Should You Reduce Your Salt Intake?

SaltThere has been a resurgence of the controversy over the effect of sodium chloride or salt on blood pressure and disease. The theory is that by reducing salt intake you reduce blood pressure and ultimately reduce cardiovascular risk. That theory was questioned recently by a researcher who suggested that salt reduction had adverse effects on human hormones and lipids which offset the benefit of the blood pressure drop.

The Cochrane Library compiles and analyzes scientific and medical research and reports on what the data really shows. They reviewed 34 studies of salt reduction and its effect on blood pressure which included 3230 participants. They found that a modest reduction in salt intake for four or more weeks resulted in a significant drop in both systolic and diastolic blood pressure in both hypertensive and normotensive patients regardless of their sex or ethnicity. They examined the effects of the salt reduction on hormones and found that there was an increase in plasma rennin activity plus aldosterone and noradrenaline. There was no change in lipid levels. They felt that the drop in blood pressure associated with decreasing your salt intake was not offset by the change in any of these hormone levels.

The authors of the Cochrane Library study concluded that we need to decrease our salt intake. This will likely lower our BP and reduce our risk of heart attack and stroke.  Current recommendations call for us to reduce our salt intake to the 5-6 grams per day level. They suggest cutting it to 3 grams per day.  I will remove the salt shaker from my table and make sure that I advise my patients to do the same.

Does Marijuana Smoking Contribute to Stroke?

Marijuana LeafMedical marijuana and now recreational use of marijuana are becoming legalized around the United States. Is it safe and can it lead to serious health consequences?

At an International Stroke Conference in Hawaii, reported on in MedPage Today, researchers found relationship between smoking pot and having an ischemic stroke. P. Alan Barber, MD., PhD, professor of clinical neurology at the University of Auckland in New Zealand, told of seeing a 30 year old stroke patient who had none of the traditional risk factors for a stroke. The patient smoked cannabis or marijuana regularly. This led to the doctor reviewing the records of all his younger stroke patients. They found a high proportion of tests positive for marijuana use in younger stroke victims and decided to expand their study.

The current study looked at 160 stroke patients with an average age of 45.  Sixteen percent (16%) of the stroke patients tested positive for cannabis whereas only 8% of the control patients tested positive. When the researchers used detailed statistical analysis to review the data the only risk factor associated with ischemic stroke, or TIA, was marijuana use. “The study provides the strongest evidence to date of an association between cannabis and stroke.”

This was a preliminary study and it could not account for the tobacco use of the control subjects. Most of the marijuana users were tobacco smokers as well. The study did not delineate the extent of the pot smoker’s use of marijuana in terms of quantity and frequency of use. Barber went on to say that more detailed and extensive studies would be coming. He feels there is a definite link between pot smoking and stroke citing the fact that cannabis constricts brain vessels and can be associated with palpitations and atrial fibrillation which is a risk factor for stroke.

As the political pressure builds on states to legalize marijuana, tax it and use it as a revenue source; it would be nice to find out the consequences of its use and its effect on future illness and health care costs? Is it the marijuana? Is it the method of delivery by smoking it rather than pill form? These questions should be addressed in future studies.

Inflammation and Vascular Disease

Heart, stethescopeI was privileged to hear Bradley Bale, MD and Amy Doneen, MSN, ARNP talk about the development of coronary artery disease and cerebrovascular disease in patients with low or few cardiac risk factors.  They cited American Heart Association studies looking at groups of men and women between ages 45 and 65 who have their first heart attack or stroke despite being in compliance with suggested lipid and blood pressure guidelines. They pointed out that the first Myocardial Infarct or Stroke occurred in 88% of women who met lipid guidelines and 66 % of men.  These are people who do not smoke, do not have untreated or uncontrolled lipid levels, are not diabetics and who lead an active life style.  They asked “why”?

Dr. Bale and Ms. Doneen work with the well respected cardiovascular Center of Excellence at the Cleveland Clinic program in Ohio, and believe that inflammation is the root of the problem.  They believe that soft plaque composed of lipids and other cells lurks beneath the endothelial cells lining blood vessels. In the presence of inflammatory stimulants, this soft plaque ruptures suddenly through the endothelial level into the blood stream. When it comes in contact with the blood flowing through the vessels the body believes we are bleeding and cut and chemical mediators are released that initiate the formation of a clot. When this clot occurs in a small coronary artery we have a heart attack or myocardial infarction or precipitate a lethal irregular heartbeat. When this clot occurs in the blood vessels of the brain, we have an acute stroke or cerebrovascular accident.

