Monthly Archives: August 2017

Drugs don’t cure everything – doctors can be helped to prescribe other options

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Drugs don’t cure everything – doctors can be helped to prescribe other options

February 10, 2017 6.13am AEDT

What if I told you half of all middle-ear effusions (persistent fluid), known as glue ear, could be fixed by the child blowing up a balloon with his or her nose? Would you be more likely to get your child to try it than have them undergo surgery? It may sound quirky, but the technique, called autoinflation, has a solid evidence base.

There is evidence many conditions can be treated without drugs or surgery. Dangerous snoring (sleep apnea), for instance, can be relieved by a simple jaw splint. Non-drug interventions can in some cases be more effective than pharmaceutical or surgical ones. And of course, they come with few to no side effects or complications.

Doctors should be provided with the necessary instructions on how best to prescribe such treatments for patients so they can have more confidence to do so. And patients should be better informed about the options available for their health care.

Non-drug interventions

Since the 1940s, drug treatments have been tested in clinical trials that prove they work for their intended purpose and are safe to take. Strong evidence for the effectiveness of non drug treatments has been slower to develop but is now available.

The research for drug treatments has been distilled and summarised for doctors in ready-reference publications such as the Australian Medicines Handbook, which supports doctors in their clinical decision-making. In some cases though, the most appropriate treatment is not a drug. It could be a recommendation for a dietary change, a specific exercise or even a phone app.

The Handbook of Non-Drug Interventions (HANDI), outlines treatments that don’t require medications or surgery. Its 54 treatments, which have been evaluated and reported to work after being tested in the same type of clinical trials as drugs, range from splints for hand pain in osteoarthritis to internet-delivered cognitive behavioural therapy for depression and anxiety.

Fluid in the ear

One treatment is for children with glue ear – persistent fluid in the middle ear resulting from infections. This can dull hearing, a particular problem for young children who are just learning to talk.

The conventional treatment for glue ear has been a surgical operation to insert ventilation tubes (grommets) through the ear drum. But HANDI references research showing the simple trick of the child blowing up a balloon with their nose fixes glue ear in 50% of cases within three months.

There is a special balloon marketed for the purpose that comes with a nose-shaped nozzle, which can be used by children over the age of three. It’s a safe and attractive option for parents that may well fix the problem in their child’s hearing while on the waiting list to see an ear, nose and throat specialist.

Peanut allergy

Other non-drug interventions can prevent conditions from occurring. For instance, over the years there has been conflicting advice on when to introduce a range of foods to infants, but there is now strong evidence that early introduction of peanut protein reduces the risk of peanut allergy.

Infants whose parents have allergies are more likely to develop peanut allergy, but this risk is reduced by 70% if babies are given peanut butter (24 grams per week in at least three meals) from the age of four months.

Foot pain

Another treatment is for a type of foot pain called plantar fasciitis. People with this experience pain in the soles of the feet, especially first thing in the morning.

Plantar fasciitis is usually worse first thing in the morning. from shutterstock.com

There are several treatments available, but the simplest and safest is a stretching routine done three times a day, with the first set of ten stretches done before standing up in the morning.

Doctors may lack confidence to recommend this treatment to a patient asking for a cortisone injection into their foot. But if they have a ready reference guide with outlined evidence and guidance, they are more likely to encourage the patient to try stretching before resorting to medication.

Why don’t doctors recommend such interventions more often?

When reading research about a medication, doctors often assume that if they give the same drug in the same dose, they can expect more-or-less the same effect each time. But for non-drug treatments, the precise operational description of the intervention used in those trials becomes of paramount importance.

For instance, physical exercise to improve circulation – also known as aerobic training – has been shown to be beneficial for heart failure. It helps improve symptoms and decrease the number of heart-related hospitalisations. But how much is needed?

Before doctors can use this with their patients they will need to know how often and how intense the training should be. They will also need to know if there are patients at particular risk who should not do the training.

