Dr. Bray Links

Monday, May 30, 2016

CU Boulder study: Narcotic painkillers cause chronic pain

Although reports of abuse, addiction and overdoses have long been attached to the misuse of prescription pain medication, researchers at the University of Colorado Boulder may have discovered a new peril.

Results of a three-month study released Monday by the university shows opioids, such as morphine, cause an increase in chronic pain in lab rats, something that could have  implications for people, too.

Peter Grace, a CU Boulder assistant research professor, and Linda Watkins, a professor, led the study that they say shows lab rats exhibited long-lasting chronic pain after using morphine treatments for five days. Those results, Grace said, using opioid painkillers may be partly to blame for chronic pain.

"Our key finding is that we were able to demonstrate that a brief treatment with a pain killer, like morphine, doubled the duration of chronic pain," said Grace, who works at CU's department of psychology and neuroscience.

The study, which was published Monday in the "Proceedings of the National Academy of Sciences," showed morphine treatment intensified the release of pain signals from specific immune cells in the rats' spinal cords, leading to prolonged pain.


Saturday, May 28, 2016

The bittersweet truth about the epidemic affecting health care workers

Hours flew by as I watched energetic members of the staff cater to the every need of the patients. I wasn't used to this 8 to 5 schedule, so I must have checked the clock at least fifteen times until lunch arrived. The clock eventually struck noon as the eleven members of our staff gathered around this rectangular table to take an hour break from work. One by one, everyone grabbed their lunch from the fridge and sat down. As I looked up from my turkey sandwich, I was surrounded by more 12-ounce cans of soda than actual human beings at my table.

The sound of fizzing became a common theme at lunchtime for the entire duration of my 500-hour internship.

Throughout my internship, I learned a significant amount by spectating, but my most surprising discovery must have been the dependence health care providers have on drinks loaded with sugar.  Packs of Coca-Cola, Mountain Dew, Dr. Pepper and Sprite were brought into work each Monday and consumed religiously during the work week. I interned at a rehab facility where the majority of patients were enrolled after undergoing a major cardiac operation. The staff preached the benefits of proper nutrition, exercise and physical health to the patients each and every time they walked in.

Why is it that the providers who make a living trying to get people healthier have the worst habits?

They know each sip is a slew of sludge running through their arteries and veins; so is temporary pleasure worth their well-being? Maybe even more shocking than the actual action, is the acceptance among health care professionals.

The fast paced and demanding lifestyle of a health professional is well documented. Quick fixes are usually the short term solution to the demands of the medical field. Our society values knowledge, yet this health epidemic is glorified in commercials and stocked at the entrance of grocery stores. The most recent dietary guidelines issued by the United States government suggest limiting one's daily sugar intake to 10 percent of daily calories. The dietary guidelines for adults and children age 4 and over are based upon a 2,000 calorie diet. Some quick grade school math shows that daily sugar intake for the average person should not exceed 200 calories a day. A 12 ounce can of Mountain Dew contains 46 grams of sugar and 1 gram of sugar is roughly equal to 4 calories.

My point being that one 12 ounce can of Mountain Dew is equal to 92 percent of the daily sugar intake for the average person. As far as sugar goes, that's getting one's money's worth.

The number of people affected by chronic illnesses such as coronary artery disease and diabetes is growing exponentially each year. There is no doubting that these diseases are becoming more prevalent due to the abundance of sugar in today's society. Next time you are at the store, check the sugar of the items in your cart. You may be surprised, even shocked at how difficult it is to eat healthy. We must demand change as consumers; it is no longer acceptable for our health to be secondary to the taste of our food. Do not be afraid to talk to your peers about their health choices. As an aspiring medical student, I believe the best treatment is prevention.

In the words of Ann Wigmore, "The food we eat can be either the safest and most powerful form of medicine or the slowest form of poison." Health care professionals are supposed to be the role models of health not the embodiment of hypocrisy.


Friday, May 27, 2016


The soy carbohydrates in tempeh become more digestible as a result of the fermentation process. In particular, the oligosaccharides associated with gas and indigestion are greatly reduced by the Rhizopus culture. In traditional tempeh-making shops, the starter culture often contains beneficial bacteria that produce vitamins such as B12[8][9] (though it is uncertain whether this B12 is always present and bioavailable).[10] In western countries, it is more common to use a pure culture containing only Rhizopus oligosporus, which makes very little B12 and could be missing Citrobacter freundii and Klebsiella pneumoniae, which have been shown to produce significant levels of B12 analogs in tempeh when present.[11] Whether these analogs are true, bioavailable B12, has not been thoroughly studied yet.[12] The fermentation process also reduces the phytic acid in soy,[13] which in turn allows the body to absorb the minerals that soy provides.


Thursday, May 26, 2016

High Risk for Breast Cancer May Be Normalized With Healthy Living, Study Finds - ABC News

Some women at high risk for breast cancer may be able to lower their risk to that of an average woman by making healthy lifestyle choices, according to a new study published today in the Journal of American Medical Association (JAMA).

Dr. Robert Shenk, Medical Director at the Breast Center, University Hospitals Seidman Cancer Center in Cleveland, Ohio said these JAMA study results may help shed light on how women can modify their cancer risk.

"We have some of those models but this takes in a lot more factors," Shenk told ABC News. "I think ultimately [doctors are] going to have to look at things more prospectively."

To understand if healthy living could lower the possibility of developing breast cancer in the approximately 23,000 high-risk white woman between the ages of 30 to 80 that they studied, researchers from several institutions including the National Institutes of Health and Johns Hopkins University poured through data from their health records about their smoking and drinking habits, weight indexes and use of hormones.

An average 30-year-old woman has approximately an 11 percent chance of developing breast cancer by the time she is 80, according to the report. However, some women have a much higher risk of developing the disease due to "non-modifiable" issues like family history, genetic markers and reproductive factors -- as much as 23.5 percent risk for developing breast cancer.

3D Printer Used to Design Custom-Made Heart Pacemakers

What You Need to Know About Uterus Transplants

Using data from the cancer cohort and national survey they included in the study, researchers created a model to estimate risk among this group of white women.

What they found is that those with seemingly high risk for breast cancer due to genetic factors or family history could lower their overall risk to the average level of 11 percent by adopting a healthy lifestyle.

"For women in the highest decile of risk owing to non-modifiable factors, those who had low BMI, did not drink or smoke, and did not use MHT [menopause hormone therapy] had risks comparable to an average woman in the general population," the authors said. They caution that more research is necessary to determine if these lifestyle choices will have the same effect on other groups of women.

Shenk pointed out living a healthy lifestyle by not having an a high BMI, which would indicate overweight or obese body types, not smoking and not drinking heavily may all help people feel more in control of their health and cancer risk. Additionally, he pointed out this data may help provide better information about who should be screened for cancer via yearly mammograms.

"You can modify some factors to decrease the risk," said Shenk.


New 'Brain Food' Scale Flags Best Nutrients for Depression

Scientists have developed a new evidence-based scale that rates animal- and plant-based foods that improve depressive symptoms.

Research on this scale and on foods that help nourish the brain was presented here at a standing-room-only session during the American Psychiatric Association (APA) 2016 Annual Meeting.

There is increasing evidence regarding the crucial role that diet plays in brain health, particularly in the areas of depression and dementia, said Drew Ramsey, MD, assistant clinical professor of psychiatry, Columbia University, New York City, who was one of the session speakers.

"The data are very clear that there's a powerful prevention signal when we help our patients eat better," Dr Ramsey told Medscape Medical News.

Plant foods are high on Dr Ramsey's brain food scale. To develop this nutrient profiling system, he and his colleagues assessed the literature and compiled a list of what they call brain essential nutrients (BEN) that affect the treatment and prevention of depression.

Key nutrients include long-chain omega 3 fatty acids, magnesium, calcium, fiber, and vitamins B1, B9, B12, D, and E.

They then gathered nutritional data for top food sources of BEN from the Agricultural Research Service Nutrient Data Laboratory and used a formula to calculate the Brain Food Scale score.

"We were very interested in using the scientific literature to winnow down the key nutrients that have evidence that they are very, very involved in depression," said Dr Ramsey.

"Critical" Nutrients

In addition to plant sources of these nutrients, they wanted to include animal sources, because some nutrients, such as vitamin B12, are predominantly found in meat and other animal products and are "absolutely critical for brain health," said Dr Ramsey.

Possible mechanisms by which these foods may boost brain function include neuronal membrane stabilization and anti-inflammatory effects.

The investigators plan to submit this research for publication, said Dr Ramsey.

