Dr. Bray Links

Tuesday, September 18, 2018

Healthcare Bluebook, your free health care guide to fair pricing for health care services

 Did you know that the cost for a single procedure could vary 400% or more at a different in-network facility just down the street? Or that the higher cost procedure could be performed by a provider with a much lower quality rating? Healthcare Bluebook levels the playing field with reliable cost and quality information that makes shopping for healthcare simple and straightforward. 

https://www.healthcarebluebook.com/
Ultimately, however, Myles envisions a day when consumer skin products are tested for their effects on the microbiome before they end up on store shelves. Topical products like soaps and shampoos, he believes, are among the "biggest offenders" behind the explosion of eczema in industrialized nations since the 1980s. In his recent study, some common preservatives, such as parabens and quaternium 15, inhibited the growth of R mucosa more than S aureus or inhibited healthy strains of R mucosa more than unhealthy ones. These preservatives can be found in skin products like baby shampoo, bubble baths, and even some lotions marketed as treatments for eczema, he said.


What should I do about insomnia?

Friday, September 14, 2018

Nutrition Training for Young Doctors Lacks Bite

The survey of the 133 US medical schools with 4-year MD programs in 2012 showed that medical students received a median of 16 hours of nutritional education that year—roughly the same as in 2000, 2004, and 2008.[1] Meanwhile, the percentage of US medical schools that do not require medical students to receive any instruction about nutrition increased from 5% in 2000 to 10% in 2012. Only around 1 in 4 medical schools have a required nutrition course.

Typically, in the first 2 years of med school, students learn about the molecular structures of vitamins and metabolites, Dr Kohlmeier said. However, teaching students about "the structure of Krebs-cycle metabolites," for example, "doesn't teach them anything about diabetes."

"Fewer than one half of all US medical schools offer any kind of clinical focus on nutrition—no rounds, no clinics—which reflects the reality in a lot of these teaching hospitals," Dr Kohlmeier observed. "Even in those that offer something, the average is in the range of 5 hours at most, which is not enough."

Students are not getting practice in "making patient assessments or understanding which patients are at risk from malnutrition before or after surgery," nor are they learning how to help motivate patients to lose weight.


https://www.medscape.com/viewarticle/886722

Wednesday, September 12, 2018

Healthy Midlife Diet May Preserve Memory, Prevent Mental Illness

A healthy diet, as reflected by AHEI-2010 score, is rich in vegetables, fruits, whole grains, nuts, legumes, omega-3 fats, and polyunsaturated fatty acids, and is light on sugar-sweetened drinks, red and processed meat, trans fat, and sodium-rich products. It is also characterized by low alcohol intake. In the current study, low alcohol intake was a "key component" associated with larger hippocampus volume, the researchers say.

"Our findings lend support for the hypothesis that overall diet may affect brain structures with a specific impact on hippocampus volume," the researchers conclude. "Accounting for the importance of hippocampus with long-term, declarative, episodic memory, as well as for flexible cognition network, our findings reaffirm the need to recognize diet and nutrition as potential determinants of cognition, mental health and social behavior."

https://www.medscape.com/viewarticle/901867

Estrogen Matters – Science-Based Medicine

Once considered a veritable fountain of youth, estrogen replacement got a bad rap with the Women's Health Initiative study. This book is an exhaustively researched and meticulously reasoned vindication of hormone replacement therapy. Estrogen matters: it's the most effective treatment for hot flashes and other symptoms of menopause, and when started early and used continuously, it has important health benefits and can actually prevent some of the adverse events it was thought to cause. Bluming and Tavris tell estrogen's story in a way that is both accessible to the general public and appropriate for professionals. What's more, they provide valuable insights into understanding research and how even the best randomized controlled studies can lead to unjustified public fears and injudicious clinical recommendations. Very enlightening!

https://sciencebasedmedicine.org/estrogen-matters/

Tuesday, September 11, 2018

Report: Pharma exec says he had 'moral requirement' to raise drug price 400% - CNN

Nirmal Mulye, founder and president of Nostrum Pharmaceuticals, commented in a story Tuesday about the decision to raise the price of an antibiotic mixture called nitrofurantoin from about $500 per bottle to more than $2,300. The drug is listed by the World Health Organization as an "essential" medicine for lower urinary tract infections.

"I think it is a moral requirement to make money when you can," Mulye told the Financial Times, "to sell the product for the highest price."