Recent research into publications in six leading medical journals that tested the effectiveness of non-drug interventions, found only 39% were adequately described so a reader – doctor or patient – could replicate the treatment.

Inadequate description makes it difficult to implement the treatments, which means the research findings are unusable and effectively wasted. For instance, there is a complicated exercise a doctor can do with a patient that helps resolve the most common cause of dizziness (“benign positional vertigo”), called the Epley manoeuver, after its inventor.

Epley Maneuver.

Unless the doctor does this often, they will not be confident in the procedure. Guidelines like HANDI appear to have filled a useful niche in the ecology of medical information as the website is getting 6000 visits per month from all over the world.

Creepy, crawly maggots are actually a medical powerhouse

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Creepy, crawly maggots are actually a medical powerhouse

January 10, 2017 6.42pm SAST

Maggots have one goal in life: to feed. They gorge ravenously in order to grow as quickly as possible. Speed is of the essence as they leave behind their vulnerable bodies, and transform from a fat, juicy maggot into a hairy adult, capable of escaping predators.

And their passion for the consumption of dead flesh makes maggots of certain fly species uniquely beneficial to human health. Man is subject to countless ailments, among the most disconcerting and painful of which are open sores and wounds.

Chronic wounds often develop in patients with underlying conditions such as diabetes or vascular disease. These wounds tend to be full of dead and infected tissue, and often become long-standing, non-healing ulcers – desperately unpleasant for patients that suffer with them. In many cases, these wounds can worsen, and sadly necessitate amputation of parts of, or even whole, limbs.

However, the application of clinical grade maggots can turn this around. Used often when all other treatments have failed, newly hatched larvae can turn a stagnant ulcer into a clean and healthy healing wound within a matter of days.

Maggot therapy

Nonetheless, our immediate response to a mass of wriggling maggots is most likely disgust. The thought of willingly inviting them to crawl and feed on our wounded bodies is, for many, profoundly disturbing. In the main, maggots are despised creatures, inviting a plethora of negative emotional responses ranging from squeamishness, disgust and disdain to absolute fear.

Many patients are afraid that the maggots themselves are dirty, and may cause further infection. But maggots are reared under special strict and sterile conditions in specialised laboratories, and in the UK, they are available on prescription, either to be applied freely onto a wound or in sealed net bags.

Maggots are sealed in a bag before being applied to wounds. Yamni Nigam, Author provided

The positive benefits of applying maggots to festering wounds have been known for centuries, dating back to biblical times, and traversing numerous ancient tribes and cultures. Remarkable, you say, but these are modern times and surely we have modern treatments which work just as well? Well, sadly not. There are no wound management treatments which can compete with the multi-actions of living maggots in a wound.

So exactly how marvellous are these tiny wrigglers? Scientists worldwide are still figuring out exactly how maggots do what they do, but what we have found out so far is simply amazing.

Maggots do not have teeth – instead they secrete enzymes which coat and break down dead tissue. Then, by moving their small hooked mouth parts over their meal, they are able to suck up the digested material. So efficient are they at eating, a young maggot can clean up a wound within just two to three days.

Maggots do more than just eat away dead flesh. We have found that collections of maggot secretions (their “spit and sweat”), can kill several species of bacteria. Moreover, we have discovered a very small antibacterial molecule – Seraticin – is released in these secretions.

Seraticin is incredibly effective against numerous pathogens and free-living bacteria, including antibiotic-resistant strains. Indeed, we have found that even small quantities of secretion containing this antibacterial factor can destroy several clinical strains of the highly resistant MRSA bacteria. We are currently trying to purify this maggot antibacterial factor, with the hope that it may one day help in the fight against resistant microbes.

In addition, maggots also secrete effective molecules which can destroy bacterial biofilm – a wall built by bacteria which helps shield them from attack, for example, by our immune systems, or antibiotics. Maggot secretions not only destroy formed biofilm, but can also prevent its formation in the first place.

