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Tuesday
09Mar2010

The Only Proven Fountain of Youth

The January Archives of Internal Medicine contained a series of articles justifying the statement: “regular physical activity has been associated with greater longevity as well as reduced risk of physical disability and dependence, the most important health outcome, even more than death, for most older people”. 

The first study, from Harvard Medical School, analyzed data from 13,500 women in the Nurses’ Health Study.  The over 70-year-olds who engaged in regular physical activity in their middle age were less likely to undergo heart surgery, have chronic diseases like diabetes or osteoarthritis, or have any physical or mental impairment.

In the next study Vancouver scientists enrolled 155 women aged 65 to 75, and assigned them to one of 3 groups for a year: resistance training once a week, the same twice a week, or no resistance exercise, just balance and tone training (controls).  Both groups doing resistance training improved their performance on mental tests (the Stroop Test of selective attention and conflict resolution) – averaging +12.6% and +10.9% for the once and twice a week training, with -0.5% for the controls.

The third study was reported from Germany.  Bavarian citizens over 55 were enrolled in a 2-year study.  Their mental functioning was measured using the 6-item Cognitive Impairment Test.  At the start of the study, 10% of the participants had ‘cognitive impairment’ according to the test.  After two years, 207 (6%) of the unimpaired participants developed cognitive impairment.  However, the occurrence of new impairment varied according to the subjects’ activity level.  Thus for participants who reported no physical activity it was 13.9%, for those who were moderately active (exercising less than 3 times a week) it was 6.7%, and for those with a high level of activity (exercising 3 times a week or more) it was 5.1%.

Finally, another German study showed the benefits of exercise on bone density and risk of falling in women over 65.  There were 115 women assigned to follow an exercise program and 112 who followed a wellness information program (i.e. they were controls), for 18 months.  The exercise consisted of a multipurpose 4-days-a-week program, emphasizing intensity of effort. Results showed that the exercising women ended up with significantly higher bone mineral density levels in the spine and hip, and a 66% reduced rate of falls.  And the women in the control group were twice as likely to have fractures due to falls than those in the exercising group.

If that isn’t enough to convince skeptics to start exercising, remember there are 60 health benefits of physical exercise – at least according to one source!

Monday
08Mar2010

Coffee and the Risk of a Stroke

An American Stroke Association meeting poster (LB-P5) contains interesting information on the benefits of drinking coffee.  We know that coffee consumption is linked to a decreased risk of developing diabetes, and can improve short-term memory.  Now a British study shows that drinking coffee is linked with a decreased risk of stroke. 

University of Cambridge scientists analyzed data from the European Prospective Investigation into Cancer; at enrollment in 1993-1997 the participants were aged 39 to 79, and had no prior stroke, heart attack, or cancer.  Roughly 10,300 men and 12,600 women were followed for an average of 11 years.   

80% of the participants drank coffee – an average of 3.1 cups a day – and 20% said they never drank coffee.  There were 669 cases of stroke during follow-up.  After adjustments were made for differences in smoking, social class, education level, BMI, alcohol intake, activity level, tea drinking, and a battery of blood chemical test results, a clear difference in the risk of stroke between the coffee-drinkers and non-drinkers was found.  Compared with non-coffee drinkers, the coffee drinkers had a 27% reduced risk of stroke.  In smokers, the reduction was 61%.  Importantly, there was no ‘dose-dependence’ in coffee-drinking’s apparent protective effect. So there’s no reason to drink more coffee – one cup a day was enough in many of the subjects. It will, of course, be interesting to see if the results can be duplicated elsewhere, and then to find what factor, or factors, in coffee may be responsible.

Friday
05Mar2010

How Doctors Can Use “The Placebo Effect”, Ethically

Long, long before clinical trials were being done to provide evidence of a drug’s activity, the placebo effect was used by physicians to provide relief to patients with a wide range of symptoms. At the extreme end there was the snake oil of the travelling “doctor” in the West, but there’s little doubt that many medicines prescribed by family physicians in the early 1900s contained little more than a bitter-tasting substance put up in colored water. Nowadays a placebo is defined by its inert content and its use as a negative control substance in clinical trials.  The trouble with an otherwise perfect experimental set-up is that the intended inert, negative control produces a measurable beneficial effect – the placebo effect.  A good example is the rigid testing protocols for evaluating new antidepressant drugs, where the placebo effect may produce a good response in 30% to 40% of patients. An “effective” drug then has to produce a comparable (or better) response in 60% or more of the patients.  

Recent research shows that placebo effects are genuine psychobiological events, and studies are reported showing that a placebo effect can be of several different kinds, and may even occur when no placebo has actually been given. This is the subject of an Australian publication in the Lancet.