The key to prevention in the so called low risk patient is to detect the inflammation in advance, and treat it. They are firm believers in performing B Mode Duplex ultrasounds of the carotid arteries in the neck to look for the presence of soft plaque beneath the endothelial cell lining. This soft plaque is distinctly different from the safe but calcified plaque we can see on CT scans used for cardiac scoring studies.  They couple this imaging study with a series of complex blood tests which identify inflammation. These include a myeloperoxidase level, the Lp-PLA2 level, the urine microalbumen to creatinine ratio, a F2-IsoPs level and the cardiac specific CRP level.

These tests and studies in combination with a traditional history and exam, sugar and lipid levels and EKG can help us identify those “low risk” patients who actually are high risk for a heart attack or stroke. The cause of the inflammation is often difficult to spot and may be in your mouth with dental or periodontal disease or in your joints with inflammatory arthritis.  Patients with excellent dental hygiene and normal appearing gums may harbor specific inflammatory bacteria that put them at risk. While this seems a bit forward thinking, remember we once questioned the research that showed that bacteria (H Pylori) caused gastric ulcers and intestinal bleeding.

I have begun instituting the inflammatory blood marker panels in my practice. Labs are sent to the Cleveland HeartLab for this purpose. I will be initiating periodic carotid ultrasound studies for the appropriate patients in the coming year.

It is often difficult for clinicians to distinguish snake oil sold for profit from cutting edge science. I have tried to spare my patients from worthless but profit driven products. I am convinced the Cleveland Clinic is just ahead of the rest of us in offering these services and I will make them available to the appropriate patients and will do it in a financially structured manner that does not add out of pocket cost to the patient. It’s not about adding another profitable income stream to the practice. It’s about identifying individuals who shouldn’t have a heart attack or stroke before they do.

Three More Strikes Against Smoking

There is no doubt that cigarette smoking is a practice that contributes to poor health and earlier death. Despite this, the practice is still popular among the young. Over the last three weeks several new research articles have been published that support the concept that smoking is severely detrimental to your health.

An Australian study published in Stroke: Journal of the American Stroke Association pointed out that individuals who had a stroke at the time they were active smokers had a far worse outcome and long term outcome than non- smokers. It additionally showed that smokers had the stroke at a younger age than nonsmokers. The group was followed for another 10 years and had a higher incidence of strokes, heart attacks and deaths than the nonsmoking group. The study emphasized the devastation and cost of “healthy years of life lost” as a consequence of continuing to smoke.

In an online publication in the Lancet, researchers working in the “Great Britain Million Women Study” noted that women who quit smoking lived longer than women who continued – irrespective of the age they decided to stop smoking. They additionally lowered their chances of dying from lung cancer.

A study out of the Mayo Clinic in Rochester, Minnesota looked at the effect of indoor smoking bans on heart attack rates in a community. This study looked at the effect of secondhand smoke on individuals. The Mayo Clinic has an exhaustive and large data base of individuals in the Midwest who have come to their clinic for health care for generations. They believe that in their study population, the number and extent of cardiovascular risk factors has remained fairly constant but, since the institution of strict bans on indoor smoking, the number of heart attacks has dropped dramatically.

How Will Doctors Handle the Flood of Newly Insured Patients?

Albert Fuchs, MD notes in the online journal Medpage that in 2014 thirty million new patients will have health care insurance and will be seeking a doctor.  This will result from the institution of the Affordable Care Act passed in March of 2010.  Dr. Fuchs observes that there is a dramatic shortage of physicians to care for this increased patient load especially in the areas of general internal medicine, family practice and pediatrics.   He cites a study by the medical malpractice insurance company, The Doctors Company, which polled 5,000 physicians about the influx of new patients under the new law.  Sixty percent of the respondents said the large influx would “hurt the level of care they provide.”  Forty-three percent said they will retire in the next five years.   Nine out of 10 respondents said they would not encourage anyone they knew to enter the field of medicine.

Medical Economics published an article in which it said patients should not expect to see a physician. They accurately stated that medical schools cannot possibly produce the number of additional physicians needed in the time allotted.  Nurse practitioners will be elevated in the national healthcare dialogue.   They cited the Massachusetts experience in which many primary care doctors have closed their practices to new patients. An opinion piece in the Wall Street Journal predicted the closing of practices to new patients as well.

It is clear that your next “doctor” may be a nurse.  I have advised my younger family members to find themselves a good primary care physician. I recommend someone who is board certified or eligible in the specialty they are practicing. I also recommend that the physician follows you into the hospital if you require inpatient care, as opposed to turning your care over to a hospital based physician.  If post-hospital care is required, it’s preferred that your doctor will go to your rehab facility to provide care and continuity.  You should also seek a physician who provides same day appointments, when you are ill, and someone who is available and returns phone calls and emails and text messages the same day.

