialty groups came together for the Choosing Wisely campaign to educate consumers on what not to do.  High up on the list is (not) getting some kind of imaging, be it xray, CT scan or MRI for simple back pain w/o any red flag signs/symptoms.  Chances are the study won't find anything wrong and certainly won't help you get better any faster than if you didn't exposure yourself to all that radiation.

But this isn't the first time that we've promulgated that bit of advice.  Yet in the article published yesterday, over the last 12 years, we've been ordering more CT scans & MRIs and prescribing more narcotics, none of which really helps. Unless you have numbness, tingling, weakness, incontinence, fever, sweats, chills, unexplained weight loss or known cancer, what you really need is time. But from personal experience, that was the longest 4 weeks of my life!

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Red Meat Increases Diabetes Risk Part 2

Just shy of 2 years ago, I pointed out an observational study published in the American Journal of Clinical Nutrition in which red meat was linked to diabetes.  Since then, I've also found studies in which red meat consumption was linked to death, stroke & even more death, as well as prostate & colon cancers.

Well, in a series of prospective cohort studies published online earlier this week in JAMA Internal Medicine (aka Archives of Internal Medicine) in which the authors concluded that red meat consumption was associated w/increase risk of diabetes.  The authors arrived at their conclusion by studying the 26,357 men in the Professionals Follow-Up Study, 48,709 women in the Nurses' Health Study, and 74, 077 women in the Nurses' Health Study II and following for an average of 4-8yrs each.

So I find myself asking if a prime Wagyu A5 rib eye is really worth the risk.

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Goldilocks Medicine: Blood Pressure & Blood Sugar

It's been quite a day so please forgive me for my digression.  I snuck in an extra home visit this morning before my shift started at Student Health.  When I left the assisted living facility, my car started driving funny.  All kinds of warning symbols lit up (in fact, 4 of the ones on the left), the turn signals didn't work, the speedometer & tachometer weren't registering correctly, etc so I was relieved when I finally parked in the garage structure.  I kept telling myself it was just a fluke.

Well, on the way home, my car just died on me.  I found an unnamed side road to pull off onto & called roadside assistance.  They promised me a tow truck in 60 minutes and sent me a text confirmation.  75 minutes later, I called back.  Oh, we're sorry but it's busy.  They should be there in 30 minutes.  The flatbed finally arrived 120 minutes after my initial call.  Mind you, I live in Las Vegas, where someone died over the weekend probably due to heat related illness.  So I wasn't too pleased when the operator told me to stay cool and wait, since my car wasn't running and I had not air conditioning.  But as you can clearly see, I made it home, albeit 4 hours after I finished up at Student Health.

So what's all this have to do w/Goldilocks medicine?  Nothing really.  I just need to ventilate, pun intended.  But I did find it interesting to briefly glance over two studies demonstrating bad things happening from dropping blood pressure & blood sugars too low.  Of course, we don't want high blood pressure which is hypertension, nor do we want high blood sugar which is diabetes mellitus.  And in fact, up until recently, our mantra was "lower is better".

But in a prospective population-based study published early online this week in JAMA Internal Medicine (aka Archives of Internal Medicine), the authors found that those diabetics who experienced hypoglycemia (excessively low blood sugar) had twice the risk for developing dementia compared to those who didn't experience hypoglycemia.

And in a prospective cohort study published early online this week in JAMA Neurology (aka Archives of Neurology), low baseline diastolic blood pressure was associated w/brain atrophy (shrinkage).  In defense of taking blood pressure medication, those with higher baseline diastolic blood pressure appeared to sustain less brain atrophy if their blood pressure dropped over time.

What's this mean for you & me?  Think like Goldilocks!  Not too hot, not too cold.  Not too hard, not too soft.  In other words, moderation is key.  So while high blood pressure & high blood sugars aren't good for us, excessively low numbers aren't either.