Such is the ability of the maggot antimicrobial armoury, that several other antibacterial molecules have recently been discovered, further suggesting that maggots mount a powerful disinfecting action to help rid wounds of problem bacterial infections.

It’s not all about bacteria-bashing: maggots also produce a potent and effective antifungal agent. Given that maggots have been sharing their decaying corpse feasts with fungal decomposers for millions of years this is hardly surprising. It stands to reason that the tiny maggot has evolved antifungal molecules for its own defence.

Healing maggots

As well as fighting infection, astonishingly, doctors have also reported that wounds they have treated with maggots appear to heal and close up faster than those treated by other non-maggot means (although this aspect of maggot therapy has yet to be thoroughly assessed and clinically proven in trials).

We have investigated this observation, to see if we could glean any evidence at the cellular level which suggests maggots are able to accelerate wound healing. Sure enough, we (and other researchers) found that maggot secretions contain specific components and molecules which can, among other things, promote good healing cells to multiply and migrate onto the wound bed – including blood vessel cells and other cells which are vital for supporting the growth of new tissue needed as the wound heals.

Maggots work and they work well. As they join the list of wound treatments at the disposal of the wound clinician, maybe it’s finally time for these humble creatures to stop lurking on the periphery of civilisation, dangling somewhere between fear and absolute disgust. Maggots are miniature medical devices, amazing and incredible creatures with the power to help cure and rid many of us from the painful and crippling burden of infected and debilitating wounds

A case-control study on hormone therapy as a risk factor for breast cancer in Finland: Intrauterine system carries a risk as well

Further proof that what you take and how you take your hormones determines risk of breast cancer. Note the increased risk of breast cancer from the use of Livial (Tibilone). The LNG-IUS mentioned in this study refers to Mirena – Note that it increases the risk of developing breast cancer.

A case-control study on hormone therapy as a risk factor for breast cancer in Finland: Intrauterine system carries a risk as well. – PubMed – NCBI

Int J Cancer. 2010 Jan 15;126(2):483-9. doi: 10.1002/ijc.24738.

A case-control study on hormone therapy as a risk factor for breast cancer in Finland: Intrauterine system carries a risk as well.

Author information

  • 1Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, HUS, Finland.

Abstract

The purpose of this study was to evaluate the association between postmenopausal hormone therapy (HT) and the risk for breast cancer in recently postmenopausal Finnish women. All Finnish women with first invasive breast cancer diagnosed between the ages of 50 and 62 years during 1995-2007 (n = 9,956) were identified from the Finnish Cancer Registry. For each case, 3 controls of the same age were retrieved from the Finnish Population Register. The cases and controls were linked to the national medical reimbursement register to assess the use of HT. The odds ratios (ORs) and 95% confidence intervals (CIs) for breast cancer were calculated with conditional logistic regression analysis, adjusting for parity, age at the first birth and health care district. Estradiol-only therapy (991 users with breast cancer, n) or oral progestagen (n = 138) was not accompanied by an increased risk. Estradiol-progestagen therapy (EPT) (n = 1,731) was associated with an elevated risk in the whole series (OR 1.36; 95% CI 1.27-1.46). The risk became detectable in less than 3 years of use. Continuous EPT use tended to be associated with a higher risk for breast cancer than the sequential EPT use. The use of tibolone(Livial) (n = 80) (1.36; 1.15-1.96), a levonorgestrel-releasing intrauterine system (LNG-IUS) alone (n = 154) (1.45; 1.97-1.77) or as a complement to estradiol (n = 137) (2.15; 1.72-2.68) was also associated with an increased risk. The association between HT use and the risk for breast cancer shows a large variation between various forms of HT, and also the use of LNG-IUS may carry a risk.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy.