The Financial Times said Mulye compared his decision to increase the price to that of an art dealer who sells "a painting for half a billion dollars" and said he was in "this business to make money." 

https://amp.cnn.com/cnn/2018/09/11/health/drug-price-hike-moral-requirement-bn/index.html

Friday, September 7, 2018

Flavorings in Tobacco Products Induce Endothelial Cell Dysfunction | Arteriosclerosis, Thrombosis, and Vascular Biology

Use of alternative tobacco products including electronic cigarettes is rapidly rising. The wide variety of flavored tobacco products available is of great appeal to smokers and youth. The flavorings added to tobacco products have been deemed safe for ingestion, but the cardiovascular health effects are unknown. The purpose of this study was to examine the effect of 9 flavors on vascular endothelial cell function.
Approach and Results—

Freshly isolated endothelial cells from participants who use nonmenthol- or menthol-flavored tobacco cigarettes showed impaired A23187-stimulated nitric oxide production compared with endothelial cells from nonsmoking participants. Treatment of endothelial cells isolated from nonsmoking participants with either menthol (0.01 mmol/L) or eugenol (0.01 mmol/L) decreased A23187-stimulated nitric oxide production. To further evaluate the effects of flavoring compounds on endothelial cell phenotype, commercially available human aortic endothelial cells were incubated with vanillin, menthol, cinnamaldehyde, eugenol, dimethylpyrazine, diacetyl, isoamyl acetate, eucalyptol, and acetylpyrazine (0.1–100 mmol/L) for 90 minutes. Cell death, reactive oxygen species production, expression of the proinflammatory marker IL-6 (interleukin-6), and nitric oxide production were measured. Cell death and reactive oxygen species production were induced only at high concentrations unlikely to be achieved in vivo. Lower concentrations of selected flavors (vanillin, menthol, cinnamaldehyde, eugenol, and acetylpyridine) induced both inflammation and impaired A23187-stimulated nitric oxide production consistent with endothelial dysfunction.
Conclusions—

Our data suggest that short-term exposure of endothelial cells to flavoring compounds used in tobacco products have adverse effects on endothelial cell phenotype that may have relevance to cardiovascular toxicity.

https://www.ahajournals.org/doi/abs/10.1161/ATVBAHA.118.311156

Thursday, September 6, 2018

More Bad News About Benzos

Benzodiazepines are in the news again—this time, not for the increased risk for falls and fractures that can come with their use.

A case-control study was conducted in Finland among community-dwelling adults who had been diagnosed with Alzheimer disease. Benzodiazepines and related Z drug use was associated with a modestly increased risk for Alzheimer disease. No real differences were seen for the drug subcategories. This included short-, medium-, and long-acting benzodiazepines, as well as zolpidem, zaleplon, and eszopiclone.

The analysis showed that 5.7% of dementia cases among adults using benzodiazepines were due to the drugs. Even this small increased risk could be significant because they are widely prescribed to elderly adults, often long term. The drugs are given to treat prodromal and neuropsychiatric symptoms of dementia like insomnia and anxiety.

The authors concluded that benzodiazepines and Z drugs should be avoided when possible, given their adverse-event profile. For patients who you would like to wean off benzodiazepines, deprescribing can be tough and take a long time. Guidelines are now available to help you with the process.

https://www.medscape.com/viewarticle/901271

There aren’t enough doctors to go around | TheHill

And then, there's economics. In 1997, the Balanced Budget Act capped federal funding of medical residency programs; in 2016, for example, the government spent about $10 billion, the overwhelming majority of it coming from Medicare. Most experts predicted that the cap would soon be lifted; more than 20 years later, it's still in place.

As a result, what we have now is a classic bottleneck condition: More and more people want to practice medicine while less and less funding is available to help create residency programs that meet the demand.

http://thehill.com/opinion/healthcare/405231-there-arent-enough-doctors-to-go-around

Sunday, September 2, 2018

Time-Restricted Feeding Prevents Obesity and Metabolic Syndrome in Mice Lacking a Circadian Clock

Increased susceptibility of circadian clock mutant mice to metabolic diseases has led to the idea that a molecular clock is necessary for metabolic homeostasis. However, these mice often lack a normal feeding-fasting cycle. We tested whether time-restricted feeding (TRF) could prevent obesity and metabolic syndrome in whole-body Cry1;Cry2 and in liver-specific Bmal1 and Rev-erbα/β knockout mice. When provided access to food ad libitum, these mice rapidly gained weight and showed genotype-specific metabolic defects. However, when fed the same diet under TRF (food access restricted to 10 hr during the dark phase) they were protected from excessive weight gain and metabolic diseases. Transcriptome and metabolome analyses showed that TRF reduced the accumulation of hepatic lipids and enhanced cellular defenses against metabolic stress. These results suggest that the circadian clock maintains metabolic homeostasis by sustaining daily rhythms in feeding and fasting and by maintaining balance between nutrient and cellular stress responses.

https://www.sciencedirect.com/science/article/pii/S1550413118305059?via%3Dihub

Making Doctors Dumber Won't Make Our Health Care System Smarter

We need more early intervention and prevention, not more late-stage expensive patches. Smoking cessation counseling isn't sexy the way humming machines and newly approved biologics are, but it's effective, inexpensive and what our country really needs. Unfortunately, the way the house of medicine is carved now, it's not the specialists who are providing it.