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Behind the Scenes: The Making of Low T

It's seems near impossible these days to pick up a magazine, listen to the radio, watch the television or drive without seeing a billboard plastered with some message related to testosterone.  Just where and how did this condition (disease?) come into being?  After all, hasn't low testosterone been around since men lived long enough to reach a point in their lives when levels dropped significantly?  So why all the press now?  Perhaps, it's partially due to the Baby Boomers reaching that very point in their collective lives since they're not about to go without a fight!  Or perhaps it's due in part to Big Pharm doing its research and developing new products that need larger markets.

On a more personal level, I was recruited out of academia a decade ago to assist a private practice in growing but more importantly in giving it the research gravitas to support its attempt to corner the market on hormone deficiencies and even suboptimal hormonal levels.  And so I tried to get my hands on as much peer-reviewed research as possible.  Unfortunately, most of it was observational in nature, albeit over half a dozen observational studies all conclude that low testosterone is associated w/higher mortality no matter which population was studied, whether American (3 different cohorts), Italian, British or Scandanavian.  Granted, there were randomized controlled trials demonstrating benefit from testosterone replacement/supplementation, but it was rarely w/o risk, and there were a few w/o any benefit at all.  

Which then leaves us w/consensus statements by "thought leaders".  Little did I know that many of these "guidelines" have been ghost-written by others as revealed in a special article published early online in JAMA Internal Medicine.  So is low T real?  Most definitely yes, but most likely not in a high enough percentage of men to warrant dramatically raising rates of testosterone prescriptions over the last decade.  So what are we to do?  As a clinician, let's not jump directly on the hypogonadism/andropause band wagon.  

Instead, let's look for other reasons that might explain the vague symptoms that overlap with so many other issues & conditions.  Stress to the relationship, family, friends, money, job security, etc.  What about poor lifestyle choices such as smoking and/or drinking to excess?  Any health conditions or diseases that predispose someone to loss of energy, obesity, decrease in libido, depression?  Anemia?  Diabetes?  Hypothyroidism?  How about (new) medications?  In other words, don't attempt to jump on the low T bandwagon w/o a thorough evaluation by your family doc.  And if you do decide to go for a test drive, so to speak, remember that testosterone replacement/supplementation/optimization is not a do-it-yourself project. 

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Is a Vegetarian Diet Really That Good for You?

The Truth Is Out There.
X-Files 1993-2002

Now, I'm game for just about anything that might make/keep me healthier and prolong (quality of) life, but I have to give you the following disclaimer:  I'm an omnivore, so you'll need to pry that well marbled USDA Prime rib eye from my cold dead hands.  But just yesterday, I stumbled upon a headline that read "Veggies Are Key to Long Life" and feared that my eating habits as I've known them for the past 5 decades were about to come to an abrupt 180o turn.  The referenced article was a prospective cohort study published early online in JAMA Internal Medicine (aka Archives of Internal Medicine) in which the authors concluded that vegetarian diets are linked to lower all-cause mortality & some cause-specific mortality.  But just like Michael Douglas' proclamation earlier this week that oral sex begat (his) oral cancer, the science isn't always so clear cut.

To arrive at their conclusions, the authors followed 73,308 Seventh Day Adventists  for close to 6yrs.  While their average age was 56-59yo, their average body mass index was only 24-28kg/m2, much less than the average American these days, which might bring into question the generalizability of the results.  Nonetheless, they were able to conclude that any vegetarian diet was associated w/12% lower all-cause mortality compared to non-vegetarian adherents (like myself).  Interestingly, the results for ischemic heart disease mortality, cardiovascular disease mortality, and cancer mortality did not reach statistical significance, while "other mortality" barely did at 15% lower risk.

However, if you looked at female vegetarians (which I'm definitely not either), there was no statistically significant reduction in either all-cause or disease specific mortality.  Male vegetarians did demonstrate 18% lower all-cause mortality and 29% lower cardiovascular disease mortality.  In case you're wondering, ischemic heart disease refers exactly & only to heart disease while cardiovascular disease includes carotid artery disease & stroke, too.

