Dietary Antioxidants vs Stroke Risk

"Le bon Dieu est dans le détail" (the good God is in the detail) - Gustave Flaubert (1821–1880).  

I thought this quote a propos given how loosely trial results are translated into headlines & sound bites.  In the EPICOR  study to be published next year (doesn't that sound so far off in the distance?), researchers of the Italian cohort of the European Prospective Investigation into Cancer & Nutrition followed 41,620 participants for an average of 7.9 years and concluded that those who consumed the most dietary antioxidants had the lowest risk of ischemic stroke but not hemorrhagic stroke.  That's the difference between the water pipes in your house clogging vs bursting.  

In fact, there was a 47% relative risk reduction by comparing those who ate the most to those who had the lowest total antioxidant capacity.  Please note, however, taking a handful of pills hasn't been proven to be equivalent to the daily & regular consumption of larger amounts of coffee, wine, fruit, chocolate, vegetables & soups, tea, and fruit juices as dietary sources of antioxidants. When broken down further, vitamin C was found to be especially helpful in preventing ischemic strokes while vitamin E was associated with increase risk of hemorrhagic strokes.

The take-home message hasn't changed over these past 12 months.  Make better, healthier, food choices, eg eat your fruits & veggies every day.  A little bit of wine & some high cocoa-content dark chocolate appears to be good for you, too.  So make a resolution to lower your stroke risk in 2011.  A votre sante!

FDA Approves Fortesta (Testosterone) to Treat Hypogonadism

Endo Pharmaceutical announced yesterday that the FDA has approved their Fortesta brand of 2% testosterone gel for men suffering from hypogonadism for application to the thigh to minimize accidental transfer to spouses & children.  Hypogonadism or andropause or low T is a clinical syndrome comprised of loss of energy, loss of libido (sex drive), erectile dysfunction, increase in fat despite appropriate nutrition, loss of muscle despite appropriate exercise, depression, cognitive dysfunction, and/or osteoporosis, in a person with confirmed low testosterone levels.  So now, men can choose from transdermal testosterone (Androderm, Androgel, Fortesta & Testim), pellets, injections, and buccal patches (Striant).

HDL vs Heart Disease

You can't rely solely on your statin to prevent heart disease.  Just last week, authors analyzed 20 randomized controlled trials including 543,210 person-years of follow up and noted that after accounting for LDL (bad cholesterol), age, blood pressure (hypertension), diabetes, and tobacco use, lower HDL (good cholesterol) was associated with an increase risk of heart attacks, regardless of whether statins were used or not.  

For every 10mg/dL decrease in HDL, there was a 7.1-8.3% increase risk of heart attack in statin users & non-users, respectively, without either threshold or ceiling effect.  In other words, while we've said in the past that normal HDL is >40mg/dL, it turns out that a progressively lower risk of heart attack exists the higher one's HDL, even above 60mg/dL.  Conversely, there's a progressively greater risk for heart attacks w/HDL <60mg/dL.  So the question you need to ask yourself is whether you want to be normal or whether you want to be optimal.  The choice is yours.  

How to Prevent Falls in Our Elderly

As I've mentioned in previous posts, the US Preventive Services Task Force (USPSTF) is a stickler for evidence-based medicine.  Unless they have enough studies demonstrating cause & effect, they won't make recommendations or at least give strong ones based upon epidemiologic data alone.  This is both their strength & their weakness.

When it comes to caring for our elderly, especially when considering healthy aging, optimizing health & preventing debilitation & frailty, the USPSTF concluded last week that it's difficult to arrive at definitive recommendations because there are so many risk factors to take into account, so many interventions & outcomes to consider, and most importantly, a scarcity of elderly participants in many clinical trials.

Which isn't to say they haven't tried.  For instance, in the very same issue, USPSTF analyzed 19 randomized controlled trials to determine interventions to prevent falls in the elderly.  It's worth noting that they actually had to screen 3423 abstracts and 638 articles to find fair-to-good quality studies.

Their conclusions:  exercise & physical therapy can reduce falls by 13% while vitamin D can reduce falls by 17% (take that, IOM!).  Multifactorial fall assessment, the geriatrician's bread & butter, showed a non-statistically significant 6% trend towards fall reduction.  Unfortunately, the individual components, medication use, visual acuity, home environment, and gait/balance assessment, demonstrated no benefit in isolation.  The good news?  No serious harm was noted as an outcome of the interventions.

The obvious question:  how much exercise and how much vitamin D is necessary?  Given the debacle over their recommendations for mammogram screenings, the USPSTF is opening up their draft recommendation statements to public comment at www.uspreventiveservicestaskforce.org/tfcomment.htm prior to making definitive final recommendations.  But there's no reason that we can't continue to recommend exercise & vitamin D for our patients now.

