All Posts tagged medical

Placebos may work – even when the patient knows

For most of us, the “placebo effect” is synonymous with the power of positive thinking; it works because you believe you're taking a real drug. But a new study rattles this assumption.Researchers at Harvard Medical School's Osher Research Center and Beth Israel Deaconess Medical Center (BIDMC) have found that placebos work even when administered without the seemingly requisite deception.

Placebos—or dummy pills—are typically used in clinical trials as controls for potential new medications. Even though they contain no active ingredients, patients often respond to them. In fact, data on placebos is so compelling that many American physicians (one study estimates 50 percent) secretly give placebos to unsuspecting patients. Because such “deception” is ethically questionable, HMS associate professor of medicine Ted Kaptchuk teamed up with colleagues at BIDMC to explore whether or not the power of placebos can be harnessed honestly and respectfully.

To do this, 80 patients suffering from irritable bowel syndrome (IBS) were divided into two groups: one group, the controls, received no treatment, while the other group received a regimen of placebos—honestly described as “like sugar pills”—which they were instructed to take twice daily. “Not only did we make it absolutely clear that these pills had no active ingredient and were made from inert substances, but we actually had 'placebo' printed on the bottle,” says Kaptchuk. “We told the patients that they didn't have to even believe in the placebo effect. Just take the pills.”

For a three-week period, the patients were monitored. By the end of the trial, nearly twice as many patients treated with the placebo reported adequate symptom relief as compared to the control group (59 percent vs. 35 percent). Also, on other outcome measures, patients taking the placebo doubled their rates of improvement to a degree roughly equivalent to the effects of the most powerful IBS medications. “I didn't think it would work,” says senior author Anthony Lembo, HMS associate professor of medicine at BIDMC and an expert on IBS. “I felt awkward asking patients to literally take a placebo. But to my surprise, it seemed to work for many of them.”

The authors caution that this study is small and limited in scope and simply opens the door to the notion that placebos are effective even for the fully informed patient—a hypothesis that will need to be confirmed in larger trials. “Nevertheless,” says Kaptchuk, “these findings suggest that rather than mere positive thinking, there may be significant benefit to the very performance of medical ritual. I'm excited about studying this further. Placebo may work even if patients knows it is a placebo.”

This study was funded by the National Center for Complementary and Alternative Medicine and Osher Research Center, Harvard Medical School.

More

Stroke deaths higher where fried fish aplenty

The steep rate of death from stroke in a swath of Southern states often referred to as America's “stroke belt” may be linked to a higher consumption of fried fish in that region, new research suggests. A study published in the journal Neurology shows people living in the stroke belt — which comprises North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas and Louisiana — eat more fried fish and less non-fried fish than people living in the rest of the country, and African-Americans eat more fried fish than Caucasians. “Differences in dietary fish consumption, specifically in cooking methods, may be contributing to higher rates of stroke in the stroke belt and also among African Americans,” says study author Fadi Nahab, medical director for the Stroke Program at Emory University Hospital in Atlanta.

The research, part of a large government-funded study, Reasons for Geographic and Racial Differences in Stroke (REGARDS), involved 21,675 participants from across the country; the average age was 65. Of the participants, 21% were from the “stroke buckle,” the coastal plain region of North Carolina, South Carolina and Georgia where stroke mortality rates are even higher than they are in the rest of the stroke belt. Another 34% were from the rest of the stroke belt and 44% were from the other states.

Participants were interviewed by phone and then given an in-home physical exam. The questionnaire asked how often they ate oysters, shellfish, tuna, fried fish and non-fried fish. The American Heart Association recommends people eat fish high in omega-3 fatty acids—essential fatty acids humans get through their diet—at least twice a week, baked or grilled but not fried. Fewer than one in four overall ate two or more servings of non-fried fish a week. Stroke belt residents were 32% more likely to eat two or more servings of fried fish each week than those in the rest of the country.

African-Americans were more than 3.5 times more likely to eat two or more servings of fried fish each week than Caucasians, with an overall average of about one serving per week of fried fish compared with about half a serving for Caucasians. When it came to eating non-fried fish meals, stroke belt residents ate an average of 1.45 servings per week, compared with 1.63 servings eaten by people elsewhere.