Now, little did I know, but among vegetarians, you can further sub-classify yourself as vegan, lacto-ovo-vegetarian, pescovegetarian, and even semi-vegetarian.  Well, the authors did, any way, lumping those who ate non-vegetables less than once per month as vegans; lacto-ovo as those who consume eggs & dairy more than once a month but no other non-vegetables; pesco- as those who consumed fish at least once a month but any other meat less than once a month; semi- as those who consumed fish & non-fish meats more than once a month but no more than once a week.  Got it?  Sound a bit like a slippery slope, right?  

Well, if you're only as strong as your weakest link, it turns out that sub-classifying vegetarians reduced statistical significance such that only pesco-vegetarians achieved 19% lower all-cause mortality & 35% lower ischemic heart disease mortality.  All others were unable to reach statistical significance.  And remember that slippery slope, while vegan, lacto-ovo & pesco tended to liver longer (albeit w/o statistical significance), semi-vegetarians showed worst statistics.

Yes, I remember that quote about "Lies, damned lies & statistics" popularized by Mark Twain.  But in this instance, that "faulty" headline doesn't nearly capture the complexity of the data.  It's unfortunate that we can't summarize new findings in 15 second sound bites or 140 characters.  I guess that means I can go back to gnawing on some gristle for a while longer.

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Dietary Supplements: Is the Fox Guarding the Hen House? Part 5

It's been a while since I talked about the fox guarding the hen house.  You know how that story ends and it's not good!  In truth, neither Big Pharma nor the dietary supplement industry are without blame.  Several pharmaceutical companies have been fined for illegal marketing while a industry subset recently set the nation abuzz by selling a contaminated product leading to infection & death.

And in a research letter published early online this past Monday in JAMA Internal Medicine, the authors noted that over the last 5 years, over 200 dietary supplements have been recalled for containing unapproved pharmaceutical ingredients.  As Disraeli is quoted to have said, "There are lies, damned lies, and statistics."  Thus, the dietary supplement industry would point out that since 2010, there has been a decrease in the number of recalls.  

But I have to agree with the editorialist who noted that these supplement recalls are initiated mainly based upon consumer complaints because the Food & Drug Administration does not have the power to proactively provide oversight.  As such, these recalls probably underestimate the number of contaminated products on the market.  And in fact, the dietary supplement manufacturers are not required to demonstrate either efficacy or safety prior to making their miraculous claims as long as they provide the ubiquitous disclaimer.  But before inciting widespread riot & chaos, let's recall that most manufacturers are out to do the right thing and improve health.  So just beware those promising miraculous improvements.  Caveat emptor.

Dietary Supplements: Part 4

Dietary Supplements: Part 3

Dietary Supplements: Part 2

Dietary Supplements: Part 1

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Be Careful What You Wish

Turns out it's allergy season around here, especially with all the olive trees blooming.  Seems everyone is complaining of itchy watery eyes & runny stuffy nose, so we prescribe a lot of oral & ophthalmic antihistamines as well as intranasal steroids.  But there's always someone who wants a course of oral steroids or a corticosteroid shot.  It's the only thing that works for me, doc!  I try to dissuade these patients of their request and point out (nicely) the folly of their shortsightedness.  When used w/o oversight, the benefit of oral/injectable steroids is outweighed by their potential side effects, including but not limited to cataracts, diabetes, immunosuppression, osteoporosis & striae (stretch marks), etc.

What amazes me is that some of these patients still insist on getting their steroids.  Well, as I mentioned yesterday, take the medication only if you need it and only if the hoped for benefits outweigh the potential risks.  Personally, I'm not convinced that the short-term gains are worth the long-term risks but I guess I've never been beset by allergies like this patients, so I shouldn't force my views on them but rather just provide education.

Well, along those lines, a population-based nested case-control study was published yesterday in JAMA Internal Medicine, in which the authors concluded that oral glucocorticoid use is linked to an increased risk of acute pancreatitis.  Of note, the participants were 40-84yo Swedes of whom 6,161 cases of initial acute pancreatitis were compared to 61,673 controls, each selected based upon similar age, gender, and calendar period.  Greatest risk for this exquisitely painful condition occurred 4-14 days after starting glucocorticoid therapy.  Recent use & former use did not increase risk, nor did stopping use.