Stopping HRT suddenly may increase a woman’s risk of  heart disease. I do not advocate a yearly break from HRT as I do not see any reason for it.
J Clin Endocrinol Metab. 2015 Dec;100(12):4588-94. doi: 10.1210/jc.2015-1864. Epub 2015 Sep 28.

Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy.

Author information

  • 1Department of Obstetrics and Gynecology (T.S.M., P.T., O.Y.), Helsinki University Hospital, 00029 Helsinki, Finland; Folkhälsan Research Center (T.S.M.), 00250 Helsinki, Finland; EPID Research Oy (H.L., P.K., F.H., P.V.), 02130 Espoo, Finland; National Institute for Health and Welfare (M.G.), 00271 Helsinki, Finland; and Nordic School of Public Health (M.G.), 40242 Gothenburg, Sweden.

Abstract

CONTEXT:

Current guidelines recommend annual discontinuation of postmenopausal hormone therapy (HT) to evaluate whether a woman could manage without the treatment. The impact of HT on cardiovascular health has been widely studied, but it is not known how the withdrawal of HT affects cardiovascular risk.

OBJECTIVE:

We evaluated the risk of cardiac or stroke death after the discontinuation of HT. Design, Patients, Interventions, and Main Outcome Measures: Altogether 332 202 Finnish women discontinuing HT between 1994 and 2009 (data from National Reimbursement register) were followed up from the discontinuation date to death due to cardiac cause (n = 3177) or stroke (n = 1952), or to the end of 2009. The deaths, retrieved from the national Cause of Death Register, were compared with the expected number of deaths in the age-standardized background population. In a subanalysis we also compared HT stoppers with HT users.

RESULTS:

Within the first posttreatment year, the risk of cardiac death was significantly elevated (standardized mortality ratio; 95% confidence interval 1.26; 1.16-1.37), whereas follow-up for longer than 1 year was accompanied with a reduction (0.75; 0.72-0.78). The risk of stroke death in the first posttreatment year was increased (1.63; 1.47-1.79), but follow-up for longer than 1 year was accompanied with a reduced risk (0.89; 0.85-0.94). The cardiac (2.30; 2.12-2.50) and stroke (2.52; 2.28-2.77) death risk elevations were even higher when compared with HT users. In women who discontinued HT at age younger than 60 years, but not in women aged 60 years or older, the cardiac mortality risk was elevated (1.94; 1.51-2.48).

CONCLUSIONS:

Increased cardiovascular death risks question the safety of annual HT discontinuation practice to evaluate whether a woman could manage without HT.

Got high cholesterol? Here are five foods to eat and avoid

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Got high cholesterol? Here are five foods to eat and avoid

December 1, 2016 3.43pm AEDT

We checked the most recent research from trials that tested the impact of specific foods on blood cholesterol. The verdict? Good news first! Eating more nuts, legumes, plant sterols (molecules found in plants) and olive oil helps lower blood cholesterol.

The bad news? Discretionary foods (aka junk) raise blood cholesterol, especially bad cholesterol (called LDL). Eating less lowers it.

Do you know your blood cholesterol level? If you don’t, ask your GP to check it. Over a third of Australian adults have high cholesterol.

1. Eat legumes

Legumes and pulses, including baked beans, kidney beans, chick peas, lentils and split peas, can help lower cholesterol levels. The most recent Australian Health Survey found fewer than one in five Australians ate them on the day of the survey.

The results of 26 randomised control trials (the gold standard of research trials), which included 1,037 people who had either normal or high cholesterol levels, were added together. The data showed LDL cholesterol was reduced by 5% in response to eating 130 grams of pulses per day. This is equivalent to one small can or about a third of a 400 gram (large) can of baked beans.

Pulses are high in vegetable protein and fibre. They lower blood cholesterol in a number of ways. The soluble and insoluble fibres assist with lowering cholesterol absorption in the gut, while they promote growth of beneficial gut bacteria in the large bowel.

