Treatment of Gastroesophageal Reflux with Magnet Device

Gastroesophageal reflux disease causes heartburn and regurgitation of food and digestive enzymes. Treatment includes weight loss, wearing loose clothing not binding at the waste, dietary restriction and medications. The main class of medications used have been the protein pump inhibitors (PPI’s) such as Nexium, Protonix, Aciphex and Pepcid. Most recently this class of medications has come under major criticism from researchers believing they may be responsible for increased risk of community acquired pneumonia, malabsorption of nutrients resulting in bone disease and even dementia and cognitive decline. Physicians have been trying to limit the use of these medications but recurrent and persistent symptoms have made that very difficult.

Last month at Digestive Disease Week, a meeting sponsored by the American Association for the Study of Liver Diseases, The American Gastroenterological Association, The American Society of Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract; a paper was presented demonstrating the success of a magnetic band placed with laparoscopic surgery around the lower esophageal sphincter (the juncture of the esophagus and stomach).

Reginald Bell, MD of the SurgOne Foregut Institute in Denver, Colorado along with MedPage reported that at six months post procedure, 92.6% of the patients with the magnetic device LINX, had relief of regurgitant symptoms compared with 8.6 % taking a double dose of PPI’s. Only one surgical complication had occurred and it was corrected. The research was done at 22 different locations enrolling 150 patients with moderate to severe regurgitation despite once-daily use of a PPI treatment.

The improvement numbers are dramatic and if this stands over time will change the way we treat this disease. The publication did not reveal the cost of LINX and we certainly want to observe these patients for more than six months before endorsing a new and promising treatment.

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International Panel Questions the Wisdom of Strict Sodium Guidelines

A technical paper published in the online version of the European Heart Journal suggested that individuals should strive to keep their sodium intake to less than 5 grams per day. This is in marked contrast to the recommendations of the American Heart Association of 1.5 grams per day and American College of Cardiology recommendations of 2.3 grams per day. The authors of the papers included some of the world’s experts on the topic of hypertension including Giuseppe Mancia, MD, Suzanne Oparil, MD and Paul Whelton, MD.  They agreed that consuming more than five grams per day was associated with an increased cardiovascular risk. They believe there is no firm evidence that lowering the sodium intake to below 2.3 or 1.5 grams per day reduces cardiovascular disease without putting you at risk of developing other health issues from having too little sodium.

The report triggered a firestorm of controversy in the hypertension and cardiovascular field with proponents on each side of the issue. Both sides agreed that we need more meticulous research to determine the best lower end of daily sodium intake because current information makes recommending one level or another a guess at best with little data to back you up. That leaves clinicians and patients scrambling for clarity and the media reporting this paper in a manner threatening to further erode the public’s confidence in the scientific method and physicians in general.

As a practicing physician I will continue to recommend a common sense approach to salt intake. Those patients who have a history of congestive heart failure or hypertension which is volume related will still be encouraged to read the sodium content of the foods they are purchasing and try to avoid cooking with or adding sodium chloride to their food at the table. This will be especially important for patients with cardiomyopathies and kidney disease who are following their daily weights closely. For the rest of my patient population I will ask them to use salt judiciously and in moderation only. I will suggest not adding salt at the table and if they do to please add it in moderation. I will allow more salt intake in those patients who work outside all day and are exposed to our high temperatures and humidity.

Like everyone else, I will wait for the meticulous research studies to be performed over time to determine how low and high our sodium chloride consumption should be without hurting ourselves.

For Arthritis of the Knee, Glucosamine and Chondroitin Sulfate is the Best Medicine to Control Long Term Symptoms of Joint Change

A paper presented at the recent American College of Rheumatology annual meeting reviewed all the research results on use of medications to control joint changes and pain in arthritic knees caused by osteoarthritis. Lucio C, Rovati, MD, of the Clinical Research Department of Rottpharm Biotech, Monza, Italy and the University of Milano Vicocca, Milano, Italy and colleagues presented the first systematic review and meta-analysis to investigate the effects of available medication used for at least a year to treat knee osteoarthritis. Their findings were published in the online journal MedPage Today. They reviewed 5992 articles discussing treatment with acetaminophen, calcitonin, celecoxib (Celebrex), chondroitin sulfate, hyaluronic acid, indomethacin, naproxen, vitamin D and zoledronic acid plus several others. The only medication that had a significant long term beneficial effect on pain and physical function was glucosamine and chondroitin sulfate. This does not mean that Tylenol, Aleve, Advil, Celebrex or other nonsteroidal anti-inflammatory drugs did not provide some immediate short term pain relief. It means that over a year they didn’t maintain the joint integrity and consistently maintain or improve function.

