Monthly Archives: July 2020
Featured Articles in Internal Medicine In the News
7 overlooked but harmful health habits to avoid
Naveed Saleh, MD, MS, for MDLinx | April 22, 2020
Every once in a while, we all practice bad habits that, for the most part, don’t seriously endanger our health. Pulling all-nighters to sift through the mountain of EHRs, skimping on sleep between shifts, skipping meals between seeing patients—all minor transgressions that, independently and occasionally, don’t pose much of a health risk. But, certain little bad habits can lead to more poor lifestyle behaviors over the long term, and they can increase the risk for dangerous health complications. https://tpc.googlesyndication.com/safeframe/1-0-37/html/container.html?6a04c9f6791759e53d0142845a91417d
Current events have taught us to be more vigilant in adhering to good hygiene practices when it comes to our interactions with others. But it’s also important to be cognizant of smaller, more personal bad habits that we may fall prey to in our everyday lives.
Here’s a look at seven overlooked, but potentially harmful, health habits to avoid.
Bonding with Fido—and not washing your hands afterward
According to the American Pet Products Association, most US households (67%) own a pet, with over 60 million US households boasting dog ownership. Plenty of research has shown that dogs improve the health of their owners in various ways, including the promotion of exercise, increased longevity, and improved heart health and mental well-being.
While dogs can enrich our lives, they can also expose us to dangerous pathogens—such as methicillin-resistant Staphylococcus aureus (MRSA) and Campylobacter jejuni—thus increasing the risk of potentially deadly infections and diseases, including septicemia and rabies. Washing your hands after petting your dog or handling their toys or food (as pathogens may also be transmitted via dog saliva and waste) is the best way to reduce, if not eliminate, the risk of zoonotic disease from your pet, according to the CDC and other health experts.
Sharing and ‘borrowing’ meds
The terms medication “sharing” or “borrowing” are misnomers. These medications are likely never to be replaced in any way. One person simply gives medication—whether prescribed or over the counter—to another without the input of a physician. And, according to the results of a systematic review, the practice is particularly widespread among prescription medication users. In an analysis of 19 studies from 9 countries involving a total of 36,182 participants, ranging in age from children to older adults, the reported prevalence rates of taking prescription medication from another person was 5% to 51.9%, and for giving prescription medication, 6% to 22.9%.
But, as you know, doing so is incredibly dangerous. Without proper medical guidance, your patients’ medication sharing habits could result in addiction, gradual resistance to efficacy, as well as serious health complications or death from allergic reaction, adverse drug side effects, adverse drug-drug interactions, or inaccurate treatment (ie, taking the wrong meds to treat a specific illness).
“Studies that examined the types of medicines shared found pain medications, allergy medications, and antibiotics to be the most commonly shared classes of medicines. In light of the addictive potential of some pain medications, the possibility of adverse reactions from allergy medications, and the development of bacterial resistance associated with uncontrolled use of antibiotics, health care providers should take proactive measures to limit the sharing of these medicines,” wrote the authors.
“Sharing of medicines with high teratogenic potential, such as isotretinoin (a US Food and Drug Administration category X drug), observed among women of child-bearing age, carries a risk of birth defects, particularly if women do not inform their health care provider about their borrowing practices,” they added.
Licking the spoon
Some of your fondest childhood memories may be of licking the batter-covered spatula while making chocolate chip cookies with your family. But, at the risk of sounding like a buzzkill, doing so could be harmful to your health. While the practice isn’t dangerous to others—pathogens from your mouth won’t survive the high heats of cooking—it is to the licker.
In recent years, flour, eggs, and frozen vegetables have all been recalled for contamination with Salmonella, Escherichia coli (E. coli), and Listeria bacteria. On further examination, manufacturers have found low levels of these pathogens either in the field (ie, kitchen) or during processing. These bugs are remarkably resilientand find their way into raw ingredients and ingredient mixes used by consumers. When improperly mixed and handled, then the risk for infection is magnified.
