August 2010

Medical Intelligence
A Periodic Review of Selected Medical Research
by Marc D. Schwartz, MD
MarcDSchwartzMD@GMail.com

Penny (and in some cases) -Life Savers

1. Lower Your Homocysteine Levels with Folic Acid and B12? Not.
Higher blood levels of homocysteine are clearly associated with a higher risk of cardiovascular disease. Folic acid and vitamin B12 are known to decrease the blood levels. It has therefore been very disappointing that now an eighth large scale study, this one involving 12,000 high risk patients, showed absolutely no benefit for cardiovascular disease or cancer from taking them.

2. Take Glucosamine for Low Back Pain and Lumber Osteoarthritis? Not.
Two hundred and fifty patients mean age 29 took either placebo or glucoamine for low back pain or lumbar osteoarthritis of at least 6 months duration. The groups did not differ on any outcome at 6 months or 1 year.

3. For diabetics: Carry out intensive glycemic control and keep your blood pressure under 130. Not. (But be sure to check with your doctor before changing your regimen) In a study of 10,000 patients over a period of at least 3.5 years, both regimens were found to either have no effect or result in higher mortality. Intensive glycemic control did not reduce vision loss. Maintaining blood pressure between 130 and 140 seemed to be the most healthy approach.

4. For women at low risk for cervical cancer: Have a PAP smear every year. Not. National practice guidelines recommend repeat Pap smear testing for this group every 2 to 3 years yet more than two thirds of a thousand surveyed physicians recommended the test be done yearly for this group.


The Last You Will Ever Hear from Me about Painful Night Cramps
For those of you who have not been following this soap opera, please review the past few issues for a catch-up. The characters in the previous episodes who took magnesium citrate tablets for relief found that its benefits (placebo) wore off in a few days to a few weeks. Desperate, veering even further off the path suggested by the name of this series (Medical Intelligence), one tried calcium carbonate, various vitamins, and glasses of water at bed time. Things got so bad that one character (who will remain nameless but was not the Editor) tried a cure widely recommended on the Internet, a bar of soap under the bedsheets, but to no avail. What finally seemed to work (for at least three weeks anyway) is the following: while lying on one's back in bed at before going to sleep, stretch your legs out straight. Then flex your ankle as far up as you can (really feeling the stretch in the calf muscle) for the count of eight. Then relax for about 15 seconds. Repeat x 3. Don't call me in the morning.

Some Reasons Why Medical Incompetence or Impairment May Go Unreported
Only a third of doctors with direct personal knowledge of an impaired or incompetent colleague in the prior three years had reported that colleague to the medical authorities. The most common reasons given were "thought someone was taking care of the problem, believed that nothing would come of the report, and fear of retribution."

The information above is for educational purposes only.
For advice about your personal medical care, consult with your care provider.

A Periodic Review of Selected Medical Research
by Marc D. Schwartz, MD
MarcDSchwartzMD@GMail.com

Painful Night Cramps Continued (Not)

In the last issue of Medical Intelligence, I discussed painful night cramps. Perhaps reflecting the advanced age of the readership, it was a topic that received more email responses that any other. Since then I had the opportunity to discuss the disorder with a naturopath (Jennifer Krebs of New Haven), who suggested trying magnesium citrate 500 mg per day. A bit skeptically I tried this treatment on two subjects. In both cases, within a few days the painful cramps stopped almost completely at night and thereafter were present only rarely and mildly during the day. Both subjects experienced at times some residual mild muscle cramping of the hands and feet. I know of no medical contraindications to this treatment, but it may be best to check with your doctor if you want to try it.

Now, have I told you about this pain in the back a subject has been having? It starts right about here and goes....

July 2010

Medical-Intelligence

A Periodic Review of Selected Medical Research
by Marc D. Schwartz, MD
MarcDSchwartzMD@GMail.com

Painful Night Cramps

The gold of the golden years is sometimes tarnished by the development of painful muscle cramps, which usually occur suddenly at night, most often in the legs. Each cramp quickly increases in intensity and is often relieved only by getting up and standing. The shock of the pain often makes it difficult to return to sleep. They sometimes occur just upon getting up out of bed. Their cause is usually unknown.