The balance between primary care and specialty services is a delicate one, and some would argue that health care is already too specialized ― why does one patient need an entire Rolodex of "-ologists" — a cardiologist, a nephrologist, an endocrinologist, a pulmonologist and a dermatologist? 

Patients are not sliced into the "organ systems" we divide specialty lines across. And there is no better example of this than the patients we see in the emergency room, confused by their multiple canisters of co-interacting meds, sent to see us by one of their specialists who, after expensive tests on the organ of expertise, couldn't figure out what was going on and sent the patient to the ER. Ophthalmologists refer patients to the ER for high blood pressure found in the clinic. Orthopedists send patients to the ER when they find incidental elevated blood sugar prior to an operation. 

Yes, some referrals are appropriate, but some are plainly wasteful. The ER, designed to be full of "resuscitation-ists" — providers trained to take care of life-threatening events like heart attacks, strokes and gunshot wounds — has quickly become a catch-all of "available-ists" — providers who happen to be available 24/7/365. In between the heart attacks and car accidents, I also counsel patients on smoking and drug cessation, advise them on the importance of seat belts, teach them to use their glucometers and adjust their daily meds. 

Why? Because not only are these patients unable to get in to see all of their specialists in a timely manner, but many don't even have a primary care doctor.

We can't force medical students to become primary care physicians, nor should we. But education reform isn't necessarily going to fix our health care system, either.

https://m.huffpost.com/us/entry/us_5b89b277e4b0cf7b0035e624/amp

Thursday, August 30, 2018

Colorectal Cancer Screening Should Begin at Age 45: Coalition

Earlier this year, the American Cancer Society (ACS) updated its guidelines for colorectal cancer (CRC) screening, and recommended that screening begin at age 45 for those at average risk for the disease. The update of the ACS guidelines was prompted by recent data showing increased rates of CRC in young and middle-aged populations.

Now a coalition of 22 public health and patient advocacy groups has joined the ACS and submitted a letter to the US Preventive Services Task Force (USPSTF) asking that the task force reconsider its 2016 guidance, in which it recommends that CRC screening begin at age 50 years and continue until age 75 years. This recommendation is scheduled for review in 2021, but the coalition is asking for earlier action.

https://www.medscape.com/viewarticle/901376

Wednesday, August 29, 2018

Curcumin Reverse Methicillin Resistance in Staphylococcus aureus

Curcumin has a significant effect on the protein level of PBP2a. The TEM images of MRSA showed damage of the cell wall, disruption of the cytoplasmic contents, broken cell membrane and cell lysis after the treatment of curcumin. These data indicate a remarkable antibacterial effect of curcumin, with membrane permeability enhancers and ATPase inhibitors, and curcumin did not directly bind to PGN on the cell wall. Further, the antimicrobial action of curcumin involved in the PBP2a-mediated resistance mechanism was investigated. 

http://www.mdpi.com/1420-3049/19/11/18283

STDs hit all-time highs in US for fourth straight year, CDC reports | Fox News

Sexually-transmitted diseases continue to hit all-time highs in the U.S. with the Centers for Disease Control and Prevention (CDC) reporting a 10 percent spike for chlamydia, gonorrhea and syphilis in 2017. The federal health agency said in a report released Tuesday that the numbers, which include nearly 2.3 million new cases of the aforementioned diseases, reflect a "steep, sustained increase" in STDs since 2013.

"We're sliding backward," Jonathan Mermin, director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, said. "It is evident the systems that identify, treat and ultimately prevent STDs are strained to near-breaking point."

The data, which was presented at the 2018 STD Prevention Conference, found a 67 percent increase in gonorrhea diagnoses, which officials sounded alarm over due to the growing threat of untreatable strains.

http://www.foxnews.com/health/2018/08/28/stds-hit-all-time-highs-in-us-for-fourth-straight-year-cdc-reports.html

Monday, August 27, 2018

Why saturated fat cannot raise cholesterol levels (LDL levels) | Dr. Malcolm Kendrick

'When the US government introduced "Dietary Goals for the United States", they did not have unanimous support. The guidelines, which urged the public to cut saturated fat from their diet, were challenged by a number of scientists in a Congressional hearing. The findings were not based on sufficient evidence, they argued.