Although these nutrients are key to brain function, 2009 statistics from the US Department of Agriculture show that most Americans are not getting enough of them. For example, the percentages of the US population that do not meet the recommended daily allowances for these key nutrients are as follows:

    Vitamin E: 86%

    Folate: 75%

    Calcium: 73%

    Magnesium: 68%

    Zinc: 42%

    Vitamin B6: 35%

    Iron: 34%

    Vitamin B12: 30%

In addition to leafy green vegetables, researchers highlighted the importance of organ meats, game meats, nuts (pecans, walnuts, and peanuts), bivalves (mussels, clams, oysters), mollusks (octopus, squid, snail), and fish (salmon and sardines). Although it is recommended that patients eat 8 to 12 ounces of fish a week, it is important to choose fish that are lower in mercury. Individuals should therefore limit consumption of shark and swordfish.

Dr Reynolds also stressed that he wants to help patients make better choices when it comes to meat. Those choices, he said, should include grain-fed and pastured animals.


Tuesday, May 24, 2016

Gout Diet

The Gout Diet

While there isn't a regimented gout diet, anyone who is diagnosed with gout should follow a healthy, balanced diet.
Avoid High Purine Foods

Because uric acid is formed from the breakdown of purines, high-purine foods can trigger attacks. It is strongly encouraged to avoid:

    Beer and grain liquors
    Red meat, lamb and pork
    Organ meats, such as liver, kidneys and sweetbreads
    Seafood, especially shellfish, like shrimp, lobster, mussels, anchovies and sardines


Instead, it is recommended to eat more lower-purine foods, including:

    Low-fat or non-fat dairy products
    Fresh vegetables
    Fresh fruit

A 2004 study published in the New England Journal of Medicine, conducted by Dr. Hyon Choi, found that each additional serving of purine-rich red meat was associated with a 21 percent increase in the risk of gout in men over age 40. The study also found that each additional weekly serving of seafood was associated with a 7 percent increase in risk. Protein, purine-rich vegetables and moderate wine drinking were found not as harmful to gout sufferers as once believed. In addition, the study found that low-fat dairy products, specifically skim milk and low-fat yogurt, may actually decrease the risk or provide some protection against gout.
Follow a Low-Fructose Diet

Gout sufferers are also encouraged to maintain a low-fructose diet, since there is a correlation between a diet high in fructose content and gout. Fructose is a naturally occurring simple sugar found in fruit, vegetables and honey. In the typical American diet, high-fructose corn syrup is added to many foods and drinks.

The Gout & Uric Acid Education Society recommends limiting table sugar, table salt and any products with high-fructose corn syrup, including:

    Soft drinks and juices
    Cereals, store-bought baked goods, ice cream and candy
    Processed foods at fast food restaurants

Many fruits have naturally occurring high fructose levels, so they should also be limited to one or two cups per day.


Friday, May 20, 2016

EPA suggests tighter limits for industrial chemical in water | McClatchy DC

guidelines Thursday for human exposure to an industrial chemical used for decades in such consumer products as non-stick pans, stain-resistant carpets and microwave popcorn bags.

The cancer-causing chemical perfluorooctanoic acid, known as PFOA, has been found in the tap water of dozens of factory towns near industrial sites where it was manufactured. DuPont, 3M and other U.S. chemical companies voluntarily phased out the use of PFOA in recent years.

Also at issue is the related chemical perfluorooctane sulfonate, or PFOS, used in firefighting foam.

The Environmental Protection Agency issued the stricter guidelines for the chemicals after years of pressure from public health experts and advocacy groups. The agency said the new limits were prompted by recent scientific studies linking PFOA and PFOS to testicular and kidney cancers, as well as birth defects and liver damage.

"EPA will continue sharing the latest science and information so that state and local officials can make informed decisions and take actions to protect public health," said Joel Beauvais, the EPA's deputy assistant administrator for the Office of Water. "This is an important part of our broader effort to support states and public water systems as we work together to strengthen the safety of America's drinking water."

Trace amounts of PFOA and PFOS can be detected in the blood of almost every American as the result of exposure through food and consumer products. But of specific concern to regulators is the risk posed to residents in the relatively small number of communities where higher levels of PFOA and PFOS have been found in public drinking water.


Clues to how popular heartburn drug Nexium may damage arteries

A popular over-the-counter heartburn medication accelerated aging of blood vessel cells in lab tests, raising red flags about its long-term effect on heart health, researchers say.

Faster aging of blood vessel cells exposed to the antacid Nexium (esomeprazole) might potentially hinder the tasks these cells perform to prevent heart attack and stroke, the new study suggests.

These lab results could explain why other studies have shown increased risk of heart disease in people who use proton pump inhibitors (PPIs) -- the class of heartburn medication that includes Nexium, said study senior author Dr. John Cooke.

"Our finding that the lining of blood vessels is impaired by proton pump inhibitors is a unifying mechanism for the reports that PPI users are at increased risk for heart attack, stroke and renal failure," said Cooke, chair of cardiovascular sciences at the Houston Methodist Research Institute.

AstraZeneca, the maker of Nexium, responded with a statement noting that the study was conducted in a laboratory setting, "not in humans within a controlled clinical trial. Therefore, conclusions around cause and effect cannot be made.

"Patient safety is an important priority for AstraZeneca and we believe all of our PPI medicines are generally safe and effective when used in accordance with the label," the drug maker said.

However, many people aren't using PPIs in accordance with FDA guidelines, which in Nexium's case would limit them to a four-week course of treatment three times a year, Cooke said.

"They are being used ubiquitously, for long periods of time. They aren't being used as originally approved," Cooke said.

Dr. P.K. Shah, director of the Oppenheimer Atherosclerosis Research Center at Cedars-Sinai Medical Center in Los Angeles, said these study results provide a reasonable explanation for how PPIs might affect the heart health of long-term users.

"We have clinical data that raises a suspicion that they might be bad if used long-term, and we have now experimental data that suggests a potential mechanism," Shah said. "But we still have unanswered questions."

For this study, Cooke and his colleagues cultured the cells that line the walls of blood vessels, which are called endothelial cells.

These cell cultures were exposed every day to doses of Nexium "similar to what a patient would receive" for an extended period of time, Cooke said.

Protective endothelial cells produce substances that relax the blood vessel, and create a slick "Teflon" coating inside the vessel that prevents plaques or blood clots from sticking, Cooke said.

PPIs treat heartburn by blocking acid-producing cells in the lining of the stomach, Cooke said. But researchers now suspect PPIs might also interfere with acid-producing cells elsewhere in the body.

In the case of blood vessel cells, researchers found that long-term PPI exposure impaired acid production by the lysosomes in the cells. Lysosomes typically clear waste products, but exposed to PPIs they didn't produce enough acid to clear waste.

The waste buildup caused endothelial cells to age rapidly, Cooke said, which could hamper their ability to protect blood vessels.

"They start to convert from Teflon to something more like Velcro," he said. "Things begin to stick."

Another prominent class of heartburn medications, H2 blockers, did not have the same aging effect on blood vessel cells, the study found. H2 blockers include Tagamet (cimetidine), Pepcid (famotidine) and Zantac (ranitidine).

Dr. Mark Creager, president of the American Heart Association, added that a lab study like this cannot prove a direct link between PPI use and increased risk of heart attack or stroke.

"It certainly raises the question. But now the question, once raised, needs to be answered in a well-designed clinical trial, which hasn't taken place yet," said Creager, a professor of medicine at Harvard Medical School. "I would not advise clinicians to jump from this important basic science study to recommendations they would provide to their patients."

Another expert said PPIs should be used with caution due to possible harms "that have nothing to do with the digestive system."

"Much more work needs to be done before we can draw a line with confidence from this class of drugs to some of these potential side effects, but these researchers are taking an important first step," said Dr. David Robbins, interim chief of gastroenterology at Lenox Hill Hospital, in New York City.

"Bottom line: If you take a daily PPI, which can save lives in the right scenario, check with your doctor and see if you really need it," Robbins said.

Lifestyle adjustments -- such as exercising, cutting down on alcohol or caffeine, and avoiding heavy meals just before bedtime -- might also ease heartburn, Cooke added.

The findings were published May 10 in the journal Circulation Research.


Lifestyle Changes Can Dramatically Cut Cancer Incidence

About 20% to 40% of cancer cases and about half of all cancer deaths can potentially be avoided by making modifications in lifestyle, according to new findings.

After investigating cancer risk among a portion of the US white population, the authors of a large cohort study concluded that a large proportion of cancer cases and related mortality could be prevented if people did not smoke, drank only a little alcohol, maintained a healthy weight (ie, maintained a body mass index [BMI] of 18.5 to 27.5), and exercised regularly at moderate intensity (ie, at least 150 minutes of vigorous exercise for at least 75 minutes every week).

The impact may even be larger — about 40% to 70% of cancer cases ― for the general white population, who for the most part follow worse lifestyle patterns than the study cohort, the investigators note.

The study was published online May 19 in JAMA Oncology.


Androgen Treatment Leads to Elongated Telomeres in Small Trial

The sex hormone danazol increased telomere length in patients with telomere diseases, according to a phase 1–2 study published in the May 19 issue of the New England Journal of Medicine.