They can often be be stopped, or better yet aborted, by strongly tensing up the involved muscle for a few seconds. If the (incipient) cramp is in the back of the thigh, push to straighten out the leg while holding it in place with the other leg. If it is in the outer side of the ankle area, push the foot or toes inward while holding it (them) in place the other foot. If it is in the calf, bend the foot upward hard. In general, if the cramp is in the side of a leg, push the leg towards the other leg; if it is in the inner side of a leg, cross legs and push against the other leg.

January 2010

Medical-Intelligence

A Periodic Review of Selected Medical Research
by Marc D. Schwartz, MD
MarcDSchwartzMD@GMail.com

Table of Contents
More Questions about the Value of Daily Aspirin
A Promising New Weight Loss Medication
Antibiotics to Avoid During Pregnancy
Yet Another Benefit of Taking Statins
Best Treatment of a Pain in the Neck
Zetia and Vytorin May Be Less Than Helpful
Pleeeze Take Your Hypertension Medication
High Dose Vitamin D Prevents Falls in Seniors
Folic Acid May Be Dangerous to Your Health

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More Questions about the Value of Daily Aspirin
We previously reported that a very large scale study that compiled all the major aspirin studies through 2008 found that the problems caused by the regimen slightly outweighed the advantages. In particular, the increase in brain hemorrhages in people taking daily aspirin was slightly greater than the decrease in brain clots.

Now a study of diabetics found that aspirin was no better than a placebo in reducing the risk for major cardiovascular events (heart attack, stroke, or death) in women though it was somewhat beneficial to men. (http://dx.doi.org/10.1136/bmj.bj4596)

A Promising New Weight Loss Medication
A new weight loss medication brought about an average weight loss of 5% in five months in over 500 obese people. This was twice the loss found with a placebo and was significantly greater that achieved with Orlistat. A closely related drug, Exenetide (brand name Byetta), is available in the US. It may be a useful adjunct to diet and exercise for overweight people. - Lancet Nov 2009

Antibiotics to Avoid During Pregnancy
With your permission, I will spare you the study details. The following medications appear to be safe during pregnancy: penicillin, erythromycin, and cephalosporin. Sulfonamides and nitrofurantoins appear to be associated with birth defects and should be avoided if possible. Quinolones are not recommended for use during pregnancy. Arch Pediatr Adolescent Med Nov 2009

Yet Another Benefit of Taking Statins
Statins were recently shown to reduce the incidence of gall stones. (They may also strengthen bones, reduce the risk of dementia and stroke, delay the onset of diabetes plus, of course, they do reduce the risk of heart attack.) - JAMA Nov 2009

A Pain in the Neck
A six week study compared the effects of three treatments on neck pain radiating into the arm: 1) a semi-hard neck collar and neck rest for 3 weeks, 2) physical therapy two or three times a week, and 3) daily activities without specific treatment. The neck collar and rest resulted in significantly less disability at six weeks than the other two approaches. At six months, there were no significant differences in pain scores over the three groups. -Brit Med J Oct 2009

Zetia and Vytorin May Be Less Than Helpful
While Zetia (ezetimibe) is used by itself or as an ingredient of Vytorin to lower LDL cholesterol. Research has failed to demonstrate that this translates into any patient benefit. (Do we need health care reform or what!) A recent study showed that, on the contrary, it caused an unhealthy thickening of the walls or the carotid artery, which serves the brain. The Journal Watch editors suggest that is should be used as "a drug of last resort if at all."

Pleeeze Take Your Hypertension Medication
It may be a bore to take anti-hypertensive medication day after day. However, in a study of 19,000 hypertensive patients, those who were highly treatment adherent to prescribed treatment had only a little more than half the number of cardiovascular events (heart attack, stroke, etc) as those who were poorly adherent. - Circulation Oct 2009

High Dose Vitamin D Prevents Falls in Seniors
Eight studies have found that high daily doses of Vitamin D2 or D3 (700 - 1000 IU, available in drug stores) lowered the risk of falling in those over 70 years of age by 20%, probably by increasing muscle strength and balance. The risk was lowered only among patients whose serum Vitamin D3 level was over nmol/liter with treatment. Doses lower than 700 mg had no effect. - Brit Med J Oct 2009