“This is good stuff. It's a well-done study, but I think one thing to bear in mind is that it's not specifically a study of stroke risk. You're looking at a community and seeing how it's behaving on the whole,” says Daniel Labovitz, a stroke neurologist at Montefiore Medical Center in the Bronx. “This study can't tell you causation. It can't tell you there's a direct link between one thing and another, it just tells you they're associated,” says stroke neurologist Victor Urrutia, an assistant professor at Johns Hopkins University School of Medicine.

How might eating fried fish impact stroke?

It could be that frying the fish leaches out the omega-3s, says Jeremy Lanford, stroke director at Scott & White Healthcare in Roundrock, Texas. Or the increased fat calorie content from the frying oil may contribute to stroke, says author Nahab. He also notes that fish used for frying, such as cod and haddock, tend to be the types lower in healthy fats. More research is needed to tease out whether cooking methods affect stroke risk, Labovitz says. “In other words, is fried fish a problem, or is it another red herring?” he says.

The study was supported by the National Institute of Neurological Disorders and Stroke, the National Institutes of Health, and the Department of Health and Human Services. Funding was provided by General Mills for coding of the food frequency questionnaire.

More

Premenopausal Visceral Fat a Risk Factor for Osteoporosis

Young premenopausal women with excessive amounts of visceral fat are at increased risk for osteoporosis, according to new research presented at the Radiological Society of North America 96th Scientific Assembly and Annual Meeting. For years, it was believed that obese women had a lower risk of developing osteoporosis and that the mechanical loading from excess weight was good for their bones. It now appears that having too much fat, particularly deep abdominal fat, might be damaging to bone health, Miriam A. Bredella, MD, from Massachusetts General Hospital and Harvard Medical School, Boston, told meeting attendees. “With this ongoing obesity epidemic, we were actually seeing more and more young women breaking their forearms or their wrists, and the single biggest risk factor in this group was actually increased body weight,” she told Medscape Medical News. “We thought we should look take a closer look at whether obesity really did protect against osteoporosis.”

Dr. Bredella and her team studied 50 premenopausal women whose mean body mass index was 30 kg/m2 (range, 19 to 46). The women underwent assessment of L4 bone marrow fat with magnetic resonance (MR) spectroscopy as a measurement of lumbar bone density. In addition, abdominal subcutaneous, visceral, and total fat depots and trabecular bone mineral density of L4 were assessed using quantitative computed tomography. “Using MR spectroscopy was a new thing that we did in this study. MR spectroscopy is a technique that is more sophisticated than the regular bone density test. It does not involve radiation,” Dr. Bredella explained. “With this test, we could actually look inside the bones and see how much fat was in the bones.”

These examinations revealed an inverse association between visceral fat and bone mineral density (r = –0.31; P = .03) and between vertebral bone marrow fat and bone mineral density (r = –0.45; P = .001). The researchers also found that there was a positive correlation between bone marrow fat and visceral fat (r =.28; P = .04) that was independent of bone mineral density.

However, there was no significant correlation between either subcutaneous fat or total fat and bone marrow fat or bone mineral density. “The more deep belly fat you have, the more fat you have in your bones, and the more fat you have in the bones, the weaker they will be,” Dr. Bredella said. “All things being equal, if you have 2 obese women and one has a lot of deep belly fat and the other one has exactly the same weight but her fat is distributed more superficially around the hips and thighs, then the woman with the deep belly fat will have weaker bones.”

She suggested that belly fat weakens bones because this type of fat secretes adipokines, which weaken bones. “It is important for people to be aware that obesity is a risk factor for more than diabetes and cardiovascular disease,” she said. “Now they need to know that excess belly fat is a risk factor for bone loss.”

Radiological Society of North America (RSNA) 96th Scientific Assembly and Annual Meeting: Abstract SSJ17-05. Presented November 30, 2010.