The soluble and insoluble fibres in legumes help lower cholesterol absorption in the gut. from http://www.shutterstock.com

Legumes and pulses take longer to digest compared to processed foods. This means you tend to eat less when they’re part of a meal.

2. Eat plant sterols, margarines and spreads

Plant sterols, or phytosterols, are chemically similar to blood cholesterol and are found in some plant foods, including nuts. Plant sterols are concentrated from plant sources and then added to some commonly eaten foods such as margarines, spreads or milk.

Plant sterols compete with two other types of cholesterol for absorption from the gut: pre-made cholesterol, which is found in some foods like prawns, and cholesterol, which is made in your liver. This “competition” process lowers the total amount of cholesterol that eventually ends up in your blood.

A review concluded that two grams of plant sterols a day leads to an 8-10% reduction in LDL cholesterol.

The type of fat the plant sterols are mixed with is important. A meta-analysis of 32 randomised control trials, involving around 2,100 people, found bigger reductions in total cholesterol (a mix of good and bad types) and LDL cholesterol when plant sterols were added to margarines or spreads derived from canola or rapeseed oil, rather than sunflower or soybean oil.

3. Eat nuts

Nuts are high in protein and fat, but the amounts of polyunsaturated, monounsaturated and saturated fat vary. In a review of 25 intervention trials, eating approximately 67g of nuts a day (about half a cup) led to a 5.1% reduction in total cholesterol and 7.4% for LDL.

It didn’t matter what type of nuts people ate; the more nuts, the bigger the cholesterol reduction. People with higher LDL cholesterol at baseline or who were not overweight had a bigger improvement. One caution is that half a cup of nuts contains about 400 calories (1600kJ), so you need to eat nuts instead of another food, or eat less each day but have them every day.

Eating half a cup of nuts a day can cut cholesterol by 5%. from http://www.shutterstock.com

4. Use olive oil

Olive oil is a major component of the Mediterranean diet and the predominant source of fat. Olive oil contains a high proportion of monounsaturated fat.

More than 80% of olive oil’s healthy compounds (called phenolic compounds) are lost during the refining process, so less refined varieties, such as virgin olive oil, are a better choice.

A review of eight trials that included 350 people consuming high phenolic olive oil found medium effects on lowering blood pressure and small effects on lowering oxidised LDL (a type of LDL), with no significant effects on total or LDL cholesterol.

In contrast, another trial randomly selected over 7,400 men and women at high risk of heart disease to follow three diets: the Mediterranean diet plus extra-virgin olive oil, or Mediterranean diet plus nuts, or a control diet (low fat). After 4.8 years follow-up, those in both the olive oil and nut groups had a 30% lower risk of heart attack, stroke or death from heart disease compared to controls.

In a recent trial, 47 men and women were randomised to substitute 4.5% of their usual food intake of olive oil or butter for five weeks, and then crossed over to the other group for another five weeks. Researchers found total cholesterol and LDL-cholesterol levels were significantly higher after consuming butter compared to olive oil.

The reduction was biggest in those who had high blood cholesterol to start with. Switching to a healthier spread makes sense for those with high cholesterol.

5. Avoid junk food

In our study, we found people were able to make a number of smaller changes across a range of the foods that lower blood cholesterol levels, including increasing nuts, soy foods and plant sterols.

But the biggest change people made was cutting back on energy-dense, nutrient-poor foods (junk foods) and eating a wider variety of healthy foods. The benefits of making these changes? They lowered their cholesterol, lost weight and lowered their blood pressure.

A big study examined changes in diet quality scores and heart disease risk in 29,000 men from the Health Professionals Follow-up Study and 51, 000 women from the Nurses’ Health Study (1986-2010). After four years of follow-up almost 11,000 people had a heart disease “event”.

Those who had the biggest improvement in their diet quality score had a 7-8% lower risk. You can check your diet quality using our Healthy Eating Quiz.

When it comes to heart disease risk factors, get your cholesterol and blood pressure checked next time you see your GP.