"Not only was telomere loss prevented by treatment with danazol in our patients, but a mean increase of 386 bp telomeric repeats had occurred by study completion, with improvement usually observed early during the course of hormone therapy," write Danielle M. Townsley, MD, from the National Heart, Lung, and Blood Institute in Bethesda, Maryland, and colleagues. "Hematologic improvement in all blood counts accompanied telomere elongation."

In an accompanying editorial, Peter Landor, MD, PhD, from the University of Groningen in the Netherlands, writes that the "exciting findings...provide food for thought about the role of telomeres and telomerase in hematopoietic stem cells."

Telomere diseases such as dyskeratosis congenita, aplastic anemia, pulmonary fibrosis, and liver cirrhosis result from inadequate or absent telomere maintenance and repair from mutations in the genes responsible for those functions. That failure can also contribute to bone marrow failure and an increased risk for cancer. Previous study of a mouse model with telomere dysfunction, however, had shown hematologic improvement and a lengthening of telomeres after male hormone treatment.

"Androgens have been a therapeutic option for marrow failure syndromes since the 1960s, without a clear mechanism for their action," the authors write. "In retrospect, some patients with a response probably had telomere deficits."


Secret Ingredients ... The Movie


Kathleen DiChiara and her family suffered from a long list of chronic health disorders: allergies, asthma, auto-immune disease, autism (and that's just the A's). Despite countless medical interventions, they just weren't getting better - until Kathleen eliminated GMOs and their associated pesticides from their diet altogether. Countless other families and physicians share similar stories of dramatic recoveries.

GMOs (Genetically Modified Organisms) are found in the vast majority of foods sold in our groceries stores and restaurants. GMOs, and their associated pesticides, have been linked to a list of serious conditions.

Secret Ingredients highlights the dramatic story of Kathleen and her family as they regain their health after eliminating GMOs and pesticides from their diet. The film also includes scientists and experts who can explain why and how GMOs may be making us sick. In addition to Kathleen's family, this film shares testimonials from other families that have gotten better, as well as physicians who have seen their patients heal after eliminating GMOs.

This is just one of thousands of stories that Jeffrey Smith has heard as he travels the world speaking about the health dangers of GMOs. Award-winning filmmakers Jeffrey Smith (Director of Genetic Roulette, and author of Seeds of Deception) and Amy Hart (Water First) are teaming up to bring this dramatic story to other mothers - as well as anyone who eats.

Thursday, May 19, 2016

Gut Microbiome Changes Contribute to Inflammatory Bowel Disease

Microbial changes are a contributing factor to inflammatory bowel disease (IBD) development, according to findings published in Cellular and Molecular Gastroenterology and Hepatology.Researchers from the University of Michigan used germ-free mice, which were colonized by the gut microbiota isolated from ulcerative colitis (UC) and Crohn's disease (CD) patients to evaluate the role of gut dysbiosis associated with the two types of IBD.

The researchers analyzed microbiomes of those mice as well as control mice in addition to using bacterial function gene analysis, luminal metabolome analysis and host gene expression analysis.
The researchers noticed that changes in the gut microbiome populations were often seen in IBD, but it was previously unclear if these changes were an effect of disease or if they actually participate in causing the disease progression.

The study authors reported that despite some similarities, the UC and CD patients' microbial composition were not identically replicated in the mice those samples were transferred into. For example, there were comparisons among decreased diversity and alteration of bacterial metabolic functions.

This suggested to the investigators that microbial community alterations, characteristic for IBD, could be replicated in the humanized gnotobiotic mice used in the study.

Experts added that colonization by the microbiota linked to IBD caused a pro-inflammatory gene expression profile in the gut that resembled the immunologic signatures found in CD patients.

The CD instigated more severe colitis in the mice than the healthy control patients developed when they were colonized in a germ free environment. "Dysbiosis potentially contributes to that pathogenesis of IBD by augmenting host pro inflammatory immune responses," the study authors concluded.


Why Does the Physical Exam Stop at the Navel? - NYTimes.com

I'd just read a recent study in the Annals of Family Medicine showing that comprehensive medical care is associated with lower costs and fewer hospitalizations. The study had some limitations, but it reinforced what most doctors and patients intuitively understand: fragmented care is worse for everyone and costs much more. I felt terrible that I was about to contribute to the fragmenting of care for this patient.

But our system is set up to favor fragmentation. It's so much easier to write a referral to a gynecologist than to do a pelvic exam myself. It's far quicker to refer to a rheumatologist than to figure out which complex tests to order, and then have to follow up on the results and figure out what they mean. It's much simpler to refer to a neurologist than to take the time to figure out if a patient's dizziness is serious or not.

In our current environment, being "comprehensive" just means more work for the primary care doctor. No one is allotting more time for this work or reimbursing for these extra efforts, so it's no wonder that most patients leave their doctors' offices with a fistful of referrals.


The smell of bacon...

I am forced to attend one of these mandatory continuing medical education (CME) events. My malpractice insurance provider has a deal with the state medical association. To get lower rates, I have to be a member of the association and every 2 or 3 years attend a risk management training session.

I make it on time, despite the traffic.

As I walk into the lobby of this rather nice building, looking for signs directing me to the room where the training will be held, I am struck with … the smell of bacon.

"Please tell me that smell is coming from some other entity renting a meeting room or something," I think to myself. There are mounds of bacon and eggs next to the entrance to our meeting room.

I find a place in the back and take a seat. A well-dressed lady walks in, finds a seat in my row two chairs down, and loudly proclaims, "Is that bacon I smell? That is wonderful! We got it." In the quiet room, it is like a proclamation. Apparently she had some kind of input on the menu.

There is a whispered conversation going on between two providers in front of me. They are apparently talking about vegetarianism. The lady is not eating. The man indicates he thinks it is a good thing that there is a trend toward less meat, but he is not vegetarian. Plate after plate of bacon and eggs comes into the room.

We begin our advanced risk management training. The room is finishing the supplied "advanced risk" high saturated animal fat and cholesterol breakfast managing further disease-causing inflammation, plaque build up, and carcinogen load. We are introduced to the 3 speakers/panelists up front and 4 to 5 insurance company people sitting around me, including the well-dressed bacon lady. The course is presented by a retired doctor and an attorney.

"Why are all these other highly-paid insurance company people here?" I am asking myself. We have 34 attendees to 8 staff. I feel like I am stuck in one of those "How many really un-smart people does it take to screw in a light bulb?" jokes. Except these are all really smart people.

Is this why health care is so expensive? Wasteful pork belly systems that control and make up the bigger wasteful pork belly system? I feel badly for my patients paying for all this fat (and myself).

During the break, I lean over and offer a few helpful suggestions to the bacon lady, as she seems to speak for the insurer and course. Her half eaten plate of now cold bacon sits next to her can of Diet Coke. I offer a few suggestions about how to make the course and message more effective, and actual use of their material much easier for the user. She expresses that she thinks they are great ideas. But she doesn't sound like they will see the light of day. I speak to the bigger underlying issues creating patient risk in health care: 1. Healthcare workers are overloaded, and the level of busyness makes quality nearly impossible; and, 2. The reams of ever increasing paperwork and bureaucracy resulting in treating insurers and checklists instead of patients. This is what root cause analysis of bad events at hospitals is for, I am told. I am stunned.

The irony of what my state medical association spends resources on does not escape me. We have been trying to work with them for close to a year to utilize one of their advertised services of helping other organizations become CME providers. We want to teach doctors and all providers how to use nutrition and the rest of lifestyle as primary treatment like multiple national guidelines call for: to treat the cause of disease. We have been put off and postponed over and over and over again. I wonder how much the association gains financially from their business relationship with the insurance company and the "mandatory" requirements imposed on those insured to boost their membership numbers.

Why did I have to take time away from productive medical care? Drive an hour into the city? At rush hour? To take 2.5 hours (not counting the hour drive each way) to cover what could easily be covered in 1 hour? Why do I have to pay insurance premiums to pay 8 highly paid people to do the work of 1 to 2? Why couldn't I just review material and answer questions on the internet? At my own pace? Why don't they spend all this money to create a few simple resources that would be way more useful? It is not about patients or providers. It is big business. I don't think it is all a grand conspiracy, like some pontificate about. It is just many big businesses controlling and managing their turf to maximize fat profits. Because they can. Until we change it.

We use our little live survey clickers to answer some questions and see real-time results from the group up on the screen. Everyone is enduring. We are finally dismissed. Our CME certificates have been efficiently prepared ahead of time and are ready for pick up on our way out. The mandatory course evaluation paperwork is dropped in the pile. Everything gets top marks. We strained gnats for 2.5 hours while swallowing camel bacon, but the presenters knew their legal stuff and covered what they were supposed to. While we committed nutritional malpractice.