They were ignored. Dr. Robert Olson recounts an exchange he had with Senator George McGovern, in which he said: "I plead in my report and will plead again orally here for more research on the problem before we make announcements to the American public." McGovern replied: "Senators don't have the luxury that the research scientist does of waiting until every last shred of evidence is in.'1

Senator McGovern might as well have said. 'Listen son, we know that saturated fat raises cholesterol and causes heart disease, we don't need any damned evidence.' Of course, they didn't have any evidence at all. None. But they still managed to find saturated fat and cholesterol guilty. Some people would call this proper leadership. Make a decision and go with it.

I would call it monumental stupidity.

As you can see I am stepping back in this blog to look at saturated fat – again. Because I am going to share some thinking with you, which I have not really shared before. Some of you will know that I am a 'first principles' kind of guy. I take very little at face value, and I am certainly highly critical of accepted wisdom: I usually translate it, in my mind, into accepted stupidity.

So, I am going to try and explain to you that saturated fat cannot raise blood cholesterol levels. By which I mean low density lipoprotein levels (LDLs) as this is the substance which someone or another ended up calling 'bad' cholesterol. It is the lipoprotein that is thought to cause CVD.

However, LDL is not cholesterol, it never was. We do not have a blood cholesterol level – but we are seemingly stuck with this hopelessly inaccurate terminology for all time.


https://drmalcolmkendrick.org/2018/07/03/why-saturated-fat-cannot-raise-cholesterol-levels-ldl-levels/

Warnings About Benzodiazepine Use in the Elderly Go Unheeded

Despite years of warnings about the hazards of prescribing benzodiazepines for the elderly, these drugs continue to be used at a higher rate than what is considered appropriate in older Americans — particularly older women, new data show.

A recent report released by Athena Health shows that individuals older than 65 years are prescribed benzodiazepines — including alprazolam (multiple brands), lorazepam (multiple brands), diazepam (multiple brands), and clonazepam (Klonapin, Roche) — more than other age groups are.

In 2017, 8.4% of individuals aged 65 and older were prescribed one of the drugs, a drop from 8.7% the previous year. Just over 8% of 50- to 64-year-olds were prescribed a benzodiazepine in 2017, compared to 7.5% of those aged 40 to 49 and 6.6% of those aged 30 to 39.

Ten percent of women older than 65 were prescribed a benzodiazepine, compared to just under 6% of men.

The data come from a sample of 3 million patients treated by primary care providers who are part of the Athena Health data network.

The data "are consistent with earlier research that suggests significant benzodiazepine overuse, especially among older adults," Mark Olfson, MD, MPH, professor of psychiatry and epidemiology, Columbia University, New York City, told Medscape Medical News.

https://www.medscape.com/viewarticle/901169

Sunday, August 26, 2018

Five-Year SCOT-HEART Update Indicates CTA Screening Reduces Heart Attack Deaths | MD Magazine

The five-year rate of heart disease death or nonfatal myocardial infarction was lower in patients initially provided CTA imaging (n= 48 [2.3%]) than in patients given standard evaluation (n= 81 [3.9%]), providing investigators a hazard ratio of 0.59 (95% CI; 0.41-0.84; P = .004).

Patients provided CTAs reported similar rates of invasive coronary angiography to standard-care patients (491 vs 502; HR 1.00; 95% CI; 0.88-1.13), as well as in coronary revascularization (279 vs 267; HR 1.07; 95% CI; 0.91-1.27). Investigators noted this difference is improved from earlier follow-up analyses, when patients provided CTAs reported notably greater rates in both procedures.

That said, preventive therapies were more frequently initiated in patients provided CTAs (OR 1.40; 95% CI; 1.19-1.65), as were antianginal therapies (OR 1.27; 95% CI; 1.05-1.54). Newby noted that there's often a "big to-do" in the idea of providing a patient preventive aspirin therapy on top of statins. He advocated against it, but noted it has its place in coronary treatment.

https://www.mdmag.com/medical-news/fiveyear-scotheart-update-indicates-cta-screening-reduces-heart-attack-deaths

Top Infectious Disease News of the Week-August 19, 2018

Health officials across the United States are investigating an increase in Cyclospora cases reported in a multistate outbreak which has been linked back to salads sold at McDonald's locations throughout the country.

The most recent case counts reveal that there have been 476 confirmed cases of cyclosporiasis related to this outbreak spanning 15 states; the majority of cases, or 246, have been reported in Illinois.
 
As of August 16, 2018, the US Centers for Disease Control and Prevention (CDC) reported that all illnesses associated with the Cyclospora outbreak started on or after May 20, with the median illness onset date of June 29. The cases have been confirmed in individuals between the ages of 14 and 91; the median age of those infected is 53. Additionally, the CDC reports that 66% of those affected in the outbreak are female. There have been 21 hospitalizations, but no deaths have been reported at this time. Illnesses that began after July 5, 2018, may not be reported or confirmed yet. 

https://www.contagionlive.com/news/top-infectious-disease-news-of-the-week-august-19-2018?p=3