More

Low Vitamin D levels common in breast cancer

More than half of women with breast cancer have low vitamin D levels, British researchers report.”Women with breast cancer should be tested for vitamin D levels and offered supplements, if necessary,” says researcher Sonia Li, MD, of the Mount Vernon Cancer Centre in Middlesex, England. The findings were presented at the San Antonio Breast Cancer Symposium.

Some studies have suggested a link between low vitamin levels and breast cancer risk and progression, but others have not, she says. No studies have proven cause and effect. Previous research suggests a biologic rationale for vitamin D putting the brakes on breast cancer development and spread, Li says. Breast cancer cells have vitamin D receptors, and when these receptors are activated by vitamin D, it triggers a series of molecular changes that can slow cell growth and cause cells to die, she says. Even if it does not have a direct effect on the tumor, vitamin D is needed to maintain the bone health of women with breast cancer, Li says. That's especially important given the increasing use of aromatase inhibitors, which carry an increased risk of bone fractures, she says.

Vitamin D is found in some foods, especially milk and fortified cereals, and is made by the body after exposure to sunlight. It is necessary for bone health.

For the study, Li and colleagues collected blood samples from 166 women with breast cancer and measured their levels of vitamin D. Of the total, 46% had vitamin D insufficiency, defined as levels between 12.5 and 50 nanomoles per liter (nmol/L) of blood. Another 6% had vitamin D deficiency, with levels lower than 12.5 nmol/L. When ethnicity was considered, vitamin D levels were lower in Asian women than in white or other women: an average of about 36 nmol/L vs. 61 nmol/L and 39 nmol/L, respectively.

The researchers theorized that vitamin D levels would be higher in the summer, when there are more daylight hours, but the study showed no association between vitamin D levels and seasons. Last month, the U.S. Institute of Medicine issued updated guidelines stating that a blood level of 50 nmol/L (or 20 nanograms/milliliter) is sufficient for 97% of people.

This study was presented at a medical conference. The findings should be considered preliminary as they have not yet undergone the “peer review” process, in which outside experts scrutinize the data prior to publication in a medical journal.

More

Diet Advice can help control diabetes

Individuals with either type 1 or type 2 diabetes know that maintaining a nutritious diet is one of the most important things they can do to control their disease. The findings of a new study suggest that the services of a registered dietitian may help individuals accomplish this goal.

A team of investigators from the American Dietetic Association reviewed evidence from previous research and summarized their findings in a report published in the Journal of the American Dietetic Association.

In their write-up, researchers laid out a set of exhaustive dietary guidelines for individuals affected by diabetes. Researchers said that the services of registered dietitians may be key in helping individuals follow the guidelines, which could help them significantly improve their condition.

“The evidence is strong that medical nutrition therapy provided by registered dietitians is an effective and essential therapy in the management of diabetes. Registered Dietitians are uniquely skilled in this process,” said Marion Franz, who led the investigation.

The guidelines developed by the research team lay out 29 nutritional points that can help diabetics improve their blood sugar control.

More

Red meat raises heart attack risk

Eating red meat and processed meats like bacon sharply increased heart disease risk in women, U.S. researchers say.Researchers at Harvard School of Public Health in Boston suggest eating healthier protein-rich foods — such as fish, poultry, low-fat dairy and nuts — instead of red and processed meats, may reduce heart disease risk.

“There are good protein-rich sources that do not involve red meat,” first author Dr. Adam Bernstein says in a statement. “You don't need to have hot dogs, hamburgers, bologna or pastrami, which are all fresh or processed meats.”

The study, published in the journal Circulation: Journal of the American Heart Association, finds women having two servings per day of red meat had a 30 percent higher risk of developing coronary heart disease than those who had half a serving per day.

The risk of heart disease was lowered 30 percent when a daily serving of red meat was replaced by nuts. Another red-meat replacement — fish — lowered cardiac risk 24 percent and poultry reduced heart risk by 19 percent.

Bernstein and colleagues examined medical history and lifestyle — including diet — for 84,136 women, ages 30-55, enrolled the Nurses' Health Study from 1980 to 2006. During the 26-year period, the researchers documented 2,210 non-fatal heart attacks and 952 deaths from coronary heart disease.