Our health care system Titanic sails full steam ahead into disease care Armageddon. The dining hall is filled with the smell of bacon. Health and caring be damned.


Ulcerative Colitis and Perfluorooctanoic Acid (PFOA)

Results: The incidence of ulcerative colitis was significantly increased in association with PFOA exposure, with adjusted rate ratios by quartile of exposure of 1.00 (referent), 1.76 (95% CI: 1.04, 2.99), 2.63 (95% CI: 1.56, 4.43), and 2.86 (95% CI: 1.65, 4.96) (ptrend < 0.0001). A prospective analysis of ulcerative colitis diagnosed after the baseline 2005–2006 survey (n = 29 cases) suggested a positive but non-monotonic trend (ptrend = 0.21).

Discussion: To our knowledge, this is the first study of associations between this common environmental exposure and autoimmune diseases in humans. We found evidence that PFOA is associated with ulcerative colitis.


Tuesday, May 17, 2016

World Health Organization International Standard To Harmonize Assays for Detection of Mycoplasma DNA. - PubMed - NCBI

Nucleic acid amplification technique (NAT)-based assays (referred to here as NAT assays) are increasingly used as an alternative to culture-based approaches for the detection of mycoplasma contamination of cell cultures. Assay features, like the limit of detection or quantification, vary widely between different mycoplasma NAT assays. Biological reference materials may be useful for harmonization of mycoplasma NAT assays. An international feasibility study included lyophilized preparations of four distantly related mycoplasma species (Acholeplasma laidlawii, Mycoplasma fermentans, M. orale, M. pneumoniae) at different concentrations which were analyzed by 21 laboratories using 26 NAT assays with a qualitative, semiquantitative, or quantitative design. An M. fermentans preparation was shown to decrease the interassay variation when used as a common reference material. The preparation was remanufactured and characterized in a comparability study, and its potency (in NAT-detectable units) across different NATs was determined. The World Health Organization (WHO) Expert Committee on Biological Standardization (ECBS) established this preparation to be the "1st World Health Organization international standard for mycoplasma DNA for nucleic acid amplification technique-based assays designed for generic mycoplasma detection" (WHO Tech Rep Ser 987:42, 2014) with a potency of 200,000 IU/ml. This WHO international standard is now available as a reference preparation for characterization of NAT assays, e.g., for determination of analytic sensitivity, for calibration of quantitative assays in a common unitage, and for defining regulatory requirements in the field of mycoplasma testing.


Datapalooza: Slavitt Admits Gov't Failed in Health IT Push

With just over 8 months on the job left to go, the head of the Centers for Medicare and Medicaid Services said Tuesday he now has "an obsession with the plight of independent physicians."

Since January, acting administrator Andy Slavitt and other members of agency have been traveling around the country listening to thousands of doctors complain about their electronic health record (EHR) systems, poor payment for their time, burnout, and confusion over quality metric requirements.

And all of this without measureable improvements in care for their patients.

It's all put the healthcare workforce on a precarious edge, he said in so many words.

Especially the primary care workforce. And that's a major problem, he told those assembled at the seventh annual Health Datapalooza conference here.

Because "knowing as we all do that if we don't invest in primary care, we'll invest double or triple when people get unnecessarily sick.


Inflammation, Not Acid, Cause of GERD, Study Suggests

Gastroesophageal reflux disease (GERD) may be caused by an immune reaction, rather than direct chemical injury from stomach acids, according to results from a small, single-center study published online May 17 in JAMA.

"In this preliminary study of 12 patients with severe reflux esophagitis successfully treated with PPI therapy, stopping PPI medication was associated with T lymphocyte–predominant esophageal inflammation and basal cell and papillary hyperplasia without loss of surface cells," write first author Kerry Dunbar, MD, PhD, from the Dallas Veterans Affairs Medical Center in Texas, and colleagues.

"If replicated, these findings suggest that the pathogenesis of reflux esophagitis may be cytokine-mediated rather than the result of chemical injury," they add.

Since 1935, convention has held that GERD, which affects about 20% of Americans, results from irritation of the esophageal lining as a result of refluxed acid from the stomach. A recent study in rats, however, has suggested that GERD may not be a result of chemical injury but, rather, a result of an immune reaction. That prompted researchers to test this new hypothesis in humans.

The study included 12 patients (11 men; mean age, 57.6 years) seen at the Dallas Veterans Affairs Medical Center for severe reflux esophagitis successfully treated with PPIs. Participants were told to stop taking their PPIs and received evaluations at baseline, as well as 1 and 2 weeks after stopping medication. Assessments included 24-hour esophageal pH and impedance monitoring (an index of mucosal integrity) and esophagoscopy (which included high-resolution confocal laser endomicroscopy). Researchers biopsied noneroded areas of the esophagus, where immune activity was assumed to be lower than in eroded areas.

At baseline, almost all participants (11/12) had no visible evidence of esophagitis. By 2 weeks after stopping PPIs, all participants developed esophagitis, and five had severe esophagitis.

Within 2 weeks of stopping PPIs, all participants developed abnormalities characteristic of GERD: basal cell and papillary hyperplasia (P < .01), papillary elongation (P < .01), dilated intercellular spaces in the esophageal squamous cell epithelium (P <. 001), reduced mucosal impedance (P = .001), and increased distal esophageal acid exposure. Between baseline and 2 weeks, acid exposure increased by 16.2% (95% confidence interval, 4.4% - 26.5%; P = .005).

Biopsies showed significant increases in infiltration of intraepithelial lymphocytes 1 and 2 weeks after stopping PPIs, with predomination of T cells (week 1, P = .005; week 2, P = .002) and few or no neutrophils and eosinophils.

"[E]sophageal basal cell and papillary hyperplasia developed in areas without surface erosions. If the traditional notion were true, that acute GERD is caused by refluxed acid directly inflicting lethal, chemical injury to surface epithelial cells, then basal cell and papillary hyperplasia would have been expected only in areas with surface erosions, and the infiltrating inflammatory cells would have been granulocytes primarily," the authors write. They note that further studies are needed to confirm these results.

In a linked editorial, Peter Kahrilas, MD, from Northwestern Feinberg School of Medicine, Chicago, Illinois, notes that the "provocative findings from this investigation are in the details": the earliest pathology occurred deep in the epithelium, not at the mucosal surface, and repair mechanisms started before the death of surface cells previously thought to provoke these changes.

"[A]lthough the inciting pathophysiology is unquestionably the reflux of gastric and duodenal secretions into the esophagus, this evidence suggests that the effect of that reflux is the initiation of cytokine-triggered inflammation rather than the long held belief of a direct chemical effect of acid, pepsin, and bile on the esophageal epithelium," he wrote.

He notes that the participants in this study — men with high-grade erosive GERD and hiatal hernias — probably represent between 1% and 5% of all patients with GERD, so the findings may not apply to all patients with GERD. However, shifting the focus away from the "burning" effect of stomach acid toward an immune reaction may help explain subtypes of GERD that have been recently recognized.

The findings may also have implications for therapy, he notes. Although PPIs will probably remain the backbone of treatment, new therapies that target the inflammatory cascade may help treat patients with more severe or refractory GERD.

"Based on these findings, perhaps the mantra for treating refractory GERD should be 'divide and conquer,' according to the clinical findings and this new information about the disease process," he concluded, "This is a heterogeneous patient group, and the therapeutic puzzle will only be solved piece by piece. Dunbar et al may have just placed a very important piece."


Are You Eating the Wrong Carbs?

Not all carbohydrates are created equal: some provide healthy nutrients, while others are more likely to simply raise your blood sugar levels. Find out what the healthiest carb choices are to add to your diet.

Looking for healthier, less-refined carb choices? These carbohydrates are minimally processed foods that are digested more slowly than refined carbs, and contain vitamins, minerals, and fiber. They do not typically cause rapid blood sugar spikes and should be the focus of your carbohydrate intake. Common examples include:

1. Whole grains (such as dense whole grain bread, and intact whole grains such as basmati rice, barley and quinoa)

2. Beans

3. Nuts

4.Vegetables and fruits

Add them to your grocery list and shopping cart for a healthier diet!


More Bad News About Red Meat - Dr Weil's Daily Health Tips - Natural Health Information

On the heels of a World Health Organization analysis concluding that processed meat is a carcinogen and red meat a "probable carcinogen" comes a report from Germany linking both of these foods with an increased risk of ischemic stroke – the type caused by blockages in blood vessels supplying the brain. Researchers from the University of Wurzberg analyzed data from about 11,000 mid-life men and women in the U.S. with no other risk factors for stroke such as diabetes or heart disease. After following half of this group for an average of 22.7 years, the investigators concluded that those who consumed the most red meat had a risk of stroke that was 47 percent higher than those who ate the smallest amount of red meat. The investigation showed that eating other sources of protein such as poultry, seafood, legumes and nuts posed no additional risk of stroke. Among the men in the study, those who ate the most red and processed meat had a 62 percent higher risk of stroke than men who ate the least amounts of these foods. The researchers also found that the risk of stroke was 24 percent higher among study participants who reported the highest intake of bacon, sausage and other processed meats compared to those whose intake of these foods was lowest. Because this was an observational study, it doesn't prove that eating red meat or processed meats caused the strokes that occurred among the participants. Instead, it indicates an association between red and processed meat and ischemic strokes.


