May 2007 #2

Fish or have trouble cutting bait
Imagine you're pregnant. You think fish oil may be good for you, but you also know that fish oil contains mercury, which is bad for the baby. What to do? UK researchers studied data from almost 9,000 pregnant women and their offspring through age 8. (British and US seafood mercury levels are similar.) The children of mothers who ate more than 340 grams of seafood a week (a dinner portion of fish weighs about 230 grams) had significantly better neurodevelopmnetal outcomes including better fine-motor, communication, and social skills and higher verbal IQ. Pregnant women might want to spice any fish they add to their diets with a bit of skepticism as theses results are pretty amazing. And bear in mind that some types of fish have more oil then others (salmon, herring, flounder, pollock, sole), and others have more mercury (swordfish, tilefish, king mackerel.) . For details, see AmericanHeart.org/presenter.jhtml?identifier=3013797.

What's the Significance of a Mildly Elevated Fasting Plasma Glucose Level?
The Fasting Plasma Glucose (FPG) level is used in making the diagnosis of diabetes. An FPG below 100 is regarded as normal; one between 100 and 125 as impaired; while higher levels are in the diabetic range. Over 5,000 non-diabetics who had recently been found to have an impaired plasma glucose level were followed for an average of six years. Of those whose first abnormal level was between 100 and 109, about 1 % a year converted to diabetes. Of those whose first abnormal level was between 110 and 125, the conversion rate was five times greater. So, what can a person do if their level is mildly elevated? See below.

What To Do if Your Plasma Glucose Level is Mildly Elevated
British researchers compared three approaches to delaying the onset of diabetes in people with mildly impaired plasma glucose levels: lifestyle changes (weight loss and exercise), medications (metformin and acarbose) and a weight loss drug (Orlistat, which blocks intestinal absorption of fat). Orlistat was found to be the most helpful, followed by weight loss and exercise, then by medications. However, Orliststat's annoying side effects (greasy stools, occasional leakage of stool) have deterred many people from using
it. In this study, the effects lasted only as long as the patients followed their treatment regimen. In another study involving a more structured and intense exercise training program, the effects were much better and longer lasting.

Pay for Performance: Reward and Punish Health Care Providers Based on Their Results
It's the latest, it's the greatest. Pay for performance! It's so intuitively right that there's no need to test whether it works - just do it. In fact, while you were out taking a walk, more than half of all private HMO's have adopted such programs. Of course, there have been other intuitively right ideas: total mastectomy for breast cancer, hormone treatment for all menopausal women, to mention a few. The fact is, evidence linking pay for performance programs to better quality of care is surprisingly thin, and some evidence for its effectiveness is based solely on improvement in record keeping without much change in the underlying quality of care. In addition, most patients receive most of their care from multiple providers. Whatever. It is an idea whose time has come. Stand aside.

First Aid for Kidney Stones
As anyone who has passed a kidney stone can attest, it can be very painful. Ultra-sound and surgical interventions are risky and expensive. An analysis of studies on various medications treatments used to help patients pass stones, including steroids, NSAIDs, calcium channel blockers, and alpha-blockers., found them all to be helpful. This may reflect a common bias towards publishing only positive findings. In addition, the studies were small and varied in quality. Still, until more conclusive studies are done, people who can't wait may want to keep on hand the two prescription medications preferred by the journal editor, calcium channel blockers and alpha-blockers because they generally have the mildest side effects. There are about two dozen of these medications on the market including Verapamil, Norvasc, Procardia, Cardura and Flomax.

Is There a Problem Taking Aspirin for Your Heart and Advil or Motrin for Your Knee (or Headache)?
In short, yes, there is a problem. Abruptly discontinuing the aspirin you take each day or two can actually increase the cardiovascular risks that aspirin is intended to reduce. Taking an NSAID like Advil or Motein at the wrong time of day can block aspirin's action, which has the same effect as discontinuing it abruptly. Here's how it happens and what you can do about it.

Opening its spigot empties a rain-barrel in a few minutes, but it may take days for the water level to build up again. Similarly, it takes aspirin only a few hours to reduce a clotting factor in the blood but, once it's been reduced, it takes days for the body to build it up again. During those days, the lower level of clotting factor in your bloodstream makes it less likely that you will have a heart attack or stroke.

It's important to avoid having anything in your bloodstream during the first few hours after you've taken an aspirin that might block its action (that is, that might clog the spigot). Unfortunately, the non-steroidal inflammatory drugs (NSAIDs) like Motrin and Advil have this blocking effect, so it's best not to keep them out of your bloodstream until at least two hours after you've taken an aspirin. And since NSAIDs remain active in your bloodstream for about eight and a half hours after they're taken, you don't want to take a NSAID for eight or nine hours BEFORE taking an aspirin. All things considered, one good time to take aspirin might be at 7 AM (assuming you haven't taken an NSAID for eight and a half hours) and then not take an NSAID till after 9 AM. (This information recently appeared in the John Hopkins Medical Letter.)