Gardasil Vaccine Prevents Anal Cancer

As physicians, we weigh the pros & cons of each therapeutic option with our patients daily.  What may be of benefit to one individual may be too dangerous for another to undertake.  I wish it were that simple but too often, emotions complicate our logic & science.  How else do you explain the 3,000-49,000 patients who refuse their yearly influenza vaccination and then end up paying the price of hospitalization & death for their illness (new reporting standards from the CDC this year).  Let's not forget the $10 billion in lost productivity and direct medical expenses and another $16 billion in lost potential earnings as a result of this preventable illness.

More recently, there has been a tremendous backlash against the use of Gardasil to prevent human papilloma virus (HPV) infections, first in women, and now in men.  Why the hesistance?  After all, multiple studies demonstrate that when administered properly, Gardasil can prevent cervical, vulvar & vaginal cancer in women, and genital warts in both men & women, all due to HPV.  Perhaps because HPV is considered a sexually transmitted illness and a vaccination against a sexually transmitted illness could be considered an e-ticket to have sex & promiscuity.  Of course it doesn't help that the vaccine is not inexpensive and that most insurance companies don't cover it.  But we're talking about preventing cancer, folks!

So in a gesture of holiday largess, the FDA just announced the approval of Gardasil for the prevention of anal cancer due to HPV types 6, 11, 16 & 18, to be administered to men & women 9-26yo (same age group as for the other above mentioned indications).  While anal cancer is not common, its incidence is increasing with the American Cancer Society estimating that 5,300 persons will be diagnosed in the coming year.  In the study used to substantiate Merck's request for another indication for their vaccine, Gardasil was shown to decrease the risk of anal cancer by 78%.

I don't know about you, but I look at this 78% reduction in cancer risk and its attendant surgery, radiation, & chemotherapy treatment and complications as being worth the relative cost of Gardasil and the risk of vaccine related side effects, such as fainting, pain at the injection site, headache, nausea, and fever.  Bottom line, for my kids, Gardasil is an ounce of prevention worth the proverbial pound of cure.

PS Don't be surprised if Gardasil receives an indication in the future to prevent HPV-related oral cancers given our society's generalized increased acceptance of oral sex.

Fish Consumption vs Stroke

Hope y'all had a very merry Christmas today!  Or happy holiday for those of you who celebrate something else. 

Exactly 3 weeks ago, we talked about how to avoid your 1st stroke.  Now comes a new study to be published next month in which the authors studied the dietary habits of 21,675 participants >45yo and discovered that less than one in four consumed at least two servings of non-fried fish weekly as suggested by nutritionists.  The chances of meeting this requirement were worst for those (African-Americans) who lived in the Stroke Buckle of the Stroke Belt which may account for the racial & geographic differences we find in stroke risk.  Ironically, African-Americans consumed more fish than Caucasians but unfortunately most of it was fried.  And those living in the Stroke Belt & Stroke Buckle were more likely to consume greater than two servings of fried fish weekly.

Let's be clear, this study does not establish causality.  In other words, this study doesn't prove that eating fried fish causes strokes.  However, the results are consistent with what we know, that fried foods aren't good for us.  But perhaps it's the omega 3 fatty acid content that's important.  Fatty fish such as salmon, herring & mackeral have significantly more of the omega 3 fatty acids EPA & DHA than their lean counterparts, eg catfish, cod & haddock, which are usually fried.  Another point that's been raised about farmed vs wild-caught salmon is also mentioned in this study regarding catfish:  farmed catfish has less EPA & DHA than its wild-caught counterpart.

So, details do matter.  We need to eat more non-fried fatty fish, not fried lean fish.  What a bummer.  I really love my fish & chips!

Andropause Part 5: Latest Research

On this Christmas Eve, I am most grateful to all of you for tuning in to my television debut and 20+minutes of fame this week on local NBC affiliate KSNV Channel 3's Healthline Today.  And many thanks to Dr. Jim Lenhart for giving me this invaluable opportunity just as I start up my private practice.  Without further ado, here is the final segment devoted to the latest research regarding andropause.  Wishing all of you the happiest & healthiest holiday yet!

Andropause Part 4: What Are Treatment Side Effects?

Andropause Part 3: What Are Your Treatment Options?

Andropause Part 2: How Is It Diagnosed?

Thanks to help from a webmaster friend who requested to remain anonymous, here is today's 4 minutes of fame.  Stay tuned for tomorrow's discussion regarding treatment options!

Andropause Part 1: What Is It?

Thanks to an anonymous webmaster's assistance, here is yesterday's 4 minutes of fame!

My Television Debut!