Melatonin better than prescription for migraine prevention

Results Mean headache frequency reduction was 2.7 migraine headache days in the melatonin group, 2.2 for amitriptyline and 1.1 for placebo. Melatonin significantly reduced headache frequency compared with placebo (p=0.009), but not to amitriptyline (p=0.19). Melatonin was superior to amitriptyline in the percentage of patients with a greater than 50% reduction in migraine frequency. Melatonin was better tolerated than amitriptyline. Weight loss was found in the melatonin group, a slight weight gain in placebo and significantly for amitriptyline users.

Conclusions Melatonin 3 mg is better than placebo for migraine prevention, more tolerable than amitriptyline and as effective as amitriptyline 25 mg.


Sunday, May 15, 2016

Mycoplasma ... and other stealth microbes

Mycoplasma, the Most Common Lyme Coinfection
by Dr. Bill Rawls | Updated 5/11/16

Mycoplasma is the stealthiest of all stealth microbes. It may be a major player in many chronic diseases associated with aging, but remarkably, most people, including most doctors, have limited awareness of it.

If you have Lyme disease, fibromyalgia, chronic fatigue, autoimmune disease, or possibly any other chronic illness, however…it is a microbe you should know about.

Mycoplasma is the smallest of all bacteria. 4,000 of them can fit inside one red blood cell in your body (only 10-15 of average sized bacteria would fit). It is a parasite—it cannot live without a host. Unlike other bacteria, mycoplasmas do not have a protective cell wall. This interesting strategy of survival allows them to change their shape and fit into areas where other bacteria cannot go. It also allows them to slip inside cells of the host. Not having a cell wall makes mycoplasma completely resistant to many types of antibiotics.

There are over 200 known types of mycoplasma (and probably many yet to be discovered) that can infect both animals and plants. It is highly adaptable and can jump species and adapt to new hosts very readily.

There are at least 23 different varieties of mycoplasma that can infect humans (and counting). A few of them are considered harmless normal flora, but most have the potential to cause disease.

Mycoplasma are spread by biting insects (ticks, mosquitoes, fleas, biting flies), sexual contact, contaminated food, and airborne droplets. Most everyone has been exposed to some form of mycoplasma. Mycoplasma (several species) have been closely linked to many chronic degenerative diseases.

Mycoplasma is a master of manipulating and outmaneuvering the host’s immune system. Half of its genetic makeup is devoted to that exclusive purpose. It has little ability to cause direct harm to the host, but it can use the host’s immune function to its own advantage.

Everything that the bacteria needs for survival (vitamins, minerals, fats, carbohydrates, and amino acids) must be scavenged from the host; it makes nothing itself. To gain access to needed resources, mycoplasma generate inflammation in the body by manipulating the signaling mechanisms of the immune system (called cytokines). Inflammation breaks down tissues and allows the bacteria to gain access to the host’s resources. Mitochondria are prime targets for energy; fatigue is always a factor in mycoplasma infections.

Mycoplasma favor infecting the cells of tissues that line different areas of the body. Common sites of infection include nasal passages, sinuses, lungs, the lining of the intestinal tract, the genital tract, vesicles inside the brain, and the synovial lining of joints. They also commonly infect white blood cells, red blood cells, and brain tissue. Different mycoplasma have a preference for certain tissues, but all mycoplasma species possess the ability to infect any type of tissue and all organ systems.

The most common mycoplasma, Mycoplasma pneumoniae, has preference for lung tissue. Initial infection with M. pneumoniae typically causes pharyngitis (sore throat), cough, fever, headache, malaise, rhinitis (runny nose); all the common symptoms of a basic upper respiratory infection. If the person’s immune system is not full strength, it can progress to bronchitis and even pneumonia (about 20% of pneumonias). The type of pneumonia caused by mycoplasma (often called “walking pneumonia”) is rarely severe enough to result in hospitalization, though it can drag on for weeks or even months.

Clearing of respiratory symptoms, however, may not be the end of the story. After mycoplasma enters the body through a prefered infection site, it also infects white blood cells. Once inside a white blood cell, it can be carried to all parts of the body and infect other tissues and organs.

The lungs are certainly not the only way for mycoplasma to enter the body. Some species of mycoplasma have a preference for causing genital infections. Others can be spread by ticks and several species of mycoplasma are commonly found in the intestines. Initial infection sites are not absolutely species-specific, however. Mycoplasma pneumoniae has been known to cause genital infections and other mycoplasma that typically infect the genitals have been found in the stomach.

No matter where the initial infection occurs, any species of mycoplasma has the potential to spread throughout the body.

Mycoplasma Facts

  • Genital infections are most common with four species of mycoplasma (M. hominis, M. genitalium, Ureaplasma urealyticum, U. parvum), but other species of mycoplasma can be spread sexually and cause genital symptoms. Genital infection with mycoplasma can cause UTI symptoms (burning and pain with urination) in both male and female. Typically the urine culture is negative.
  • Genital mycoplasma has been associated with prostatitis, kidney infection, pelvic inflammatory disease, cervical infection, and infertility (male and female). In pregnancy, mycoplasma has been associated with premature rupture of membranes, miscarriage, growth retardation, and postpartum infection. The genital area is an entry point for mycoplasma and can lead to systemic infection.
  • M. pneumoniae is the most common mycoplasma to be associated with respiratory infections, but other species of mycoplasma also are found. Mycoplasma has been associated with childhood asthma. The feeling of needing to “catch breath” in fibromyalgia, Lyme disease, and chronic fatigue may be related to mycoplasma.
  • Mycoplasma commonly infects the synovial lining of joints (lining protecting the joint). 90% of people with rheumatoid arthritis test positive for mycoplasma in the synovial fluid. The most common mycoplasma species associated with rheumatoid arthritis is M. fermentans, but M. pneumoniae and other species have also been found. Mycoplasma or other stealth microbes may be an underlying factor in most forms of arthritis.
  • Mycoplasma scavenge fats from the myelin sheath covering nerve tissue. Not surprisingly, mycoplasma (and other stealth microbes including chlamydia and borrelia) have been linked to multiple sclerosis. Mycoplasma has been closely linked to other neurodegenerative diseases including ALS (M. fermentans is most common) and Parkinson’s disease.
  • Mycoplasma has been found in the bone marrow of children with leukemia.
  • Mycoplasma has been found in cancer tissue, including cervical and ovarian cancer.
  • Finding mycoplasma in cervical cancer suggests that it may be a cofactor in cervical cancer, along with human papillomavirus (HPV). (Mycoplasma has been demonstrated to facilitate the entry of certain viruses into cells.)
  • Mycoplasma as a top candidate for explaining autoimmunity; it stimulates host self-damage and that it can live inside cells while simultaneously turning off the ability of the immune system to recognize the cell as abnormal. Mycoplasma has been linked to many autoimmune diseases; which disease occurs is dependent on the genetic profile of the person and other stealth microbes that may be involved.

Endocrine-disrupting chemicals and reproduction


    Although EDCs primarily affect sex steroid hormone pathways, some can affect adrenal, thyroid, and other endocrine pathways.

    Human-produced EDCs vary widely in their properties. Many, but not all, concentrate in fat, and some have a very long half-life.

    Because it would be impossible to perform randomized, controlled trials of the health effects of the thousands of manufactured EDCs encountered in daily life, physicians should follow the precautionary principal when counseling patients: ie, tell them to avoid chemicals when possible, especially those that have proven or plausible health risks.

    On the other hand, physicians need to keep in mind the economic hardships patients may face in switching to potentially safer products or foods and unavoidable exposures at work and at home.

A 28-YEAR-OLD WOMAN presents for routine follow-up of asthma. She has a 1-year-old son and is considering a second pregnancy. She says she read on the Internet that the US Food and Drug Administration recently banned baby bottles and "sippy" cups that contain bisphenol A (BPA), as recommended by the American Medical Association. She wonders if there are other sources of BPA and if they pose a health risk to her, her son, and possible future children.



Saturday, May 14, 2016

ACP guidelines for managing insomnia

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the management of chronic insomnia disorder in adults.

Methods: This guideline is based on a systematic review of randomized, controlled trials published in English from 2004 through September 2015. Evaluated outcomes included global outcomes assessed by questionnaires, patient-reported sleep outcomes, and harms. The target audience for this guideline includes all clinicians, and the target patient population includes adults with chronic insomnia disorder. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence)

Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence)

These new guideline recommendations from the American College of Physicians provide evidence-based advice for the management of chronic insomnia disorder in adults. Implementation of these guidelines requires major changes in practice.


