Q&A Session at Avvo.com

I have ongoing uti i have pain in my side as well.do i have kidney stones?

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Q&A Session at Avvo.com

Hello I am a type II diabetic and I am starting to experience problems getting an erection. What can you tell about ED medicines

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Q&A Session at Avvo.com

Will smoking marijuana effect my growth hormone and testorne injecting treatment

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What happen to take Viagra and do not have sex?

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How can you control his temper?

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Q&A Session at Avvo.com

I'm 5'9" 50 years old. Constant runny nose and bring up clear sputum. I'm about 219lbs and find I break out in sweats

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Q&A Session at Avvo.com

I want to make a change but depression seems to be holding me back what can i do?

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IOM: Environmental Impact on Breast Cancer

Commissioned by Susan G. Komen for the Cure, the Institute of Medicine released earlier this week its latest findings regarding the environment's impact on breast cancer.  To be clear, they defined the "environment" a bit more broadly than you and I might typically do.  In fact, they looked at the evidence regarding anything non-genetic in nature.

Turning against the current tide of research proclaiming that environmental chemicals are increasing our risk for cancer, the IOM concluded that while animal research is supportive, no clear cut cause & effect relationship has yet been established between environmental chemicals and breast cancer, just an associative link.  And as you all remember, correlation does not imply causation.

On the other hand, the IOM came away convinced that women do have some control over their breast cancer risk.  They concluded that poor diet, more than moderate alcohol consumption & lack of exercise (all leading to weight gain), active/passive smoking, medical radiation, eg CT scans but not mammograms, and hormone therapy, can increase one's breast cancer risk.  

The full report is a heft 371 pages while the executive summary is still a lengthy 39 pages long.  However, I would direct your attention & time to the succinct 11 page question & answer written to address the layperson's concerns.

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How Normal is Normal?

What does it mean to be normal?  If your lab results aren't boldfaced, aren't listed in the abnormal column, and don't have an abnormal label next to them, then they're normal.  Which means you're normal, right?  Wrong!  Or at best, maybe!

So how do we arrive at the normal reference range?  And what does it mean for us?  For starters, take a thousand similar aged, similar sex participants w/o any (known or declared) medical issues.  Throw out the highest 25 and the lowest 25 values such that you're left with the middle 950, which should all then plot out as the proverbial bell shaped curve.  Of the middle 950, the 2 most extreme values represent the upper & lower limits of normal.  

But what about the highest 25 and lowest 25 that were originally a part of group of 1,000.  By definition, you've just made them abnormal, even though the group was supposedly all normal before plotting out the results.

Do this over & over again for each test result and start increasing the total number of subjects from 1,000 to 10,000 to 100,000, etc.  And don't forget to throw out the highest 2.5% and lowest 2.5% each time so that you're always left with the middle 95% that then forms the normal bell shaped curve.

I give you this long winded prelude as background for a study to be published next month in JCEM in which 10,083 women and 5,023 men free of baseline thyroid disease were followed for 11yrs after noting that their baseline TSH (thyroid stimulating hormone) was normal and within the normal reference range.

And yet, after over a decade of follow up, even though they all had normal TSH initially, those with normal TSH closer to the upper limit of normal were at greater risk for developing hypothyroidism.  And those with normal TSH closer to the lower limit of normal were at greater risk for developing hyperthyroidism.  Which goes to show you that Goldilocks was onto something.  You want your TSH just right, not too high and not too low, even though it's normal.  

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Vitamin D & T2DM Risks in Obese Children

I call it medical ping pong.  First, the headlines tell us that coffee is bad for you.  Then, it's bad for you.  Then it's good for you again.  Likewise, salt.  Most of the time it's bad for you, but every now and then, a headline says it's ok.  Many moons ago, we put every perimenopausal woman on estrogen.  Nowadays, we try to do our best to avoid doing so.  At one point, getting annual mammograms and Pap smears was a good thing.  Now we're not so sure.  Same w/annual PSA screenings for prostate cancer.  You'd think that you're listening to politicians rather than physicians!

As usual, the devil is in the details.  It's impossible to capture all the nuances of each study in those pithy headlines and 10 second sound bites.  For instance, there's a huge difference between observational studies and randomized controlled trials.  The former help us develop hypotheses while the latter help (dis)prove them.  Case in point is a cross-sectional study (published online prior to print next month) of 411 obese kids compared to 87 non-overweight controls, all 6-16yo.  Compared to their non-overweight controls, the obese children were more likely to have vitamin D insufficiency and deficiency.  Moreover, low vitamin D was associated with greater risk for type 2 diabetes mellitus (T2DM).

But that's a far cry from stating that vitamin D causes T2DM, even though studies have demonstrated that impaired pancreatic insulin secretion in vitamin D deficient rats.  And let's not forget that low vitamin D was also inversely associated with soda consumption, juice intake, and skipping breakfast, all of which have been correlated with being overweight or obese.  So while vitamin D may be linked with T2DM, it's just as likely that it's the soda & juice consumption and skipping of breakfast that leads to overweight/obesity which is really what puts someone at risk for T2DM.  Remember that correlation does not prove causation.

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What's In Your (Parents') Medicine Cabinet? Part 2

Just 10 days ago, I wrote about a link between inappropriate medication use and hospitalizations.  One of the issues that I wanted to point out was just how do we define inappropriate?  After all, what's inappropriate for one person might be appropriate for someone else.  More importantly, what's inappropriate for one person at a particular point in time might be appropriate later on (or previously).