Folic Acid May Be Dangerous to Your Health
Not all supplemental vitamins are healthy for you. Half of 7,000 middle aged patients were randomized to get folic acid or not each day for six and a half years. The risk of dying among those taking folic acid was 18% higher than those who did not take it. This study supports the concern about daily folic acid supplements generated by previous studies that found it increased the risk of prostate cancer. - JAMA Nov 2009

"See, I told you Mabel. Four drinks a day make my brain really sharp."
A recent study suggests that people over 60 who consume moderate amounts of alcohol have a reduced risk for Alzheimer's disease and other dementias. In an article published in the July 2009 issue of the American Journal of Geriatric Psychiatry, researchers reviewed 15 studies that together followed more than 28,000 subjects for at least two years. The studies defined light to moderate drinking as one to 28 drinks per week (sic) . That's up to four a day! (hic)

Compared with abstainers, male drinkers reduced their risk for dementia by 45 percent, and women by 27 percent. If true, this is pretty exciting news, but two years seems to me to be a pretty short period of time to study the progression of dementia, and calling people who average four drinks a day moderate drinkers seems a bit loose, some might say enabling.

The real downside of this news is that it might turn drinking into a virtue, thereby subverting some of its pleasure.

July 19, 2009

Who Will You Ever Trust Again?

Do you remember Woody Allen's line in the movie Sleeper? Sitting in a McDonald's two hundred years in the future ("Trillions Sold"), he mentions that scientists recently discovered that hamburgers are actually very healthy for you. Well, sit down before you read this one.

95,000 patients without diabetes, without overt blockage of their arteries, and without previous cardiovascular disease were randomly given daily aspirin or not. (You can guess where this is going.) There was virtually no difference found in the frequency of heart attack or stroke between the two groups and no difference in mortality. Patients who received aspirin had fewer brain clots, but this was balanced by the number that had more brain hemorrhages. Patients who received aspirin experienced slightly more (non-brain) bleeding.

The authors of this study, which appeared in Lancet, May 30, 2009, suggest that the benefits of aspirin to most people may no longer outweigh the risks, especially if their cholesterol is controlled, they're not smoking, and are generally taking care of themselves.

If you own Bayer stock, take two of the many aspirin pills on your medicine shelf and call your broker.

Readers' Responses:
#1:
Hmmm. So what are the implications (if any) for us nonsmokers whose cholesterol and blood pressure are controlled but who have had cardiovascular disease and arterial blockages sufficient to warrant CABGs? Inquiring minds want to know.

My answer: I dunno. As I read between the lines of the article, a situation like yours might seem to shift the balance towards taking aspirin. But your question takes me way beyond my area of expertise. You might want to print out the article (reference above), send it to your doctor then discuss it with him/her. The conclusion was the author's, and recent, and I'm not sure how widely it is shared in the medical community which, as you know, is generally conservative about changing recommendations.

#2:
"Thanks" for this bad bit of news.

#3:
"That article makes me feel better. I stopped taking "an aspirin a day" a year and a half ago as I was covered in black and blue. Every time I bumped into anything , I looked like a battered wife. Much better since I stopped even though I still bruise easily.

#4:
Years ago you suggested that I take an aspirin a day for heart protection. I chose not to. From my reading then and since I have seen that aspirin has a multiplicity of effects including blood thinning and clot prevention. Some of those effects are not as desirable. Personally, I like it when a wound clots easily and I get a scab rather than continued bleeding. It is nice to be able to have procedures (like a prostate biopsy (even though that is not pleasant)) immediately without having to wait a few days for the blood thinners to clear my system.

July 19, 2009

Sweet Forgetfulness

Insulin helps the body convert glucose (sugar) to energy and, in doing so, keeps glucose blood levels moderated. Starting in people's thirties however, for unknown reasons, insulin does not work as well, and people tend to experience glucose spikes particularly after meals or sugar binges.