So be careful what you wish for.  That short course of corticosteroids might relieve your allergies but could also potentially bring about some rather painful consequences.  Granted that's a big step to assume cause & effect, which this study was not designed to do, but the association was strong and the outcome poor.  So why take that risk unless you feel it's absolutely necessary?  Caveat emptor.

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Do It Because You Can or Do It Because You Should? Part 2

Capitalism appeals to our inner drive.  After all, the more we do, the more we achieve, and the more we're rewarded.  Or something like that.  As much as I believe in this economic freedom, it isn't always the best solution when a fiduciary is required.  I mean, we're human after all.  And unfortunately, this weakness was confirmed once more in a retrospective cohort study published early online earlier this week in JAMA Internal Medicine when the authors found that almost 1 in 4 colonoscopies in our elderly were potentially inappropriate, especially among surgeons, US medical school graduates before 1990, and those w/high volume practices.

But therein lies the rub: just what constitutes potentially inappropriate?  The United States Preventive Services Task Force recommends screening for colon cancer in average risk adults from 50-75yo.  USPSTF recommends against routine screening in 76-85yo although individual considerations may warrant doing so.  However, the USPSTF is adamant against screening any >85yo regardless of biologic age.  

So the authors found 119,477 Medicare beneficiaries who lived in Texas and underwent a colonoscopy from October 2008 to September 2009.  The colonoscopies were considered screening (as opposed to diagnostic) if there was no diagnostic indication.  These screening colonoscopies were then deemed inappropriate if they were performed early without pathologic indication (previous normal colonoscopy <10yrs ago), or performed in 76-85yo w/o diagnostic indication.

As a physician, I'd hoped that we were better than that, that we'd hold our fellow human beings up on a pedestal (not the other way around) and put their health & benefit above our need for financial recompense.  Unfortunately, it doesn't appear that we've learned anything since August 2011 when another study published in Archives of Internal Medicine came to the same conclusion.  Let's promise to do something because we should, not because we can.  Greed does not become us.

By the way, check out what the American Gastroenterological Association had to say (see #2 & #3) in their recommendations for ChoosingWisely.org.

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To Sleep: Perchance to Break A Hip

To sleep: perchance to dream.
Shakespeare in Hamlet

Of late, much has been made of our need to get adequate sleep.  We generally quote an average of 7-8 hours/night as being the minimum necessary for proper function.  However, there are also studies suggesting that our sleep requirements change as we age.  And yet, for many of our retired or institutionalized, they still adhere strictly to this dogma, despite having no absolute need to meet a schedule.  And if they can't fall asleep at a time they consider "normal" or if they wake up earlier than they'd like, they take on the label of insomnia and demand some sedative-hypnotic, whether benzodiazepine or non-benzodiazepine.  We generally look askance at the former with its potential for addiction & confusion.  Yet, the non-benzodiazepines are not without fault.

In fact, a case-crossover study was published early online last week in JAMA Internal Medicine in which the authors noted that among nursing home residents, hip fracture risk was linked to non-benzodiazepine use.  Let's be clear at the outset: this study cannot prove cause & effect, just an association.  Specifically, the authors found 15,528 institutionalized patients (3 out of 4 of whom were female w/avg 81yo) who'd already sustained a hip fracture of which 1,715 had been given a non-benzodiazepine sedative hypnotic prior to the fracture.  These participants served as cases while controls were located in the cohort.  The authors noted also that greatest risk for hip fracture within the 1st 2 weeks of starting this medication & continued out through the quarter, especially in those with cognitive impairment and/or functional impairment.

Bottom line: focus on sleep hygiene first (try to avoid napping during day which can upset sleep cycle).  Then inquire as to a need to keep to a strict schedule, especially in those who've walked away from an 8A-5P job.  Without that need for a strict schedule, there's no reason why our patients can't turn into nightowls if they so choose, staying up late & waking up late, too.  So let them be, rather than increase their rate for hip fracture by sedating them.

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