The researchers cite a large study of patients with irritable bowel syndrome.  Patients were given either no treatment at all, a placebo (a sham acupuncture treatment) or the placebo (sham acupuncture) plus supportive care (the clinician followed a script to convey attention, warmth, confidence, and thoughtful silence as he inserted the needles).  The response rates in the 3 groups were 28% (no treatment), 44% (sham acupuncture alone), and 62% (sham acupuncture plus supportive care).  Clearly the placebo effect of supportive care was added to that of the sham acupuncture; i.e. different sorts of placebo effect can be additive.  Side effects can also be induced by placebos.  In a similar study, patients given an inert pill were told they might experience adverse effects such as drowsiness, while those in another group were informed about the side effects of acupuncture.  Both groups reported a 30% incidence of side effects, but in the first they were of the drowsiness type, and in the sham procedure they were those of acupuncture.  Both these studies indicate that the placebo effect is the result of suggestibility.

So why shouldn’t the placebo effect be used deliberately in treatment, as in the bad old days?  Maybe because it raises ethical issues, given our modern array of drugs and treatments that have been proven to be effective (at least to the FDA’s satisfaction).  The Australian group point out that supportive care is clearly ethical, but only as an additive. They go on to suggest that one way a placebo pill might be given alone would be to tell the patient “this pill has no active drug and will work through psychological mechanisms to promote self-healing”.  Good luck with that, as they say. 

However, now it’s been shown that supportive care has a placebo effect, there’s no reason not to encourage all treatment regimens to include additional supportive care, without any practice of deception.

Thursday
04Mar2010

Sound Advice on Treating Muscle Cramps

A muscle cramp, commonly called a ‘Charley Horse’, arises when a muscle or group of muscles involuntarily contracts and cannot be relaxed by the subject’s will.  Although cramps recover in a minute or so, prevention is often sought, as they are usually very painful.  The American Academy of Neurology (AAN) formed a committee to establish guidelines for the best approach to treating or preventing leg muscle cramps; their recommendations are published in the journal Neurology.  Here’s a summary.   

For years, quinine or quinine derivatives have been the most popular drugs for leg cramps.  Quinine is approved for treatment of malaria, and because malaria is life-threatening, the risks associated with quinine use are justifiable for that condition. But because of the drug's risks, the FDA believes it should not be used to prevent or treat leg cramps.  The AAN committee also says that quinines should not be used routinely because of the potential for adverse events.  Serious side effects include: cardiac arrhythmias (irregularities), thrombocytopenia (a decrease in blood platelets that can cause hemorrhage or clotting problems), severe hypersensitivity (allergic) reactions, and the potential for serious interactions with other drugs.  Quinines should be considered only when cramps are very severe and the patient can be monitored for serious side effects. 

What about other therapeutic approaches?  None have been recommended as better than “possibly effective” by the committee, based on a positive result in a single clinical trial of questionable quality. The “possibly effective” substances are: vitamin B complex, naftidrofuryl oxalate (Praxilene® - a blood vessel dilator), lidocaine, and calcium channel blockers such as diltiazem (Cardizem®).

Things that don’t work, or haven’t been studied in clinical trial at all,  – include gabapentin, baclofen, carbamazepine, oxcarbazepine, and stretching exercises for the affected muscle group.     

I imagine most sufferers have tried the stretching approach. Your family physician can prescribe one or other of the “possibly effective” drugs.  And, if all else fails, she/he can see if you are eligible to take prescription quinine.   Being a former Brit, I take my quinine as an evening gin-and-tonic, but that’s less than a quarter of a therapeutic dose, so I still get the occasional Charley Horse.

Wednesday
03Mar2010

Feeding Tubes Shouldn’t Be Needed for Dementia Patients

A study from Brown University, published in the Journal of the American Medical Association, has shown that larger, for-profit hospitals are more likely than smaller, non-profit hospitals to insert feeding tubes during acute-care admissions of nursing-home patients.  It’s simplistic to conclude that the profit motive is responsible for this difference, but clearly it’s time to re-evaluate the need for feeding tubes in such patients.  This is more important now that US Catholic bishops have announced that it’s not permissible to remove a feeding tube from someone who is not dying, except in rare circumstances.

Back in October last year the New England Journal of Medicine published an analysis of the clinical course of advanced dementia patients. Boston researchers studied 323 patients from 22 nursing homes, gathering clinical data and interviews with the patients’ health proxies.  About 70% of the patients had Alzheimer’s, and 17% had vascular dementia.  Over 40% of the patients developed pneumonia, 50% had at least one febrile episode, and 85% developed eating problems; 55% of them died during the 18 months study period.

During their final 3 months of life, over 40% of the patients had at least one ‘intensive intervention’ such as hospitalization, visit to the ER, tube feeding, or intravenous treatment. It was notable, however, that when the patient’s health proxy or surrogate understood the expected short time remaining, these interventions were much less likely, compared to those patients with less well-informed proxies.