Several friends informed me that they saw my andropause interview on KSNV Channel 3 earlier today.  Unfortunately, as my wife & I were still rangling 8 girls for our daughter's birthday slumber party, neither one of us caught the airings.  Luckily, the television station has made a copy available for your viewing pleasure at http://www.mynews3.com/story.php?id=34311&n=27237.  The 4 minute video is also available on YouTube under "alvinblin".  Part 2 airs tomorrow during the 6AM, 9AM and 12 noon news programs.

What to Do for the Common Cold?

The problems with studying herbal supplements include product variability (both as to content of active ingredient as well as potential contaminants) and the wide variety of protocols used for any given indication.  For instance, some claim that the leaves are the active portion of the plant, rather than the root, seeds or flowers, or vice versa.  Others might claim that the manufacturing process removes the active ingredient.  As recently pointed out by the FDA, one also has to monitor for potential contaminants, some of which can be deadly in isolation while others are if taken in conjunction w/other meds & supplements.  Proponents might claim benefit due to chronobiology, in other words, some feel that it matters what time of day you take the supplement.  Or perhaps a loading dose is required.  Complicating the above for us non-botanists, many different plant species are known by a common name, ginseng, for instance.  With all these variables, it's no wonder that studies of herbal supplements have such disparate results.

In the latest salvo to be published tomorrow, the authors randomized 713 patients 12-80yo who self-presented w/upper respiratory symptoms, eg common cold, to either no treatment, unblinded echinachea pills, blinded echinacea pills, or blinded placebo pills.  They self-assessed the severity of their symptoms and underwent objective measures of their immune response.

While the results were not statistically significant, there was a trend towards better symptom scores and shorter duration of illness for those randomized to echinacea (although there was no difference noted with regards to impact upon immune response).  The good news to report is that the product studied was of good quality as per the American Botanical Society and the dose/regimen was appropriate.  The bad news is that given this information, one would have hoped for better statistically significant results.

Will the above results dissuade someone from taking echinacea for the common cold?  Probably not.  But I would certainly have great difficult recommending it to anyone over rest & fluids.  In the meantime, wash your hands religiously because the best way still to treat a cold is to prevent it in the first place.

Exercise Affects Your Weight Gain & Waist Circumference

File a study published in this week's JAMA under "been there, done that" in which the researchers followed for 20yrs 3,554 men & women 18-30yo at baseline and concluded that those who were the most physically active gained the least in both weight & waist circumference over the following two decades. 

The algorithm used to determine physical activity took into account intensity, frequency & duration leading to an activity score in exercise units, 300 of which was deemed equivalent to the suggested 150 minutes/week recommendation of moderate intensity.  However, it turns out that men in the lowest tertile of physical activity averaged just this amount, while men in the highest tertile, those who gained the least in body weight & waist circumference, were more than twice as active.  For the ladies, 300 exercise units only placed them in the middle tertile while twice that much garnered them a place in the highest tertile.

There are two take home points from this study.  First, everyone gained weight & expanded their waist circumference as they aged from young adulthood into middle age, regardless of physical activity.  Second, it takes quite a bit of activity to minimize said gain & expansion, more than double what is currently recommended.

FDA Says Stop Taking Contaminated "Man Up Now"

Fresh off the press:  FDA is now warning consumers to avoid taking the "Man Up Now" dietary supplement which is marked as an "all natural" and/or "herbal" alternative to Cialis, Levitra & Viagra, which are prescription medications indicated for erectile dysfunction. 

However, as I mentioned in an earlier posting, Cialis, Levitra & Viagra are members of a class of medications, phosphodiesterase inhibitor type 5 (PDE-5 inhibitor), that should not be taken in conjunction with nitrates & nitroglycerins as the combination may cause an abrupt drop in blood pressure leaking to loss of consciousness and possibly death.  Most physicians know to avoid prescribing this combination so patients who take nitrates & nitroglycerins (typically those with heart disease caused by blood vessel blockage which also blocks the blood vessels to the penis) are forced to search for alternatives. 

Unfortunately, mass marketers are aware that we tend to look more favorably upon "all natural", "herbal", and "organic" products, especially compared to "synthetics" and thus label their products as such.  The problem arises when their products actually contain either prescription medications or substances chemically similar to said prescription medications.  Thus the unsuspecting patient takes this "all natural", "herbal", and "organic" product in conjunction with his nitrates & nitroglycerins and ends up dead.  In the case of "Man Up Now", the FDA analyzed the dietary supplement and found it to contain sulfoaildenafil, a chemical similar to sildenafil, the active ingredient in Viagra. 

If you need help in achieving an adequate erection while also taking nitrates & nitroglycerin for your heart such that you can't take any PDE-5 inhibitor, consider checking your testosterone level.  Many studies demonstrate an association between testosterone and heart health (more is better).  In case you're told you don't qualify for testosterone supplementation because you're normal and passing, ask yourself, do you want to settle for being normal or do you want to be the best that you can be?  Do you want to settle for a "C" or "D" grade or do you want an "A" or "B" grade?  Just saying . . .