Light Pollution

Cities and towns are shifting their outdoor lighting to LED bulbs (Light Emitting Diodes) because they use less energy and fuel to burn and are more environmentally friendly.  They last longer and ultimately will be cheaper. The cities of New York and Seattle have replaced, or are in the process of replacing, all their street lights with white LED bulbs at a color temperature of 4000 – 5000k.  Why then did this environmentally friendly and economically sound decision result in the American Medical Association (AMA) issuing a statement condemning this practice?

It seems that the older less efficient street lamps or incandescent bulbs had a color temperature of 2400 K or less Candle light is actually a bit less than 1800 CT. At the higher color temperature the light contains more of the blue spectrum of light which has a shorter wavelength than the former incandescent bulbs which had more yellow and red. The result is that the new bulbs produce significant glare resulting in pupillary constriction and reduced vision. In addition, blue light scatters more on the retina and at sufficient levels can damage the retina in addition to making driving and night walking more difficult.

The American Medical Association believes the white LED light suppresses natural production of melatonin by the brain more than five times what the former bulbs were capable of. This has a major effect on human’s circadian rhythm and ability to fall asleep. For the animal kingdom it can adversely affect the migratory pattern of animals and can adversely affect aquatic animals such as turtles and their nesting and reproductive habits.

The AMA statement called for using the lowest level of blue wavelength light possible to reduce glare. They encourage the use of 3000k or less CT for outdoor lightings and roadway lighting to reduce glare and improve safety.  They additionally asked for dimming of these lights for off peak periods. They did not condemn or call for a ban on LED lights just for municipalities to be aware of the dangers of using the products with a high color temperature (CT) above 3000k and blue wave length predominant light.

CDC and ACP: Stop Prescribing Antibiotics for Common Respiratory Infections

The Affordable Health Care Act has created patient satisfaction surveys which can affect a physician’s reimbursement for services rendered plus their actual employment by large insurers and health care systems. This has created a fear of not giving patients something or something they want at visits for colds, sore throats and other viral illnesses. Aaron M Harris, MD, MPH, an internist and epidemiologist with the CDC noted that antibiotics are prescribed at 100 million ambulatory visits annually and 41% of these prescriptions are for respiratory conditions. The unnecessary use of antibiotics has resulted in an increasing number of bacteria developing resistance to common antibiotics and to a surge in Emergency Department visits for adverse effects of these medications plus the development of antibiotic related colitis. To address the issue of overuse of antibiotics, Dr Harris and associates conducted a literature review of evidence based data on the use of antibiotics and its effects and presented guidelines for antibiotic use endorsed by the American College of Physicians and the Center for Disease Control.

  1. Physicians should not prescribe antibiotics for patients with uncomplicated bronchitis unless they suspect pneumonia are present”. Acute bronchitis is among the e most common adult outpatient diagnoses, with about 100 million ambulatory care visits in the US per year, more than 70% of which result in a prescription for antibiotics.” The authors suggested using cough suppressants, expectorants, first generation antihistamines, and decongestants for symptom relief.
  2. Patients who have a sore throat (pharyngitis) should only receive an antibiotic if they have confirmed group A streptococcal pharyngitis. Harris group estimates that antibiotics for adult sore throats are needed less than 2% of the time but are prescribed at most outpatient visits for pharyngitis. Physicians say it is quicker and easier to write a prescription than it is to explain to the patient why they do not need an antibiotic.
  3. Sinusitis and the common cold result in overprescribing and unnecessary use of antibiotics often. Over four million adults are diagnosed with sinusitis annually and more than 80% of their ambulatory visits result in the prescribing of an antibiotic unnecessarily. “ Treatment with antibiotics should be reserved for patients with acute rhinosinusitis who have persistent symptoms for more than ten days, nasal discharge or facial pain that lasts more than 3 consecutive days and signs of high fever with onset of severe symptoms. They also suggest patients who had a simple sinusitis or cold that lasted five days and suddenly gets worse (double sickening) qualified for an antibiotic

Last year two patients in the practice who were treated with antibiotics prescribed elsewhere for situations outside the current guidelines developed severe antibiotic related colitis. They presented with fever, severe abdominal pain and persistent watery bloody diarrhea. Usual treatment with oral vancomycin and cholestyramine did not cure the illness. One patient lost thirty pounds, the other sixty pounds. Fecal transplants were required to quell the disease. At the same time community based urine infections now require a change in antibiotic selection because so many of the organisms are now resistant to the less toxic, less expensive , less complicated antibiotics that traditionally worked.