Good diet better than calcium or individual vitamins for osteoporosis

Osteoporotic fractures constitute a major burden for health care systems in aging societies. Although considerable research1- 6 has examined whether intake of nutrients involved in bone metabolism, such as protein, calcium, or unsaturated fat, can prevent fracture events, the findings are not consistent. However, suboptimal single nutrient intake does not occur in isolation but rather reflects a poor-quality diet.7

Several descriptive epidemiologic studies8- 10 have shown that the incidence of osteoporosis and osteoporosis-related fractures varies across nations, with a tendency of lower rates in Mediterranean compared with northern European countries. These differences have been attributed to life-style factors, including specific dietary patterns. The traditional Mediterranean-style diet emphasizes the consumption of dietary components, such as plant foods, fish, nuts, and monounsaturated fat, which have been shown11,12 to impart beneficial effects on bone health. Adherence to a Mediterranean diet was previously operationalized by a dietary scoring system and modified to be applied to non-Mediterranean populations.13 This Mediterranean diet score has been associated with a decreased hip fracture risk, particularly among men,14 but overall evidence is inconclusive.15 Moreover, data are sparse as to whether other dietary scoring systems that characterize a high-quality diet preserve bone health.16 Comprehensive analyses investigating the association between various commonly recommended dietary quality indexes and fracture risk in the United States are warranted.

The primary aim of this study was to examine the association between adherence to a diet quality index constructed on the basis of dietary recommendations or existing healthy dietary patterns and bone outcomes (hip or total fractures) in a large population of postmenopausal women. Specifically, diet quality was assessed using the alternate Mediterranean Diet (aMED) score,13,17 the Healthy Eating Index 2010 (HEI-2010),18 the Alternate Healthy Eating Index 2010 (AHEI-2010),19,20 or the Dietary Approaches to Stop Hypertension (DASH) score.21 As a secondary aim, the associations between diet quality, bone mineral density (BMD), and lean body mass measurements were examined. Given prior epidemiologic data14,16 and the composition of the aMED index, we hypothesized that high aMED scoring would be associated with a lower fracture risk.


Thursday, May 12, 2016

Limit Fluoroquinolone Use in Light of Risks, FDA Says

The US Food and Drug Administration (FDA) said today that unless they lack other treatment options, patients with uncomplicated infections should not receive fluoroquinolones, given the risk for disabling and potentially permanent adverse events.

Labels for these antibiotics already warn about the risks for tendonitis, tendon rupture, central nervous system effects, peripheral neuropathy, myasthenia gravis exacerbation, QT prolongation and torsades de pointes, phototoxicity, and hypersensitivity. These adverse events can occur together. The FDA will update the labels to state that the serious risks posed by fluoroquinolones generally outweigh their benefits for patients with sinusitis, bronchitis, and uncomplicated urinary tract infections that are treatable by other means.

There are seven FDA-approved fluoroquinolones for systemic use on the market:

    moxifloxacin (Avelox, Merck),

    ciprofloxacin (Cipro, Bayer HealthCare),

    ciprofloxacin extended-release,

    gemifloxacin (Factive, LG Life Sciences, Inc),

    levofloxacin (Levaquin, Janssen Pharmaceuticals Inc),

    moxifloxacin injection, and

    ofloxacin (available only as a generic).

An FDA advisory panel in November 2015 recommended stronger label warnings for the antibiotics, given widespread reports of adverse events.


Wednesday, May 11, 2016

Functional Medicine: A Science Whose Time Has Come · Experience Life

A few years ago, Louis Messina was in pain. Despite being on a variety of big-gun drugs to control his psoriatic arthritis, an autoimmune disease that attacks the joints, he still suffered from constant pain and swelling throughout his body. He walked with a limp because his left knee had arthritis-induced tissue damage; the big-toe joint on his right foot was similarly destroyed; and in the mornings, he would awake to find his hands balled up into fists. (They would unclench only after he submerged them in warm water for several minutes.)

"Morning stiffness may sound like a minor problem, but it's a big thing," Messina says. "If you can't open your hands up in the morning, you really can't do much. You can't brush your teeth, or wash your face, or shave."

Nor can you perform surgery. At the time, Messina was in his early 50s and putting in 60 to 80 hours weekly as chief of vascular surgery at the renowned University of California, San Francisco School of Medicine.

"I was quite incapacitated," he recalls. "It was at the point where I couldn't really make rounds with the residents in the mornings because I wasn't able to easily walk up and down the stairs."

Frustrated and thinking about early retirement, Messina made an appointment with Mark Hyman, MD, the medical director and founder of the UltraWellness Center in Lenox, Mass., and a leading expert in functional medicine. "I had never even heard of functional medicine," Messina says. "I went on the recommendation of a friend of mine and, frankly, because my wife wanted me to go."

Hyman took a detailed medical history, asking Messina very specific questions about his diet, lifestyle, early childhood illnesses, stresses, and recent health challenges, which included reflux, migraines, and more. Then he ordered a battery of tests to deepen his understanding of Messina's overall health. (To get an idea of some of the tests Hyman ordered, see "Basic Tests Used in Functional Medicine" below in the sidebar.)

The results showed a variety of underlying gut problems, such as yeast overgrowth, a leaky gut, and allergies or sensitivities to many foods, including gluten. Tests also revealed low levels of vitamin D and magnesium; hypothyroidism; and prediabetes.

"He had all kinds of problems," says Hyman. "But once we treated his poor, inflammatory diet and his underlying gut issues, which generated significant inflammation throughout his body, all of those problems went away."

For Messina, who up until this point had been offered only surgery or drugs (which cost more than $30,000 annually and had serious side effects), it was an unprecedented medical experience.

"The rheumatologist that I had been seeing before Dr. Hyman still can't believe it. She's never seen anything like it," he says. "My arthritis, my pain and swelling, it's all gone. I now go faster on the stairs than my residents."

Messina's experience, while notably rare in conventional medicine, is actually quite characteristic of functional medicine, an increasingly popular healthcare model. Its claim to fame: seeing the big picture, treating the whole patient, and recognizing and treating the root of disease, as opposed to just the most visible symptoms.

Some folks have the mistaken idea that functional medicine is simply lifestyle-based medicine, but it is a systems-oriented, science-based approach that involves taking a patient's biochemistry, physiology, genetics, and environmental exposures into account when looking for the cause of a specific medical issue or set of symptoms.

Practitioners in the hyperspecialized, overbooked world of conventional medicine, says Hyman, sometimes don't have the time or inclination to adopt this wider perspective. In Messina's case, doctors had focused only on suppressing the inflammation — which was just a symptom — as opposed to digging deep and investigating what was causing that inflammation.

"Most doctors aren't trained to think about the underlying causes of disease, such as toxins, allergens, microbes, nutrition, and stress," says Hyman, who is chairman of the Institute for Functional Medicine (IFM). "Conventional medicine is the medicine of what — what disease do you have, what drug should I give you. Functional medicine considers the diagnosis, of course, but it also seeks to answer the question why."


Monday, May 9, 2016

10 ways electronic health records are leading to physician burnout

LAS VEGAS – Doctors are dreading what some have started to call EHR "pajama time.”

“That’s the hour or two that physicians are spending – every night after their kids go to bed – finishing up their documentation, clearing out their in-box,” according to Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association.

At a session held in conjunction with the annual meeting of the Healthcare Information and Management Systems Society, Dr. Sinsky spoke about how electronic health records have not lived up to their promise of helping streamline patient care and instead have added hours and headaches to most physicians’ days.

Data on the impact of EHR systems on physicians’ workflows and satisfaction is beginning to accumulate, she said. University of Wisconsin researchers studying the impact of EHR systems on physicians’ workflow and lives looked at how often and when doctors were accessing their patients’ medical records, she said. What they found was that so many doctors don’t have enough time in their days to finish their documentation, so they spend their evenings and weekends finishing up. Their preliminary findings were presented in 2015 at a primary care research meeting.

Dr. Sinsky said the researchers see “a bump” of time spent on Saturday nights.

“I call that ‘date night’. That Saturday night belongs to Epic, Cerner, or McKesson,” she said sarcastically. “Well, I don’t want my doctor on her electronic health record on a Saturday night. I want my doctor having fun on Saturday night, because I want her to love her job.”

That same study “found that primary care physicians were spending 38 hours a month after hours doing data entry work,” in other words “working a full extra week every month doing documentation after hours, between 7 p.m. and 7 a.m.,” said Dr. Sinky, who is also an internist in Dubuque, Iowa.