Risk of Dying After a Stroke

Just under 2 weeks ago, I reviewed how to avoid your 1st stroke.  Besides the obvious loss of function, a study published online yesterday points out something even more compelling: an increase risk of death soon thereafter.  The researchers followed 91,134 participants (avg 79yo) for 3yrs.  6.1% died while hospitalized, 14.1% within the 1st 30 days, and 31.1% within the 1st year.  In other words, 1 out of 3 patients who were hospitalized for their 1st stroke were dead within a year.  So go back and review that list of how to avoid your 1st stroke.

BMJ & Christmas III: Bicycle Weight vs Speed

I'm just as guilty as the next cyclist who's willing to spend tens if not hundreds of dollars in order to shave grams off one bicycle component or another.  But my body weight?  It's pretty steady.  The bigger question is whether this expensive mechanical weight reduction really matters, at least to a recreational cyclist, over a relatively short distance.

Thus, in this 3rd of a series of humorous studies published online in the BMJ, the author timed himself on a 27 mile roundtrip from his home to the hospital & back.  So as not to allow a chance spurious ride to throw the results, he averaged his times over 809 miles on his 30 pound steel frame bicycle and another 711 miles on his 21 pound carbon frame bicycle.  From personal experience, I can tell you that the 9 pound difference in weight costs on the magnitude of thousands of dollars.  Yet the average difference in time for his ride was just an 32 seconds (1:47:48 vs 1:48:21 in hours:minutes:seconds) with the confidence interval anywhere from 3 minutes slower to 2 minutes faster on any given day regardless of the bicycle ridden.

So go buy the brand new carbon kevlar titanium bike because you can't stop drooling over it.  Just don't rationalize that it'll make you a faster rider, at least not over 27 miles.  Even the seven time winner of the Tour de France, Lance Armstrong, said "It's not about the bike".

BMJ & Christmas II: You Can't Get Drunk With Your Feet In Alcohol

Here's another study just published online in BMJ's Christmas issue.  Apparently there's a Danish urban myth that one can get drunk by leaving one's feet in alcohol.  At least that's what the 3 authors posited in order to determine if the legend is indeed true or false.  Anything in the name of science!

In essence, they wasted perfectly good vodka by soaking their feet in 2,100ml of 37.5% alcohol by volume for 3 hours, all the while checking their blood alcohol levels every 30 minutes.  They also assessed how they felt, whether they were more confident, more voluble, or more spontaneously given to hugs.  Alas, their blood alcohol levels did not budge one iota and their were no symptoms of intoxication.  Chalk one up for the mythbusters! 

And in honor of the holiday season and the cardiology field which is known for the catchy acronyms given to its studies, the authors declared this the PEACE ON EARTH (or Percutaneous Ethanol Absorption Could Evoke Ongoing Nationwide Euphoria And Random Tender Hugs) study.  God bless us, every one!

BMJ & Christmas: Beauty Rest

The British are known for their wry sense of humor.  That's why I look forward to the Christmas issue of the British Medical Journal (BMJ) each year as it's filled with unique, shall we say, studies.  For instance, published online this week, the author's asked whether beauty sleep is real or just a phrase.

In fact, by randomly comparing the photographs of 23 healthy participants after a normal (8 hours) night's sleep and then again after 31 hours of consciousness after just 5 hours rest, 65 untrained observers were able to distinguish sleep status based upon appearance alone without actual knowledge as to when each photo was taken.

In other words, the participants appeared less healthy, less attractive, and more tired in the latter sleep deprived state compared to their former rested status.  So getting one's beauty rest isn't an excuse after all!

HDL vs Alzheimer's Disease

Known knowns.  Known unknowns.  Unknown unknowns.  Hmmm . . . We know that higher levels of physical are associated with lower risk of Alzheimer's disease (AD).  Multiple studies have demonstrated this over & over again.  We also know that physical activity tends to increase HDL, the good cholesterol.  But is there a link between HDL & AD?  As of this month's issue of Archives of Neurology there is!

The authors studied a cohort of 1,130 elderly (avg 76yo) free of cognitive impairment followed for just 4+yrs.  Those whose HDL was in the highest quartile (>56mg/dL) had a 60% lower risk of developing AD or probable AD compared to those in the lowest quartile (<38mg/dL), regardless of age, sex, education, ethnicity, and APOEe4 genotype. For what it's worth, average age at diagnosis was 83yo.

Ironically, there weren't enough cases of vascular dementia to arrive at a statistically significant answer, but the results suggested once more that high HDL is associated w/lower risk of vascular dementia, too.

Hmmm . . . that chocolate is looking pretty good to me right now to raise my HDL.