“My doctor always gives me an antibiotic and I know my body and what it needs,” can no longer be the criteria for antibiotic use.

American College of Physicians Rejects “Heart Screening in Adults at Low Risk”

Heart screeningI am often asked by potential new patients, “What do you consider a complete annual checkup?” When I tell them it is a detailed history session reviewing their personal medical history and family history followed by a comprehensive medical physical examination they inquire about testing. We generally perform a urinalysis and a blood panel measuring things such as the blood sugar, the cholesterol and lipid profile, kidney and liver function plus thyroid function. In addition to that we personalize the testing based on the information presented by the patient during the history session and exam. Despite having few risk factors for the development of heart disease, peripheral arterial vascular disease or cerebrovascular disease they ask how often they can have a nuclear stress test, an echocardiogram and imaging of their hearts and blood vessels. When I tell them they probably do not need such testing they tell me about their highly fit and athletic friend with no symptoms who just had a stress test and ended up with a three vessel coronary bypass procedure “saving“ their life.

An article in the Annals of Internal Medicine the American College of Physicians (ACP) supported that position saying that individuals with a Framingham cardiovascular risk assessment of <10% over the next 10 years should not be tested. “These recommendations are based on the lack of evidence showing that screening improves clinical outcomes.” They went on to say that screening has unclear effects on risk reclassification and the use of risk reducing therapies and noted that while abnormalities discovered via resting or exercise EKG were associated with an increased risk of subsequent cardiovascular events, they had no effect on clinical outcomes. According to the authors, “even if a cardiac abnormality is uncovered via screening, the most effective treatment may be adjustments in diet, exercise and other modifiable CHD risk factors that would be recommended regardless of screening results.”

I am frequently asked about the health conscious individual who had the testing and was found surprisingly to have critical disease requiring a lifesaving procedure. The ACP cited a thorough Coronary Artery Surgery Study in which cardiac catheterization on patients with “nonspecific“ or unclear chest pain revealed atherosclerosis in 40% of men and 24% of women, but only 3% of men and 0.6% of women had severe enough disease to benefit from a revascularization procedure.

The ACP paper cited the harm done by screening low risk individuals including excessive radiation exposure and the cost and morbidity of doing additional testing and or procedures to follow up false positive test results. The group stated that a nuclear stress test exposed an individual to an effective radiation dose that is twice the dose of an abdominal CT scan (15.6 mSV) which is the equivalent of ten years’ worth of chest x-ray irradiation. They also projected an increased risk of 2 -25 cancer cases per 10,000 nuclear medicine stress tests in people age 50 or older.

What is clear from the ACP recommendations is that the decision to perform cardiovascular screening should be based on the personal and individual patient history and physical exam findings which indicate a significant possibility of their being cardiac or vascular disease. If in fact the risk is low then testing for the sake of wanting to know causes more problems than solutions.

Irritable Bowel Syndrome Responds To Rifaximin

Abdomin v2In a study presented at annual meeting of The American College of Gastroenterology, Anthony Lembo, MD, of the Harvard Medical School and Beth Israel Deaconess Medical Center, presented data that showed that the non-absorbable antibiotic Rifaximin helps control cramping and diarrhea related Irritable Bowel Syndrome (IBS). Irritable bowel cripples individuals by causing abdominal cramping and multiple loose or watery stools per day. These patients have been screened by colonoscopy and imaging studies for more serious diseases such as Crohn’s Disease and ulcerative colitis with testing ruling these entities out. They are left with severe symptoms but no objective findings on available tests.

The study was comprised of 2,579 patients who received either Rifaximin or placebo three times per week. The decision to try an antibiotic was based on the theory that some IBS patients have excessive bacteria in the gut causing the problem. The treatment was successful in a significant number of participants compared to placebo based on a reduction of pain and frequency and number of stools. The patients were then observed for four weeks during which time some patients relapsed. If these patients were treated for another two weeks they showed significant improvement.

Irritable bowel incapacitates millions of individuals. While this data is extremely preliminary, it gives us hope of another treatment regimen, becoming available soon, that is effective and safe.