Dip your chip in a communal bowl of salsa and take a bite. You now have a whole lot of chip left—but no salsa to cover it. Annoying! You may be tempted to double dip—especially if no one is around to scowl—but the practice is highly unhygienic.
Results from a small study published in the Journal of Food Safety, for instance, found that crackers bitten before being dipped into salsa, chocolate sauce, or cheese—as one might expect—had higher bacterial concentration than those that weren’t bitten and dipped. To make matters worse, salsa had the highest immediate bacterial transfer.
“The practical application of these results to food safety will be similar to studies on hand washing. It is clear that foodborne disease can be spread by both practices (double‐dipping and improper hand washing), and showing this is true using controlled studies may change the behavior of some people of the time,” the authors wrote.
“But like hand washing, a no double‐dip policy will not prevent the practice nor prevent the spread of disease. By determining that the bad practice of double‐dipping does in fact transfer oral bacteria to a food dip, the practice may be reduced, subsequently reducing the spread of harmful microorganisms to some degree,” the authors concluded.
However uncouth, sharing a toothbrush is a remarkably common occurrence, at least according to a survey conducted by the Oral Health Foundation and Philips out of the United Kingdom. About a quarter of those polled (26%) reported their willingness to share their toothbrush with another person, with significantly more men (32%) amenable to the gesture than women (20%).
Although sharing a toothbrush with a loved one may seem like an extension of intimacy, it’s more likely a predictor of disease. The mouth is home to more than 700 types of bacteria, with any person harboring 200 or more types, as well as fungi and viruses. To boot, wet toothbrushes are ideal surfaces for mold growth.
Common harmful bacteria found in the mouth include Porphyromonas gingivalis and Treponema denticola, which both play a role in gum disease. Streptococcus mutans,which is linked to tooth decay, can also make its way onto a toothbrush. Even scarier, HIV and hepatitis B virus have also been known to hop onto the head of a toothbrush, making for potentially deadly cargo.
Sharing and reusing razor blades
Like toothbrushes, couples may also share or reuse razor blades. But, used razor blades can serve as vectors for the transmission of all types of pathogens. Case in point: Researchers of one Turkish study used PCR to identify the presence of hepatitis B virus on used razor blades (n = 151), and they found that 6.6% of used razor blades harbored the virus.
“[U]sed razor blades may be contaminated with [hepatitis B virus], and the practice of sharing used razor blades may pose a risk of transmission,” noted the authors.
Handling money without sanitizing
The fibrous surfaces of money offer the perfect scaffolding for various nasty pathogens. Lower-denomination bills, which are circulated more frequently, are at higher risk of picking up nasty bacteria. Thus, washing your hands after touching money is imperative to reduce the risk of disease.
But if that isn’t reason enough for you to wash your hands, consider this: Researchers at New York University’s Dirty Money Project found about 3,000 microbes on dollar bills—including dermal bacteria, vaginal bacteria, and oral microbes—with many demonstrating antibiotic resistance.
Similarly, Turkish and Dutch researchers who examined a variety of international currencies found MRSA, vancomycin-resistant Enterococcus, and extended-spectrum beta-lactamases–producing E. coli present on the surfaces of bills.
As far as coins and newer polymer-constructed currencies go, here’s what the authors of one study found:
“Smooth, polymer surfaces provide a poor means of adherence and survival, while coarser and more fibrous surfaces provide strong bacterial adherence and an environment to survive on. Coins were found to be strongly inhibitory to bacteria with a relatively rapid decline in survival on almost all coin surfaces tested. The inhibitory influence of coins was demonstrated through the use of antimicrobial disks made from coins. Despite the toxic effects of coins on many bacteria, bacteria do have the ability to adapt to the presence of coins in their environment which goes some way to explain the persistent presence of low levels of bacteria on coins in circulation.”