It was also found that, in general, patients who could eat normally were not likely to die within the study period – only about 10% - compared with the 70% deaths in those with eating problems at some point.

I believe it’s time to ensure that health proxies are aware of the inevitability of death in advanced dementia patients who show one or more of the common complications – pneumonia, fever, and eating problems.  The remaining time available to these patients should not be burdened by distressing interventions, such as the use of tube feeding or intravenous nutrition.  And removal to hospital should be a well-studied decision, not just a speedy shifting of responsibility to another institution.

Tuesday
02Mar2010

Poor Eyesight in the Elderly, if Untreated, May Predict Dementia

Vision problems – due to cataracts, glaucoma, or diabetic retinal disease - are common in the elderly, and can have serious consequences if left untreated.  This is the conclusion of a study reported in the American Journal of Epidemiology

University of Michigan researchers analyzed data from the Health and Retirement Study, as well as Medicare and Medicaid records.  They selected 625 elderly US study participants who had normal mental skills (normal cognition) at baseline, and followed them over an average of 8½ years.  At the end of the study the patients were classified as having dementia, cognitive impairment but no dementia, or normal cognition, and their eyesight problems were scored for each group.

Those subjects with very good or excellent vision at baseline had a 63% reduced likelihood of developing dementia during the study period.  Those with poorer vision who didn’t have treatment had a 9-fold increased risk of Alzheimer’s disease, and a 5-fold risk of cognitive impairment but no dementia.  Poor vision without any procedure to treat it had a 5-fold risk of increased Alzheimer’s.  And looking at things from a different angle, 78% of the 90-year-olds who had normal cognition had received treatment for eye problems, compared with only 52% of those with Alzheimer’s.  The researchers concluded that untreated poor vision is linked with cognitive decline – particularly Alzheimer’s disease. 

Why is this?  A possible reason is that older folk with poor vision cannot take part in some of the activities that are known to help in staving off Alzheimer’s – social interaction, puzzles, board, and word games, and physical exercise. Obviously, family members and care-givers should be alert to visual problems in their elderly charges, and schedule regular visits to the ophthalmologist.

Monday
01Mar2010

Statins and the Risk of Incurring Diabetes

I have discussed the benefits of statin drugs, along with their excellent safety record, at frequent intervals.  Now an international collection of analysts have done a meta-analysis of clinical trials of statin drugs to see if there is a relationship between their use and the development of diabetes.  Their findings are published online in the Lancet

Trials included in the analysis had to have at least 1,000 patients and duration of more than a year.  There were 13 such trials, which provided more than 91,000 patients, of whom roughly 2/3 were assigned a statin and 1/3 took a control treatment (placebo or another type of medication), for an average duration of 4 years. 

The researchers found that there was a 9% increase in the risk for developing diabetes among those receiving statins compared with the controls.  Adjustments for weight (body mass index or BMI) and changes in LDL cholesterol levels did not affect the results substantially. However, the association between statin use and diabetes was stronger with increasing age.

Put another way, this finding means that 255 patients would have to be treated with statins for 4 years to produce one additional case of diabetes. The researchers state that this small risk "is outweighed by cardiovascular benefit in the short and medium term."  One possible reason for the association could be improved survival in the patients taking statins i.e. there would be more of them extant to develop another condition. 

The risk of diabetes that’s reported here is low compared with the reduction that statins produce in coronary artery events – heart attack, severe angina, or heart failure.  It might be wise, however, for patients on statins to have a blood sugar exam every 6 months or so, especially if they are in an older age group.

Friday
26Feb2010

Herbal Meds Can Worsen Asthma

As many as four out of five asthma sufferers report having used complementary or alternative medicines (CAM) to treat their disease.  This may be because they aren’t getting adequate relief from their prescribed medications, or because of the higher cost of meds for those without insurance.  New York’s Mount Sinai physicians surveyed patients with persistent asthma being treated as outpatients in Harlem and New Brunswick, NJ.  They report in the Annals of Allergy, Asthma & Immunology

There were 326 patients in the survey.  Questions covered the use of CAM (teas, herbs, and rubs) for their asthma over the last 6 months, as well as a validated estimate of their adherence to their prescribed medication, in particular inhaled corticosteroids.

In this population, 25% of the patients said they had used herbal remedies.  Herbal use was associated with decreased adherence to inhaled corticosteroid medication, and a worsening of their asthma.  Those taking herbs were more likely to worry about the adverse effects of steroid medication, which may have accounted for their decreased inhaler use. 

The answer to the problem raised by these findings?  Physicians should ask their patients about their use of CAM, advise them of possible interactions, and urge them not to discontinue their prescribed meds in favor of non-prescribed CAM.