The Wall Street Journal predicted the growth of concierge medicine where patients pay an annual membership fee in exchange for a doctor being accessible.  The cost is about the same as a cup of coffee per day, at most nationally recognized coffee chains, and in many instances is less than one’s monthly cable TV bill.

Let’s face it, your health, which has a direct impact on your quality of life, is a much wiser investment than a daily double chocolate chip frapuccino or 489 cable television channels.

How Long Do Prescription Drugs Last?

In a letter to the Archives of Internal Medicine, Lee Cantrell, PharmD of the California Poison Control System in San Diego, discussed his research that showed that many prescription medications and their main ingredients retain their effectiveness and potency 40 years after the expiration date. He and his group specifically looked at aspirin, butalbital, phenacetin, caffeine, phenobarbital, homatropine, chlorpheniramine and acetaminophen. Of the 14 compounds analyzed, 12 retained the generally recognized minimal acceptable potency of 90% of the labeled amount almost 40 years after they had reached the expiration date. Out of the 14 compounds, Aspirin and amphetamine were the only 2 that didn’t retain their effectiveness some 336 months beyond the expiration date.

The authors did not advocate relying on outdated and expired pharmaceuticals. They did see a cost savings in re-defining how long a product will last and remain effective when stored appropriately. This could save consumers thousands of dollars each year if they store their prescription drugs in the correct environment.

I will certainly not advise my patients to use significantly outdated and expired prescriptions. The study shows that, under emergency conditions, these specific outdated compounds still maintain their efficacy.

Their research did not answer questions about the multitude of newer drugs that have been developed over the last 40 years and how long they will last.  Nor did not address the question of whether over time any new chemicals developed within the 40 year old products that may be harmful. The research certainly did raise the question of why we need to look at the traditional expiration dates and reassess the length of time a product still is safe and of value to the consumer.

Spray on Skin Cells Heal Wounds Fast

Non healing ulcers and wounds in the elderly are a common and severe problem. These skin breakdowns are painful, often get infected and often require wound care teams to treat the problem.  Robert Kirsner, MD, PhD of the University of Miami Miller School of Medicine Division of Dermatology reported in the online edition of the prestigious Lancet magazine that he is using a spray bottle containing a mix of skin cells called keratinocytes and fibroblasts to enhance the rate of healing.

Dr. Kirsner is looking at healing venous stasis ulcers of the legs. It is common to find venous insufficiency of the legs in senior citizens (poor return of blood from the legs through the veins and back towards the heart).  Venous ulceration and skin breakdown occur in 1 – 2.5% of these adults 65 years and older.  Treatment routinely consists of clearing and controlling infection with antibiotics, primary dressings and compression bandages and stockings. This is successful in 30% – 75% of the situations.  The remaining cases require skin grafting and surgical procedures to heal.

To treat this common and persistent problem, Dr Kirsner and associates have been working with a product known as HP802-247 which is a cryopreserved sampling of fibroblasts and keratinocytes derived from neonatal foreskin tissue that is discarded after circumcision of newborn infants. Thawed cells are suspended in a spray for application to a wound.   The researchers created three strengths of the spray and tested all against standard treatment.  All patients in the study, whether receiving the experimental spray or a placebo, received standard and traditional wound care.  Kirsner’s results show that by using the lowest dose of the spray he was able to achieve complete healing in almost a third more patients as compared with the placebo group.  Differences in the healing rate became apparent within the first week of the treatment.

The product, HP802-247, has shown enough improvement in healing rate and total healing to warrant advancing it to Phase III studies which have begun in the United States and Europe.  While the initial studies have looked only at wounds caused by venous insufficiency, it will be interesting to see if similar studies are initiated on additional slow healing wounds common in seniors as well as in burn unit situations.

Hot Cocoa And Other Foods May Boost Brain Power

G. Desideri, PhD, of the University of L’Aquila in Italy performed a controlled double blind study that looked at the effects of cocoa flavonoids on cognitive function in seniors who were mildly cognitively impaired.  The data was presented in the online journal Hypertension and reviewed in the University Of Pennsylvania School Of Medicine online journal MedPage.  Existing “evidence” suggests eating flavonoids, polyphonic compounds from plant-based foods, may confer cardiovascular (heart and blood vessel) benefits.  Flavonols are a type of compound found in abundance in tea, grapes, red wine, apples and cocoa products including chocolate.

