Vol. 207 February 1, 2019 Things That Threaten

February 1, 2019

With our President and our own intelligence agencies currently in public disagreement about our greatest threats (Southern border migrants {Tweets} VS China, Russia, and North Korea {“Worldwide Threat Assessment”} ), it seems an appropriate time to list again some of the things that might threaten us from a medical point of view.  I last did this on February 1, 2010.

Repeats from 2010:

Watching TV – increase chance of a cardiac death by 18%, increase chance of obesity in children by 5%. 

Tanning Booths – Increase chance of malignant melanoma by 75%; 20 minutes in the booth equals 5 hours in the sun.

Cell phone use in cars – Increase risk of accident by 400%

Toys – 13,663 head injuries in children from toys seen in an ER in 2005; 251,000 toy injuries seen in ERs in 2018; 41% (102,910) were injuries of face or head.

Sleep apnea in truck drivers – Sleep apnea increases the chance of a driving accident by about 100%; 17% of truck drivers have sleep apnea

Brain cancer from cell phones– no evidence for it in 2010; “maybe” in 2019; very heavy users over 10 years in Sweden had an increased incidence of acoustic neuroma (non-cancerous growth on hearing nerve).

Contaminated herbal supplements – more studies continue to find supplements with incorrectly labeled ingredients and/or unlabeled contaminants. Most of these supplements are for sexual enhancements, body building, or weight loss.  

Vaping of nicotine products – “Unknown risks” noted in August 1, 2009; Still unknown over the long term, but of more concern because of the alarming explosion of use by junior high students and 21% of twelfth-graders.( an increase of 1.3 million teens just since 2017) (NEJM 2018 Dec 17)

New threats:

Gun Violence – I am surprised that this wasn’t in my 2010 list since it seems like we have been talking about this threat for years, but it was before the Sandy Hook and Stoneman Douglas school massacres . Wikipedia has a handy list of 122 world-wide school massacres by country, dates, number killed, etc. Do you remember what the auto industry said in the past regarding proposed laws requiring seat belts? – “Cars don’t kill people; people kill people.” I don’t either. Someone must have made that up to make a point. Check my two previous blogs (2015 and 2018) for the comparison of “the frog sitting in the gradually heating up water” with our pace of achieving gun safety. (“By Degrees”, Markerelli.com)

Climate Change – Extreme weather events and raging wildfires in California have caused some to label climate change as a “Health Emergency”. Accompanying an article describing the stress on emergency medical care resources and the significant contribution to air pollution caused by the California wildfires, a lead editorial in the New England Journal of Medicine stated: “Climate change is already adversely affecting human health and health systems, and projected climate change is expected to alter the geographic range and burden of a variety of climate-sensitive health outcomes and to affect the functioning of public health and health care systems.”  

Large Gathering in Any Public Place – During a break in the interminable Boston TV coverage of the Patriots prior to Super Bowl LIII one channel showed a segment on the security planned for the Mercedes Benz Stadium in Atlanta. It was impressive; ten miles of fencing, prohibition of drones, helicopter fly-overs, fully-armed policemen, and more-fully-armed soldiers (always shown walking in pairs). Nothing new to us since September 11th. Just another reminder, but now at least we realize it is not actually foreign “terrorists” that have caused the most havoc in our country.

Enough about threats. Any good news?

Salt-free diet not necessary for heart failure patients- A review of 9 studies showed “a paucity of evidence supporting low-sodium diets for patients with heart failure”. The recommended first step is to “… retreat from an unbridled and potentially harmful insistence on rigorous sodium restriction” in these patients. (JAMA Internal Med 2018 Dec; 178)

Vitamin D supplements of no benefit to preventing cancer or cardiovascular disease –A study of 25,800 participants over 50 years old followed for 5 years showed that daily 2000 IU of Vitamin D “did not keep the doctor away” compared to placebo. This is good news for people spending money on vitamin D supplements for this purpose. (NEJM January 3, 2019:380;1)

Omega-3 Fatty Acids (“fish oil”) of no benefit in preventing cardiovascular disease – Ditto  (JAMA Cardiology March 2018; 3)

Stand-up desks at work reduces sitting times – See “Watching TV” above, but unfortunately there are no studies that standing does anything but improve psychological well being of the worker with some work-related benefits.  When arising from the sitting position, the authors recommended doing some physical activity. Standing alone is not any healthier. (BMJ 2018 Oct10:363)

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Vol. 112 October 15, 2014 MORE Medical Mixed Messages?