While current events have taught us to be more vigilant in adhering to good hygiene practices when it comes to our interactions with others, it’s important to be cognizant of smaller, more personal bad habits that we may succumb to in our everyday lives. As physicians, you know that even the smallest lifestyle habits can make or break an individual’s health. After all, as we’ve seen in recent days, it only takes one opportunistic pathogen to ruin your health.
Worrying about not being able to sleep pushes it further away. from http://www.shutterstock.com
I have posted more blogs over the years on insomnia, than any other topic. It is a major problem for menopausal women. Search my site for insomnia”and “sleep” to read previous posts.
Health Check: how to soothe yourself to sleep
October 30, 2017 11.48am AEDT
- Joanna Waloszek Postdoctoral Research Fellow in Psychology, University of Melbourne
Joanna Waloszek does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
University of Melbourne provides funding as a founding partner of The Conversation AU.
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Getting a good night of sleep can seem like the most effortless and natural thing in the world, but when we can’t fall asleep it can quickly feel elusive and frustrating. There are a few techniques we can use to help us fall asleep, and some things we should always practise before we go to bed to give ourselves the best chance of being able to drop off easily.
Before you hit the sheets
Many major causes of not being able to drop off to sleep actually happen before bedtime. Caffeine, nicotine, alcohol and food can all stimulate our brains and keep us awake at night, so be sure to limit these activities to earlier in the day.
While alcohol may help you fall asleep, it’s also associated with more awakenings during the night which can leave you feeling more tired the next day.
Bright lights and screens just before bed can also keep us awake. And not just because the scary movie or heartbreaking drama arouse our emotions. What many don’t realise is the light these devices emit (particularly blue wavelengths) suppress melatonin, the hormone that encourages sleep, making it harder to fall asleep.
Never take these screens to bed. Bed should be for two activities: sleep and intimacy. This encourages your brain to think of your bed as a place of rest. You should also create a wind down routine and a calm environment. This might involve dimming the lights and taking a bath.
Your circadian rhythms, or “body clock”, sync many of your bodily functions, including hormone release. Keep a routine to keep your rhythms regular. Big shifts in your sleep timing are like being in a constant state of jetlag. If you have problems falling asleep, go to bed when you’re tired and make sure to get up at about the same time every day. Try to keep this routine on the weekend and even after a night of poor sleep.
Another good idea is to turn your clock away. Watching the minutes pass can contribute to worries.
What if I can’t fall asleep?
Sometimes thoughts or worries can keep us awake at night, contributing to a feeling of being “wired”, even though we’re tired. To make matters worse, poor sleep is linked with poor mood, which means you may feel more anxious and easily frustrated the next day.
Increases in the stress hormone cortisol make it harder to fall asleep. Relaxation techniques such as deep breathing and progressive muscle relaxation can help release tension and decrease stress that has built up during the day.
Mindfulness meditation techniques have been found to be effective in helping people drop off to sleep. These involve relaxation, meditation and awareness exercises that help focus your attention to be “in the moment”, acknowledge different sensations, and “let go”.
By learning how to manage your physical sensations, thoughts, and emotions in a non-critical way, you can move from a stressed to a calm state during the day and at night. Join a class or download a mindfulness app with guided meditation you can listen to at bedtime.
If you can’t fall asleep after about 30 minutes, don’t stay in bed. Lying in bed counting sheep doesn’t help. Get up, go to another room and do something quiet and restful in dim light like reading a book (preferably one that is not too thrilling!). Avoid your computer, mobile or TV, because the light they emit can stimulate your mind and keep you awake. When you start feeling tired, go back to bed. If you still can’t fall asleep, get up again. Don’t worry if you have to repeat this several times. Remember to get up at your regular wake time.
What if I find it hard to get up in the morning?
Our “body clock” is wired to sunlight. If you have trouble getting up in morning, try opening your blinds to let the sunlight in. The dawn light will help you wake up naturally.
Things to remember
The amount of sleep we need changes with age. Newborns need around 16 hours of sleep per day, adults about seven to eight hours, and older people generally sleep less. There are individual differences too – the main thing is that you feel refreshed the next day.