More

Dementia Can Be Avoided By Reading, Eating Well And Keeping Spirits High

According to the study published today in the British Medical Journal, the combined effects of reading, eating well and keeping spirits high would far outstrip the theoretical possibility of eliminating a gene known to increase the risk of dementia.

Dr. Karen Ritchie, a neuro-psychologist at the French National Institute of Medical Research leading her team of researchers assessed the change in the cognitive ability of 1,433 pensioners in Montpellier, over a period of seven years.

The participants in the study were asked series of questions regarding their lifestyle, medical history and educational background, including carrying out reading tests.

According to their findings, the amount of intellectual exercise a person indulges in greatly influences their likelihood of developing dementia.

Those with lower reading scores were 18% more likely to develop mild cognitive impairment or dementia, the former the forerunner of the latter.

Those suffering from depression were 10% more likely to develop it; while eating fruit and vegetables less than twice a day meant a 6.5% chance of developing dementia. Having diabetes was also a significant factor, leading to a 5% higher risk than those without.

In comparison, possessing a gene associated with dementia increased the risk by 7%.

These findings indicate intellectual activity to be the most important factor, which means the public health message should be to encourage literacy at all ages irrespective of innate ability.

Similarly, while the study found depression to be strongly linked to the development of dementia, treating it did not necessarily offer protection, nor was it easy getting people to eat more fruit and vegetables.

In conclusion, due to these problems, the most practical short-term solution was tackling diabetes, previous studies have also confirmed to be a causal factor. Obesity, high blood pressure and high cholesterol are other risk factors associated with the disease.

More

Iranian scholars share Avicenna’s mediaeval medical wisdom

For pulmonary ailments, certain mediaeval physicians had a useful medical textbook on hand offering detailed information remarkably similar to those a modern doctor might use today. One of the fathers of medicine, the great Persian scholar Avicenna left a wealth of information in his many works. Iranian academics dust off one of these in an article published today in the SAGE journal Therapeutic Advances in Respiratory Disease, sharing in English details of Avicenna's work that still fascinate both physicians and historians of medicine alike.

Seyyed Mehdi Hashemi and Mohsen Raza dug deep into Avicenna's original ancient text, housed in the Central Library of the Tehran University of Medical Sciences in Iran, where they both work. In particular, they aimed to highlight Avicenna's work on respiratory diseases, which may be informative or interesting to physicians and pulmonologists today.

Avicenna discusses respiratory diseases in volume three of the Canon of Medicine, covering the functional anatomy and physiopathology of the pulmonary diseases that were known in his time in detail. His descriptions of the signs and symptoms of various respiratory diseases and conditions are remarkably similar to those found in modern pulmonary medicine. The topic is covered under five chapters: breathing, voice, cough and haemoptysis, internal wounds and inflammations and principles of treatments.

The authors also highlight both herbal and non-herbal treatments Avicenna recommends for respiratory diseases, and their signs and symptoms from the second volume of the Canon of Medicine. Avicenna suggested 21 herbs to treat respiratory disorders, and today we know that several of these herbs contain bioactive compounds with analgesic, antispasmodic, bronchodilatory or antimicrobial activities. For instance, Avicenna would have prescribed opium at that time for cough and haemoptysis, a practice which today has an established therapeutic basis.

“In the time of Avicenna, the presentation of respiratory diseases, their treatment and their prognosis was much different than in modern times,” says Hashemi. Mediaeval physicians had a greater reliance on history, physical examination (which was mostly based on visual observation), individual variation, environmental factors, diet, and so on, for diagnosis and treatment.

Even so, several of Avicenna's observations related to signs and symptoms, aggravating and relieving factors and the treatment of pulmonary disorders are still valid and can be explained by modern science. For example, one of the important symptoms in the diagnosis of asthma that Avicenna discusses is dyspnea during sleep that leads to awakening. Avicenna also observed plaster-like material in tuberculosis patients' sputum, which is now known as lithoptysis (stone spitting), where a patient coughs up calcified material due to perforated bronchial lymph node.