Here are 10 ways EHRs contribute to more work, Dr. Sinsky said:

1. Too many clicks. “It takes 33 clicks to order and record a flu shot. And in the emergency room, it takes 4,000 clicks to get through the day for a 10-hour shift,” Dr. Sinsky said. “Studies have shown that physicians are spending 44% of their day doing data entry work, [but] 28% of the day with their patient.”

In her own EHR, she said, “it took 21 clicks, eight scrolls, and five screens just to compose the billing invoice, and within that EHR, the responsibility, which used to be a clerical responsibility, has transferred many things to the physician. All of those clicks, all those screens, and all those minutes add up.”

2. Note bloat. With her current EHR, Dr. Sinksy said, “I have six pages of notes for an upper respiratory infection.” This is not efficient. She offered another example: “I had a patient recently who I sent to a local university,” Dr. Sinsky said. “I got back an enormous note, about 12 pages long. But I still didn’t know, at the end of it. Did she have cancer, or not?”

3. Poor workflow. Today’s EHRs have a workflow that doesn’t match how clinicians work, she said. “Right now, many clinicians are encountering these very rigid workflows that don’t meet the patient’s need and don’t meet the provider’s need.” For example, “in some EHRs, the physician can’t look at any clinical data while dictating the note. This means that the physician has to rely on memory or print lab results, x-ray reports, medication lists, etc., in order to reference these data points in their clinic note.”

4. A lack of focus on the patient. Most EHRs lack a place for a photo of the patient and his or her family, and a place for the patient’s story, a deficiency that detracts from the value of the encounter.

5. No support for team care. Often, both a physician and a nurse or medical assistant need to add documentation to the EHR. Yet many systems are set up such that each party must log in, then log out, before another can contribute. “The nurse has to sign in and sign out; the doctor has to sign in and sign out. That’s about a 2-minute process, so it’s completely unworkable,” Dr. Sinsky said.

6. Distracted hikes to the printer. While most health care settings have installed the computer in the exam rooms, few have also installed a printer. “The doctor types up the exit summary, hits print, runs around the corner, down the hall, around the corner to the one printer, picks up the visit summary, goes back down the corner down the hall. Meanwhile, they’ve broken their bond with the patient and been interrupted several times on that journey.”

7. Single-use workstations. Doctors who can sit side by side with their nurses and talk about the patient as they’re working on the EHR can save 30 minutes per day. But most office practice setups don’t accommodate that interaction.

8. Small monitors. Being able to see a large display of information rather than a tiny swatch can save 20 minutes of physician time a day, Dr. Sinsky said.

9. A long sign-in process. Streamlining the way a doctor signs into a computer, perhaps with the use of technologies like the tap of one’s badge, “can save 14 minutes of physician time a day,” Dr. Sinsky said.

10. Underuse of medical and nursing students. Practices are beginning to hire premed and prenursing students as assistants who shadow the physician with each patient. While the physician is “giving undivided attention to the patient, the practice partner is cuing up the orders, doing the billing invoice ,and recording much of the encounter.” At the University of California, Los Angeles, researchers found that the use of these assistants saves 3 hours of physician time each day (JAMA Intern Med. 2014;174[7]:1190-3).


Sunday, May 8, 2016

Drink alcohol: How much are you influenced by media "programming"?

"These companies, they’re pushing this idea, like that champagne should be associated with celebrations like weddings. Who ever actually invented the idea that to celebrate you have to drink champagne? I’ll tell you who invented it, a marketing company behind a champagne company. Who says that you have to drink beer to watch sporting games? Well, the beer companies, of course. Who says that you have to have a bottle of wine over a romantic dinner? The wine companies, that’s who.

The truth is, you can enjoy all of these activities without the alcohol, and you can live a life filled with celebration and joy and energy and clarity, without the alcohol. When you drink, you’re not actually drinking for pleasure. You’re actually drinking just to relieve you of your alcohol withdrawal. Alcohol is a highly addictive drug, and when it passes out of your system, it leaves you wanting more, like hunger. Then you feel like you’re craving a drink. You’re not actually craving the drink for pleasure, you’re craving it to relieve you of your craving."


James Swanwick – Be Wiser Without Budweiser

James Swanwick is an Australian-American entrepreneur, former SportsCenter anchor on ESPN and host of The James Swanwick Show podcast. He is the creator of the 30 Day No Alcohol Challenge, which helps you reduce or quit alcohol; and creator of blue-blocking glasses “Swannies,” which help you sleep better. On today’s episode of Bulletproof Radio, James and Dave talk about the social pressure to drink alcohol and how to conquer it, the marketing tactics of the alcohol industry, James’ blue-blocking glasses, considering light as a drug and more.

Bigger, Brighter, Bluer-Better? Current Light-Emitting Devices – Adverse Sleep Properties

A growing body of evidence suggests that the use of light-emitting (LE) devices in the evening may adversely affect sleep quality and timing, daytime performance, health, and safety (1–3). The brightness, timing, color, pattern, and the duration of light exposure all influence important physiological body rhythms (4–6). When modern LE devices are used in the evening before bedtime all these factors combine to produce a “perfect storm,” which can adversely affect sleep.

The role of light and its influence on many aspects of our physiology, behavior and well-being is increasingly well understood (4–6). In particular, the light/dark cycle is critical in synchronizing the circadian (daily) clock to the 24 h day. The hormone melatonin (“the hormone of darkness”) is produced at night, with the duration of secretion mirroring the dark period, and its production is associated with sleep (7).

While light during the daytime can beneficially enhance alertness, performance, and mood (8), in the evening it can suppress the production of melatonin, increase alertness, and delay sleep onset (9).

Importantly, not all colors of light have the same effect. Short-wavelength-enriched light (blue-enriched) is likely to cause the most disruption, as it most effectively suppresses melatonin (10) and increases alertness (11). Many older LE devices have been shown to have peaks specifically in these short wavelengths (3).

The development of LE devices means that for many people, a “book at bedtime” is now often an “e-book.” Traditional paper books with dim incandescent bedside lighting reflected off the pages of the book expose the readers to a low-intensity tungsten light with a yellow–red spectrum that has little impact on sleep. In comparison, the same book read in electronic format will provide a very different light signal with biological effects. This is not an insignificant issue with over a quarter of the US population reading e-books in 2014 (12). Furthermore, these same LE devices allow access to the Internet, social media, and games as well as reading, with evidence that multi-tasking is becoming the norm rather than the exception (13).

Studies considering the potential impact of light exposure at night have employed a variety of methodologies, including animal studies (14), laboratory-based controlled-environment studies (3–6), and epidemiological studies (13, 15). All have important roles, with advantages and limitations.

Until 2000, the majority of photometric studies quantified light stimuli in terms of photopic illuminance (lux) (16). During that time, inexpensive lux meters were used because of their existing role in lighting and photography. As the existence and role of melanopsin and the intrinsically photosensitive retinal ganglion cells (ipRGC) in the inner retina have become clearer, so has the realization that current methods of light measurement are incomplete (16). In order to better characterize the biological effects of light, a “toolkit” to calculate the effective irradiance experienced by each of the rod, cone, and melanopsin photoreceptors has been developed (16).

We set out to measure light levels and spectral profiles of three of the most popular contemporary LE devices to verify and compare their short-wavelength-enriched light emissions. We decided to include three categories of devices; one tablet, one smartphone, and one e-reader. As we were not aware of studies comparing activities such as reading an e-book with playing a game, we also compared the light signals emitted when playing a popular game, with those emitted by e-book text.

Since there are a number of potential strategies that claim to reduce the intensity of short-wavelength light exposure, we also sought to test the actual effect of some of these strategies on the spectral profile of these light emissions.

By characterizing the extent to which each of the five photopigments in the human eye are activated by all the light conditions we tested, we intended to provide reliable benchmark data for each LE device, to allow later comparison with other devices, other conditions, and extrapolation to physiological and behavioral responses.


ACP: Therapy before Medications for Insomnia

Patients suffering from chronic insomnia should receive cognitive behavioral therapy (CBT) as a first-line treatment for the condition, the American College of Physicians (ACP) recommends in new clinical practice guidelines published online May 3 in the Annals of Internal Medicine.

"[CBT] for insomnia consists of a combination of treatments that include cognitive therapy around sleep, behavioral interventions (such as sleep restriction and stimulus control), and education (such as sleep hygiene)," write Amir Qaseem, MD, PhD, from the ACP, and colleagues.

Relying on moderate-quality evidence, the ACP strongly recommends that "all adult patients receive [CBT] for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder." If CBT by itself does not effectively treat insomnia, the ACP relied on lower-quality evidence to recommend that providers and patients discuss the benefits, harms, and costs of short-term use of medication and then use a shared decision-making approach to determine whether to add medication to a patient's treatment plan.