Read more: Explainer: how much sleep do we need?
Our bodies cycle through different sleep stages every 90 minutes ending with a short period of wakefulness. Remember, short awakenings during the night are normal.
If you have a night of poor sleep, try not to put too much emphasis on it during the day. Know that breaking bad habits and creating good ones takes time. Don’t give up, stick to your healthy sleep routine.
If you continue to have problems or suspect you have an underlying sleep disorder, see your doctor or a sleep specialist. Sleep medications can help in some cases in the short term and should always be monitored by a medical practitioner.
Cognitive behavioural therapy for insomnia (CBT-I), which addresses thoughts and behaviours around sleep, has been proven to be effective in the long term. To access this treatment, ask your doctor to refer you to a sleep psychologist. There are also effective CBT-I programs online such as SHUTi that can be accessed from home.
. 2019 Oct;7(10):754-766. doi: 10.1016/S2213-8587(19)30189-5. Epub 2019 Jul 25.
Safety and Efficacy of Testosterone for Women: A Systematic Review and Meta-Analysis of Randomised Controlled Trial Data
- PMID: 31353194
- DOI: 10.1016/S2213-8587(19)30189-5
Background: The benefits and risks of testosterone treatment for women with diminished sexual wellbeing remain controversial. We did a systematic review and meta-analysis to assess potential benefits and risks of testosterone for women.
Methods: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science for blinded, randomised controlled trials of testosterone treatment of at least 12 weeks’ duration completed between Jan 1, 1990, and Dec 10, 2018. We also searched drug registration applications to the European Medicine Agency and the US Food and Drug Administration to identify any unpublished data. Primary outcomes were the effects of testosterone on sexual function, cardiometabolic variables, cognitive measures, and musculoskeletal health. This study is registered with the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42018104073.
Findings: Our search strategy retrieved 46 reports of 36 randomised controlled trials comprising 8480 participants. Our meta-analysis showed that, compared with placebo or a comparator (eg, oestrogen, with or without progestogen), testosterone significantly increased sexual function, including satisfactory sexual event frequency (mean difference 0·85, 95% CI 0·52 to 1·18), sexual desire (standardised mean difference 0·36, 95% CI 0·22 to 0·50), pleasure (mean difference 6·86, 95% CI 5·19 to 8·52), arousal (standardised mean difference 0·28, 95% CI 0·21 to 0·35), orgasm (standardised mean difference 0·25, 95% CI 0·18 to 0·32), responsiveness (standardised mean difference 0·28, 95% CI 0·21 to 0·35), and self-image (mean difference 5·64, 95% CI 4·03 to 7·26), and reduced sexual concerns (mean difference 8·99, 95% CI 6·90 to 11·08) and distress (standardised mean difference -0·27, 95% CI -0·36 to -0·17) in postmenopausal women. A significant rise in the amount of LDL-cholesterol, and reductions in the amounts of total cholesterol, HDL-cholesterol, and triglycerides, were seen with testosterone administered orally, but not when administered non-orally (eg, by transdermal patch or cream). An overall increase in weight was recorded with testosterone treatment. No effects of testosterone were reported for body composition, musculoskeletal variables, or cognitive measures, although the number of women who contributed data for these outcomes was small. Testosterone was associated with a significantly greater likelihood of reporting acne and hair growth, but no serious adverse events were recorded.
Interpretation: Testosterone is effective for postmenopausal women with low sexual desire causing distress, with administration via non-oral routes (eg, transdermal application) preferred because of a neutral lipid profile. The effects of testosterone on individual wellbeing and musculoskeletal and cognitive health, as well as long-term safety, warrant further investigation.
Funding: Australian National Health and Medical Research Council.
Copyright © 2019 Elsevier Ltd. All rights reserved.
. 2017 Dec 5;359:j5224. doi: 10.1136/bmj.j5224.
The British Medical journal is a very esteemed publication.