Desideri and associates looked at 90 seniors diagnosed with minimal cognitive impairment (MCI) who were randomly assigned to drink cocoa for eight weeks containing high, intermediate and low levels of flavanols per day.  They found improvement in the cognitive performance of those in the high and intermediate flavanol intake groups.   They additionally noted improvements in blood pressure and insulin resistance for these same groups. Systolic blood pressure decreased 10 mm in the high intake group and 8.2 mm in the intermediate group. A drop in diastolic blood pressure was noted as well.     There was no elevation of blood cholesterol or triglyceride levels in any of the groups and blood sugar actually decreased in the high and intermediate intake groups.

They concluded that “regular dietary inclusion of flavanols could be one element of a dietary approach to maintaining and improving not only cardiovascular health but also, specifically, brain health.”

Clearly more research is needed but initial studies like this certainly encourage clinicians to feel comfortable suggesting that a cup of hot cocoa, a glass of red wine (in moderation), red grapes and dark chocolate are healthy as well as pleasurable.

The Calcium – Vitamin D Supplementation Picture Gets More Confusing

As a geriatrician who believes strongly in prevention, my perspective is that the recent high volume of research on healthy aging, chronic disease and its association with Vitamin D and Calcium supplementation has done nothing but confuse the picture for us all. I have always been an advocate of healthy eating – a balanced diet that is prepared in a manner that retains and promotes the absorption of the foods nutrients. Also, I have supported the recommendations of blue ribbon panels to supplement the diets of women of child bearing age, peri-menopausal women and post menopausal women with 1200- 1500 mg of calcium per day in addition to dietary calcium to promote healthy bones.

I have read extensively about the lower measured values of Vitamin D in men and women who are ill and have many different types of acute and chronic diseases. I have not truly accepted the idea that raising their measured serum level of Vitamin D with pill supplements did anything to improve the disease state even if we did raise the measured serum Vitamin D level. I have been amazed by experts in Europe and Asia and in the World Health Organization setting a normal lower value of measured Vitamin D level at 20 while in the USA it is 28.  I am not convinced that healthy adults with healthy kidneys cannot get adequate Vitamin D levels by 10 minutes of sun exposure a few times per week in increments which will not dramatically increase the risk of lethal skin cancers.

This was made all the more confusing by the United States Preventive Services Task Force suggesting  that Vitamin D supplements reduce the risk for older people prone to falls and this month announcing that “there is no value for postmenopausal women using supplements up to 400 IU of Vitamin D and 1000 mg of calcium daily.”  This latest ruling was based on data which showed that at 400 IU of Vitamin D and 1000 mg of Calcium daily there was no effect on the incidence of osteoporotic fractures.

Much of the data used to reach this conclusion came from the Women’s Health Initiative Studies of more than 36,000 postmenopausal women.  The USPTF noted that at this dose of Vitamin D and Calcium there was a clear increase in kidney stones which they considered a harmful effect.  At the same time as this data was being discussed, the impartial Institute of Medicine (IOM) presented suggestions and data that Vitamin D at 600 IU daily plus 1200 mg of calcium per day prevented fractures in postmenopausal women.

For my postmenopausal patients I will continue to suggest they supplement their diets with 1200 mg of calcium per day as per the IOM suggestions unless they are prone to kidney stones. They will need to stay well hydrated while I ask them to take a daily 30 minute walk exposing their arms and legs to the sun for at least 10 minutes to allow their healthy kidneys to manufacture Vitamin D.

FDA Approves New Prostate Cancer Blood Test

The PSA blood test which has been used to screen for prostate cancer has come under a barrage of criticism in recent weeks. The PSA level increases in many non-cancer conditions and this has led to many biopsies and procedures that created more harm, and cost, than good. For this reason, the prestigious Institute of Medicine (IOM) and the U.S. Preventive Task Force have indicated that men should not be routinely screened for prostate cancer with the PSA blood test.

A new test may be on the horizon.  Beckman Coulter said its application for the Prostate Health Index test has been approved by the FDA. The test measures a PSA precursor protein known as [-2] pro-PSA in men with elevated PSA’s between the level of 4 and 10. This, coupled with the PSA and free PSA, helps create the Prostate Health Index.  The company’s data showed that by using the Prostate Health Index there were 31% fewer negative biopsies of the prostate.   The test will be commercially available by the fall of 2012.

We will make this test available when the commercial labs inform us that they are ready to perform it. It remains to be seen whether the health insurance companies will pay for it immediately.  We will need to monitor whether the promise and initial data are accurate when the test is introduced into the general public. We will also need guidelines on how often to follow this index.