It has recently been found that these glucose spikes can damage the part of the brain that is responsible for recall. One thing you can do to reduce the frequency or intensity of the spikes and hopefully minimize age-related memory decline is to exercise, as this reduces blood glucose by converting it to muscle energy. Also, it probably wouldn't hurt to eat smaller meals and eschew frequent candy bar and ice-cream orgies.

June 2009:

* PSA Tests Are Not Always To Be Relied Upon.

* Some Antidepressants May Cause Diabetes.


PSA Test Results: Strongly Suggestive but Hardly Definitive
PSA (prostate specific antigen) blood tests are used to screen for prostate cancer. While they are often useful, the test gives so many false positive and false negative results that it must be viewed with some reservation. (False positives suggest cancer when there is none; false negatives suggest there is no cancer when cancer is in fact present.)

A number of studies have followed men who had two or more annual PSA tests. Fairly consistently, between 20%and 25% of those who tested positive one year had normal results the following year. In addition, routine biopsies have discovered prostate cancer in a substantial minority of men with normal PSA levels. In some cases these cancers have been aggressive. Hopefully a more reliable test will be developed soon.


Long Term Use of Some Antidepressants May Bring on Diabetes
Depression seems to increase the risk of diabetes, but it has been unclear what the role of antidepressants are in this phenomenon. 2,243 adults who developed diabetes after starting anti-depressant therapy were compared to 8,962 age and sex matched patients without diabetes for a three year period. Factors found to increase the risk of diabetes were:

1) taking certain antidepressants (Paxil (paroxetine), Luvox (fluvoxamine), Effexor (venlafaxine), and Elavil (amitriptyline)) but not others (Prozac (fluoxetine), Celexa (citalpram) or Zoloft (sertraline))
2) taking above the median dose of the medication
3) taking the medication for a longer period of time.

But the strongest predictor of new onset diabetes was being overweight at the time the medication was started. In addition, in my experience, the diabetes inducing antidepressants are more likely than the others to cause weight gain. Patients taking them might want to consult their physicians about been monitored for pre-diabetic or diabetic blood levels or consider a change in anti-depressant medication if that is feasible.

May 2009 (2)

Vitamin D Deficiency Increases the Risk of Fractures, Infection, Tumors. Really.

The current poster child of vitamin deficiencies is D. Unlike some others, this one is not uncommon and has actual scientific evidence to supporting the value of supplements for some people. Symptoms of Vitamin D deficiency in its milder forms are barely distinguishable from hypochondiasis: muscle aches, frequent colds, and "immune system problems". But studies of large numbers of people have shown that those with D deficiency in fact suffer more often from a variety of problems including softening of the bones, immune diseases, cardiovascular disease, cancer, and infections.

For example, a study of 6,000 men over 65 years of age found that low Vitamin D blood levels are associated with low bone density, which predisposes to hip fractures, which predispose to nothing good, I assure you. The Journal of Nutrition recently reported that a study of over 400 pregnant women found that vaginal infections were 26% more common in those with D levels lower than 50 and 65% more common in those with levels lower than 20. Black women were more likely to have lower levels because darker skin (and aging) interferes with synthesis of the vitamin.

The normal level of Vitamin D in the blood is 80 nanamoles per liter. If you want to know whether yours is lower, it is unfortunately very unlikely that your medical insurance will cover the cost of a blood test unless your doctor states there is clinical evidence that you have a deficiency. If the test is done, and the level is low (or if you are a vitamin hypochondriac and this article has made you worry that it might be low), you can increase the level by taking inexpensive, over the counter vitamin D3 supplements. These raise the level slowly over time. Engaging in outdoor activities also helps. Other things you can do to increase your D levels are be thin, be Caucasian, live in the South, and be younger. If a blood test shows that you have a severe deficiency, you can get an injection of D from your health care provider that will raise it more rapidly.

Hyper-vitaminosis D is extremely rare in people taking vitamins at recommended levels. When it does occur, it is usually caused by taking a form of vitamin D that requires a doctor's prescription.

May 2009

Avoiding Kidney Stones

A kidney stone can be extremely painful to pass. In a recent study, 503 people who had recurrent stones, including ones from calcium and from gout, were treated with potassium citrate for about three and a half years. Prior to the treatment, subjects had had averaged about 2 stones per year. During the treatment period they averaged fewer than half a stone per yer.