Coincidentally, I just stumbled upon yet another study (published 8d ago) looking at inappropriate medication use among community dwelling elderly.  More specifically, the authors analyzed the results of 19 retrospective studies using various iterations of Beers criteria (1991, 1997 & 2002), Zhan's derivation of Beers, HEDIS subset of Zhan, and other measures.  Depending upon the measure applied, the prevalence of inappropriate medication use ranged from 11.5% to 62.5%.  In other words, at least 1 in 10 community dwelling elderly had an unsafe (combination of) medication(s) in their regimen.  And depending upon the criteria used, as many as 2 in 3 community dwelling elderly were at risk.

Of course, just as with other studies, we're more interested in patient oriented evidence that matters (POEMs), those studies that look into clinical outcomes.  We're less interested in disease oriented evidence (DOE) that looks into the disease process.  In this study, it appears that the authors were more focused on the latter since there was no assessment on the clinical impact of inappropriate medication use, such as emergency room visits, drug-drug interactions, and/or drug-disease interactions.

Nevertheless, the take home point is that clinicians need to be more aware of the medications that they (and their colleagues) prescribe.  And you & I need to chat w/our parents and older family members and ask about what medications they're keeping in their medicine cabinet.  Great way to strike up a conversation around the holiday dinner table!

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Androgen Deprivation Therapy - Yes or No?

The American Heart Association, American Cancer Society, American Urological Association, and American Society for Radiation Oncology came together early last year and issued a joint statement regarding an association between androgen deprivation therapy (ADT) and an increase risk for cardiovascular events.  This scientific advisory was based upon secondary analysis of several major observational studies.  

So in typical medical badminton fashion, a study was published in JAMA today stating the opposite, that ADT was not associated with an increase risk of cardiovascular events.  Well, who's right?  These authors claimed the upper hand because their conclusion was based upon a meta-analysis of 8 randomized controlled trials (RCT) involving 4,141 patients followed for 7-13yrs, rather than a rehash of epidemiological studies.

The two editorialists pointed out that while RCTs are the gold standard in proving cause & effect, those of us practicing in the trenches must always ask ourselves whether our patient has enough characteristics similar to the group studied for the conclusion to be applied.  Different patient populations, study design, selection bias, etc may have confounded the data still.  Remember the initial turmoil that the Women's Health Initiative stirred up 9yrs ago?  Then we began to realize that the 65yo female who's 10yrs post-menopause might have different physiology than the 45-50yo w/peri-menopausal issues.

But what are we to do in the meantime while we wait for a more definitive answer?  Let's realize that many of the same patients w/prostate cancer are also dealing w/heart disease.  Regardless of how ADT affects their cardiovascular event rate, these patients must have their heart disease risk factors aggressively treated.  And for now, the major medical groups haven't rescinded their collective guideline.

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FDA/FTC Going After Homeopathic hCG

The word is out.  Big Brother is watching.  The Food & Drug Administration along with the Federal Trade Commission just announced the issuance last week of Warning Letters to several manufacturers/marketers of over-the-counter "homeopathic" hCG (human chorionic gonadotropin) for weight loss.  

As I've noted in the past, manufacturers of dietary supplements are not legally obligated to demonstrate either efficacy or safety of their products prior to reaching the store shelf.  However, they are prohibited from using/including prescription medications in their products and from making health claims.

In this particular situation, hCG is a prescription medication which is typically used for female infertility purposes and off-label in hypogonadal men.  For what it's worth, hCG is also recognized as a performance enhancing drug or substance w/guidelines recently promulgated by WADA (World Anti-Doping Agency).

While I am not by any means an expert in homeopathy, the idea is that a substance is serially diluted to such a degree that none would be found/available but that the dilution would work its benefit via water's memory.  

I suspect the FDA & FTC are upset since one can either claim the inclusion of hCG as a prescription product or disclaim its presence in a dietary supplement.  But one shouldn't attempt to sell even "homeopathic" dilutions of prescription medications as supplements w/health claims.

Regardless, whether one chooses to search for "homeopathic" hCG or purchase prescription hCG from the myriad clinics sprouting up around the country, there is no credible data demonstrating any additional benefit of hCG in achieving weight loss beyond that from an extremely low calorie diet in isolation, ATW Simeon's writings notwithstanding.  Such is the arcane legal battlefield that governs our health & science.

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Higher T = Less Loss of Lean Body Mass in Older Men

Double negative.  I was taught in my English classes to avoid using double negatives.  In other words, I was supposed to write in the affirmative, in a more direct fashion.  So I find it ironic to read a double negative in the title of published study (although the use of multiple negatives is apparently common place around the world).  Of course, in mathematics, we didn't worry about such issues.

In a prospective cohort study published in this month's JCEM, 1,183 ambulatory American males average 72+yo were followed for 4+yrs. Unfortunately, the Osteoporotic Fractures in Men (MrOS) participants were not as diverse as one would have liked with Caucasians accounting for almost 75% of the group.

Nevertheless, everyone lost muscle. The question then was how much. It turned out that the higher one's endogenous testosterone level, the less muscle mass one lost over time (apparently their skeletal muscle didn't believe in avoiding double negatives). To be clear, there was no association w/physical function, although it would correlate with the observation that higher testosterone is associated with less frailty and lower risk of falls.

But what's most impressive is the conclusion arrived at by the authors: "Endogenous testosterone may contribute to healthy aging."  Of course, the next step is to determine whether exogenous or supplemental testosterone will achieve the same effect . . . In the meantime, don't forget all the other modifiable tenets that affect our health. 

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