CBT-I "typically involves 6 to 8 customized sessions in which patients are encouraged to change sleep and daytime habits, alter nonproductive sleep schedules, and modify beliefs about insomnia," write Roger G. Kathol, MD, from the University of Minnesota in Minneapolis, and J. Todd Arnedt, PhD, from the University of Michigan Medical School in Ann Arbor, in an accompanying editorial. "By engaging patients to be active participants in their sleep health, CBT-I therapists teach cognitive and behavioral skills that resolve or attenuate chronic insomnia in 70% to 80% of treated persons, often without supplemental medication."

Despite the clear evidence base, however, the ACP recommendations have several obstacles to overcome, Dr Kathol and Dr Arnedt write. Those challenges primarily include some clinicians not considering insomnia a health problem, some physicians' biases against psychological/behavioral interventions, and insufficient training among providers to deliver CBT, especially in medical settings.

"The first step in implementing the new ACP guideline is for physicians to recognize that a psychological alternative to pharmacologic therapy will accomplish better and safer patient outcomes," Dr Kathol and Dr Arnedt write. However, patients receiving CBT need ongoing support and instruction, as they must be more actively engaged in their treatment than if they were solely taking medication. "Support and encouragement to continue, despite initial adversity, can be the difference between CBT-I success and failure."

They note with frustration that most patients have insufficient access to CBT because of both insurance reimbursement requirements and too few trained practitioners. "[I]nadequate access to well-trained CBT-I practitioners contributes to the broader finding that only 1 in 9 patients treated in the general medical sector receives minimally effective behavioral health treatment," they write. Although they mention virtual CBT delivery options, Dr Kathol and Dr Arnedt note that CBT works best in person and often requires face-to-face treatment to qualify for reimbursement.

"A long-term solution requires a team effort by policymakers, physicians, health care administrators, sleep medicine specialists, and CBT-I therapists," Dr Kathol and Dr Arnedt write.

In writing the recommendations, Dr Qaseem and colleagues relied on two evidence reviews also published online May 3 in the Annals of Internal Medicine. A systematic review by Timothy J. Wilt, MD, MPH, from the Minneapolis Veterans Affairs Health Care System in Minnesota, and colleagues analyzes data from 35 randomized controlled trials and 11 long-term observational trials on pharmacologic treatments for insomnia, all published from 2004 to 2015. This review also includes data from product labels and a US Food and Drug Administration review for nonbenzodiazepine hypnotics and orexin receptor antagonists. A second evidence report, by Michelle Brasure, PhD, MSPH, MLIS, from the Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, and colleagues, focuses on assessing the benefits and harms of psychological and behavioral interventions to treat insomnia and includes a review of 60 randomized controlled trials.

In the pharmacology systematic review, eszopiclone, zolpidem, and suvorexant all moderately improved short-term sleep outcomes compared with placebo, but insufficient evidence existed to suggest that benzodiazepine hypnotics, melatonin agonists, antidepressants, or other medications helped.

"Benefits of pharmacologic treatment include improved sleep outcomes, such as sleep onset latency and total sleep time, and in some cases improved global outcomes in the general population and in older adults," Dr Qaseem and colleagues write.

"There was insufficient evidence overall on the comparative effectiveness and safety of the various pharmacologic treatments."

Data from the US Food and Drug Administration and observational studies suggest the risks from hypnotics or other pharmacological treatments for insomnia include dementia, fractures, major injury, driving impairment, and cognitive and behavioral changes.

The systematic review on behavioral interventions for insomnia found CBT most beneficial among various behavioral interventions, leading to "improved remission, treatment response, sleep onset latency, wake after sleep onset, sleep efficiency, and sleep quality in the general population," Dr Qaseem and colleagues write. The review also showed a low risk for harm from CBT or other behavioral therapies.

Too little data existed to compare behavioral therapy with medication for treatment of insomnia or to assess the safety or efficacy of complementary and alternative treatments such as acupuncture and Chinese herbal medicine.


Many Surprising Foods Found to Contain Monsanto’s Deadly Poison

Congress is in the process of updating the Toxic Substances Control Act, a 40-year-old piece of legislation in serious need of overhaul. Once reformed, the Act will determine how the chemical industry is regulated, including which chemicals are allowed and who can sue over any related problems.

That latter part is important, especially when faced with the type of devastation caused by chemicals like PCBs. But the House of Representatives has slipped in a clause that many are calling a "gift" to chemical giant Monsanto; the paragraph shields the company from legal liability related to PCBs.

Monsanto produced almost all PCBs sold in the U.S. — all 1.25 billion pounds of them.12 If the clause is allowed to remain in the Toxic Substances Control Act, PCB lawsuits against Monsanto by state and local governments and individuals would be blocked. States would also be blocked from passing PCB regulations.

As reported by The New York Times, Monsanto insists it did not ask for the clause to be added, and the House denies it is a "gift."13 But the clause benefits only one company.


Potent Form of Vitamin B Helps Slow Aging

Science. 2016 Apr 28. pii: aaf2693.

Cell. 2013 Dec 19;155(7):1624-38. doi: 10.1016/j.cell.2013.11.037


One of the most potent forms of vitamin B3 stops the aging process of organs and can only be described as restorative. Nicotinamide riboside is naturally produced in our bodies and studies continue to validate its effectiveness in preventing disease and regenerating cells.

B3 is one of eight B vitamins. It is also known as niacin (nicotinic acid) and has 2 other forms, niacinamide (nicotinamide) and inositol hexanicotinate, which have different effects from niacin.

An earlier study involved researchers at Harvard University and the University of NSW. Published in the scientific journal Cell, the landmark paper was one of the first to provide valuable insights into Nicotinamide's brain performance and anti-aging.

Nicotinamide riboside is naturally produced in our bodies. It’s a chemical compound which acts as a precursor to vitamin B3.

Nicotinamide riboside has been linked to a number of surprising and powerful benefits. Foods high in Nicotinamide include Brewer's Yeast, Sunflower Seeds, Raw Peanuts and Beets. Interestingly Beet Juice & Yeast have been shown to have remarkable cancer killing attributes. Possibly due to the sugars in the beets causing a beneficial form of fermentation to occur with the B vitamins in the Brewer's Yeast.

Now a team of researchers at EPFL's Laboratory of Integrated Systems Physiology (LISP), headed by Johan Auwerx, has unveiled even more of its secrets. An article written by Hongbo Zhang, a PhD student on the team, published in Science and describes the positive effects of NR on the functioning of stem cells. These effects can only be described as restorative.

As mice, like all mammals, age, the regenerative capacity of certain organs (such as the liver and kidneys) and muscles (including the heart) diminishes. Their ability to repair them following an injury is also affected. This leads to many of the disorders typical of aging.

Mitochondria: also useful in stem cells
Hongbo Zhang wanted to understand how the regeneration process deteriorated with age. To do so, he teamed up with colleagues from ETH Zurich, the University of Zurich and universities in Canada and Brazil. Through the use of several markers, he was able to identify the molecular chain that regulates how mitochondria -- the "powerhouse" of the cell -- function and how they change with age. The role that mitochondria play in metabolism has already been amply demonstrated, "but we were able to show for the first time that their ability to function properly was important for stem cells," said Auwerx.

Under normal conditions, these stem cells, reacting to signals sent by the body, regenerate damaged organs by producing new specific cells. At least in young bodies. "We demonstrated that fatigue in stem cells was one of the main causes of poor regeneration or even degeneration in certain tissues or organs," said Hongbo Zhang.

This is why the researchers wanted to "revitalize" stem cells in the muscles of elderly mice. And they did so by precisely targeting the molecules that help the mitochondria to function properly. "We gave nicotinamide riboside to 2-year-old mice, which is an advanced age for them," said the researcher. "This substance, which is close to vitamin B3, is a precursor of NAD+, a molecule that plays a key role in mitochondrial activity. And our results are extremely promising: muscular regeneration is much better in mice that received NR, and they lived longer than the mice that didn't get it."

Scientists have long used NAD+ as a powerful anti-aging tool. While trying to find a cure for aging, scientists increased the levels of NAD+ within the mitochondria. The mitochondria responded by increasing their performance and energy, which effectively neutralizes the effects of aging.

Specifically, nicotinamide riboside effectively delays early- and late-stage disease progression, by robustly inducing mitochondrial biogenesis in skeletal muscle and brown adipose tissue, preventing mitochondrial ultrastructure abnormalities and [mitochondrial DNA] deletion formation.

A breakthrough for regenerative medicine
Parallel studies have revealed a comparable effect on stem cells of the brain and skin. "This work could have very important implications in the field of regenerative medicine," said Auwerx. "We are not talking about introducing foreign substances into the body but rather restoring the body's ability to repair itself with a product that can be taken with food." This work on the aging process also has potential for treating diseases that can affect -- and be fatal -- in young people, like muscular dystrophy (myopathy).

So far, no negative side effects have been observed following the use of NR, even at high doses. But caution remains the byword when it comes to this elixir of youth: it appears to boost the functioning of all cells, which could include pathological ones. Further in-depth studies are required.