The potassium citrate works by making the urine more acid, which tends to dissolve stones. It is available without a prescription and is found in many soft drinks. If you can't get it from your pharmacy, Vitamin C pills may also be used to acidify the urine. You may want to check with your doctor before trying either.

April 2009

Why Not Take Vitamins Containing Folic Acid.
It Can't Hurt. Or Can It??

Supplemental vitamins are marketed to the public as risk-free aids for improving health and extending life. A series of randomized research trials have called this assumption into question.

For example, regular doses of folic acid (folate) to have been used, with no research support, as a way to prevent recurrence of colo-rectal cancers. A recent study found this practice to be associated, in fact, with a slightly higher risk of more aggressive recurrence of the cancer.

Many men take high dose folic acid supplements to avoid a heart attack or stroke. The same study found no support for this practice either. Worse, it found that folic acid taken in daily doses commonly used in vitamin pills actually increases the ten year probability of prostate cancer in men over 57 years of age. The probability was only 3% among those taking placebo compared to almost 10% among those taking folic acid.

There may be a clue here why, compared to other countries, health care costs are higher in the US than in other first world countries, while life expectancy is shorter. More health care does not necessarily equate with better health care.

March 2009

Medical-Intelligence

A Periodic Review of Selected Medical Research
by Marc D. Schwartz, MD
MarcDSchwartzMD@GMail.com

Table of Contents

I Hear $400. Do I Hear $600?
Having a Hip Fracture Increases a Person's Chance of Dying for Up to Ten Years
Avoid NSAID's Following Hospitalization for Heart Failure
On the Brighter Side
New Standard for Treating Locally Advanced Prostatic Cancer

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I Hear $400. Do I Hear $600?
Fifteen percent of people who were paid $400 to stop smoking for six months did so. This is over twice the cessation rate of those not paid. A year later eleven percent were still not smoking.

This cure rate is good (for those who stopped) and no so good (for the almost 90% who didn't).
Since the annual smoking-related cost of smoking (including medical care and lost productivity) is $3,400 per person per year, I'm sure another researcher will up the bid shortly.

Having a Hip Fracture Increases a Person's Chance of Dying for Up to Ten Years
Four thousand Australians over 60 years of age were followed for 18 years. During that time, over a quarter had a fracture of some kind, most commonly of the hip. The mortality rate of those who had a fracture was almost twice that of those who did not. A second or third fracture doubled or tripled that rate.

The increased risk of dying persisted for five years for any fracture and for ten years for a hip fracture. The controllable risk factors associated with fractures are weak quadriceps (thigh) muscles, smoking, and low physical activity. If this does not get you to the gym, I don't know what will!

Avoid NSAID's Following Hospitalization for Heart Failure
Over 100,000 Danish patients who were hospitalized for heart failure were followed over a ten year period. Risks for death, hospitalization, and heart attack were all higher with any use of a non-steroidal anti-inflammatory drug. The greater the dose taken over time, the greater the risk.

On the Brighter Side
Over a three month period, women who reduced their calorie intake by 30% had a dramatic increase in memory. Don't even think about it. Most people, including you, just can't sustain this level of calorie reduction over time. The good news: new drugs are actually being developed that mimic the consequences of calorie restriction.

New Standard for Treating Locally Advanced Prostatic Cancer
A study was carried out of the effects of two cancer treatments on 875 men under 75 of age who had prostate cancer that did not involve the nodes and did not have known metastases. The study was restricted to men in otherwise good health.

Men were randomly treated with either anti-androgen hormones or anti-androgen treatment plus maximum dose radiation. Mortality was significantly lower in the combined therapy group. The authors of the editorial in Lancet, where the study was published, believe that long term combined therapy should be the new standard of care for such patients.

ADHD Stimulants and Genetic Damage

Do stimulants cause genetic damage?
A study of white blood cells of 47 children taking either methylphenidate or mixed amphetamine salts for a period of three months showed no more chromosome damage than did the white cells of children not taking these medications. While somewhat reassuring, longer term studies, now under way, are warranted. J Amer Acad Child Adolescent Psychiat December 2008