October 15, 2014

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Science and medicine over time often seem to be giving us mixed messages. That is actually a good thing. It shows that medicine is always seeking and responding to new information, new data, and revising “the truth”. In our modern world, egged on by rapid technology upgrades and our insatiable demand for “no-risk” living, these “truth revisions” can be difficult to keep up with. Here is a brief update on some recent evidence-based revisions of the truth.

TREATMENT OF THE FLU
The World Health Organization for several years and still currently puts Tamiflu on its list of “essential drugs” and recommends its use in clinical practice as an anti-influenza drug.

A new Cochrane Collaborative meta-analyses of 20 controlled studies which included thousands of pages of previously unavailable data from drug manufacturers concluded that Tamiflu provided minimal benefit for treatment of flu symptoms. Flu symptoms in adults treated with Tamiflu were reduced from 7 days to 6.3 days, about 17 hours. In children, flu symptoms were reduced for a whole day (29 hours). Use of Tamiflu did not reduce hospitalizations and did not decrease complications like otitis media, pneumonia, or sinusitis. There were no flu-related deaths in any of the studies, so effect on mortality could not be determined. (1)

A 10 day course of 75 mg. per day of Tamiflu costs anywhere from $70 to $340 on the internet. At CVS and Kmart it costs about $125, or $12.50 a pill. The Cochrane study did show that if Tamiflu was taken as a drug to prevent flu symptoms after one was exposed to someone with flu, it could reduce the incidence of symptomatic flu by 55%.

So, like so many things in medicine, “ya (or your insurer) payz yur money and takes yur choice”.

VITAMIN SUPPLEMENTS AGAINST HEART DISEASE AND CANCER
In 2003 The United States Preventative Services Task Force (USPSTF) studied vitamin supplements as a means to reduce the incidence of heart disease and cancer. They concluded that there was insufficient evidence to recommend Vitamins A, C, E, folic acid, beta-carotene, or anti-oxidant combination supplements as beneficial in reducing the incidence of heart disease or cancer.

This year the USPSTF studied all evidence published since 2003, and came up with the same conclusion and recommendations. It reemphasized that Vitamin E “more certainly” does NOT reduce the risk of heart disease and cancer, and repeated its warning that the use of beta-carotene (vitamin A) pills actually increased the risk for lung cancer in smokers. The 2014 USPSTF report also added Vitamin D, calcium, and selenium (may actually increase risk of prostate cancer) to its “insufficient evidence of benefit” list. (2) In a separate study, swallowing omega-3 pills (fish oil) did not significantly reduce the risk of stroke or heart attacks. (3)

But remember, these vitamin supplement studies, perhaps spurred by the $28 Billion-plus vitamin supplement industry, are prompted by evidence showing that diets (real food, not supplements) rich in these trace vitamins and minerals are associated with decreased incidence of heart disease and cancer.
If the diet does it, why don’t the pills?
“The biology is complicated,” says Stephen Fortmann, MD, Kaiser Permanente Center for Health Research.

WHAT ABOUT HERBAL SUPPLEMENTS?
“Supplements are regulated (by the FDA) more like foods, which is to say, they’re generally considered safe unless proved not to be”.

A FDA 2013 study using DNA analysis of 44 readily available herbal products revealed that fewer than 50% could be verified as containing the advertised ingredient. Since 2008 the FDA has issued warnings about 330 supplement products that turned out to be adulterated with active drugs not listed on the label. (3)

Three herbal supplements NEVER to take because of serious adverse side effects:
Kava to relieve stress and anxiety can cause liver failure
Yohimba to treat erectile dysfunction can cause volatile blood pressures and rapid heart rate.
Aconite to relieve joint pain can cause nausea and vomiting, low blood pressure, breathing paralysis, heart rate dysfunction, and even death.

GLUCOSAMINE FOR KNEE PAIN
Many patients take and some physicians recommend glucosamine for knee and hip pain due to osteoarthritis because a few small studies have suggested a benefit.

A study of 201 adults with knee pain who were given 1500 mg of glucosamine daily for six months showed no benefits. Compared to the placebo there was NO protection against progression of MRI changes, reduction of biochemical markers of cartilage degradation, or reduction of pain. (4)

References:
1. Journal Watch, General Medicine, May 15, 2014, vol. 34, no. 10
2. Journal Watch, General Medicine, June 1, 2014, vol. 34, no. 11 3.
3. Consumer Reports on Health, June 2014, pg.4
4. Arthritis Rheumatol 2014 Apr; 66:930


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