Despite many limitations and the lack of modern instruments in his day, Avicenna adopted a scientific approach to the diagnosis and treatment, not only of respiratory disorders, but also more generally to illnesses he treated and mentioned throughout the Canon of Medicine.

More

Bran Tied To Longer Life

Grains consist of three layers: the fiber- and nutrient-containing bran and germ layers and the starchy kernel layer. Refined grains, like white flour, are largely stripped of the bran and germ; whole grains — such as oatmeal, brown rice, barley and breads made from whole wheat — retain more of those components.

Studies suggest that the fiber, antioxidants and other nutrients in whole grains may help lower cholesterol, blood sugar and insulin levels, as well as improve blood vessel functioning and reduce inflammation in the circulatory system.

In the new study, Qi and his colleagues at Harvard Medical School in Boston found that among 7,800 U.S. women followed for 26 years, those with the highest bran intake were 28 percent less likely to die during the study period than those who consumed the least bran.

Similarly, they were 35 percent less likely to die of cardiovascular disease (heart disease or stroke) specifically.

The findings, published in the journal Circulation, do not prove that bran-heavy diets were the reason for the lower risks.

However, the connection was not explained by generally healthier lifestyles among the bran lovers. When the researchers accounted for other diet habits — like fat intake and total calories — as well as the women's weight, exercise levels, smoking history and drinking habits, the link between higher bran intake and lower death rates remained.

This suggests that bran intake itself may help lower diabetics' risk of premature death, according to Qi.

He suggested that women and men with diabetes try to replace refined grains in their diets with bran-rich whole grains.

That said, the researcher pointed out that the risk reductions in this study were seen across a large population — with bran lovers showing a relatively lower risk of death than those who ate little bran. That does not mean that for any one person with diabetes, boosting bran intake would have a substantial effect on longevity.

The findings are based on 7,822 women with type 2 diabetes who were part of the Nurses' Health Study, a long-term study of U.S. female nurses begun in 1976. Every two years, the women answered the questions about their lifestyle, medical history and any disease diagnoses.

Over 26 years of follow-up, 852 study participants died, including 295 women who died of heart disease or stroke.

Overall, Qi's team found, women in the top 20 percent for bran intake had a 28 percent lower risk of dying from any cause during the study period, compared with women in the lowest 20 percent. Their risk of death from cardiovascular disease was 35 percent lower.

The group with the highest bran intake typically consumed 9 grams of bran per day — about 10 times more than the lowest-intake group. In general, experts recommend that adults get at least 3 to 4 “ounce equivalents” of whole grains each day; a slice of whole-grain bread or a cup of whole-grain cereal are examples of one ounce equivalent.

SOURCE: http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONA HA.109.907360v1 Circulation, online May 10, 2010.

More

When and how to make a referral

A referral to Nastaran Habibi should be made when your patient needs more intensive dietary, nutritional and lifestyle behavior education than you can provide in your office environment. Nastaran can help particularly when the patient is in the preparation, action or relapse stages of change.

A consultation generally includes a diet and lifestyle assessment, and nutrition education and counselling. Nastaran will review your patient’s medical and social status, including biochemistry and othe relevant test results, dietary and family history and home environment. In addition she will take anthropometric measurements and collect information on the patient’s individual food preferences and cultural, socio-economic and lifestyle needs. Taking into account the patient’s own goals, knowledge, skills and access to resources, Nastaran will custom design a program for your patient based on the principles of Medical Nutrition Therapy. She integrates self-management training regarding information on nutrient content, food choices, and meal preparation based on each patient’s particular and unique circumstances. Initial appointments are more than 1 hour.

What happens next:

  • You will receive a formal report assessing your patient’s nutritional, physical activity and lifestyle status including Nastaran’s recommendations for improvement, possible barriers to success and guidelines for evaluating progress.
  • During the 45-90 minute follow-up visits, Nastaran will review your patient’s progress, provide further education, encourage continued adherence to the plan and identify any obstacles to success.

In order for your patient to qualify for a Medicare rebate, referral must be through an Enhanced Care Plan. Referrals outside Medicare will still qualify for a Health Fund rebate.

More