Effectiveness of and Overdiagnosis From Mammography Screening in the Netherlands: Population Based Study
Free PMC article
Objective To analyse stage specific incidence of breast cancer in the Netherlands where women have been invited to biennial mammography screening since 1989 (ages 50-69) and 1997 (ages 70-75), and to assess changes in breast cancer mortality and quantified overdiagnosis.
Design Population based study.Setting Mammography screening programme, the Netherlands.Participants Dutch women of all ages, 1989 to 2012.Main outcome measures Stage specific age adjusted incidence of breast cancer from 1989 to 2012. The extra numbers of in situ and stage 1 breast tumours associated with screening were estimated by comparing rates in women aged 50-74 with those in age groups not invited to screening. Overdiagnosis was estimated after subtraction of the lead time cancers. Breast cancer mortality reductions and overdiagnosis during 2010-12 were computed without (scenario 1) and with (scenario 2) a cohort effect on mortality secular trends
.Results The incidence of stage 2-4 breast cancers in women aged 50 or more was 168 per 100 000 in 1989 and 166 per 100 000 in 2012. Screening would be associated with a 5% mortality reduction in scenario 1 and with no influence on mortality in scenario 2. In both scenarios, improved treatments would be associated with 28% reductions in mortality. Overdiagnosis has steadily increased over time with the extension of screening to women aged 70-75 and with the introduction of digital mammography. After deduction of clinical lead time cancers, 33% of cancers found in women invited to screening in 2010-12 and 59% of screen detected cancers would be overdiagnosed.
Conclusions The Dutch mammography screening programme seems to have little impact on the burden of advanced breast cancers, which suggests a marginal effect on breast cancer mortality. About half of screen detected breast cancers would represent overdiagnosis.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
30 June 2020
Those of you who have been following my blogs over many years, will know this is one of my favorite hobby-horses- viz the dangers of mammography in normal women. This is the latest article, this time from Professor Burton, further confirming my long held views. I am amused that he refers to the Breastscreening Industry as a Military Industrial complex. Further information on this topic is covered on my web-site under “Breast screening-Mammography” There are two sides to this discussion, which should be of great interest to all women. I am not advocating women should not have mammograms routinely, but that women be aware of all sides of this debate. Women should be allowed to make an informed decision to have a mammogram or not, and not steamrollered into having one.
Should we scrap routine mammography?
A new analysis suggesting treatment is primarily responsible for the decline in breast cancer deaths in Victoria has reignited debate over whether to scrap routine mammography.
An analysis of breast cancer registry data in Victoria found that routine mammographic screening, BreastScreen, did not result in a drop in advanced cancer diagnoses nor an increase in early cancer diagnoses.
Study author Professor Robert Burton, epidemiologist and preventative health expert at Monash University, said that the lack of benefit, coupled with the harms of overdiagnosis, meant the program should be scrapped.
“We found that adjuvant therapy accounted for the observed 30% mortality decline,” Professor Burton said. “Given this finding, we propose that BreastScreen should be terminated.”
Professor Burton, and his co-author, Associate Professor Christopher Stevenson, an epidemiologist at Deakin University, analysed health data from more than 75,000 Victorian women who were diagnosed with breast cancer since 1982.
The paper, published in JAMA Network Open, showed that breast cancer mortality dropped by 30% in the 20 years following 1994, from 34 women per 100,000 to 24 women per 100,000.
This corresponded with a big boom of interest in mammography screening around the world in the 1990s. But for breast cancer screening to be effective, mammograms should result in more early stage breast cancer diagnoses and fewer advanced stage diagnoses.
Research from NSW, the US, Norway and the Netherlands indicates that the incidence of advanced breast cancer has either remained stable or increased.
In this analysis, Professor Burton found that advanced stage breast cancer actually doubled, from 12 to 24 women per 100,000, between 1986 to 2013. Meanwhile, they found that adjuvant therapy for early breast cancer, which included tamoxifen and chemotherapy, more than tripled 1986 and 1999.
According to their calculations, this could account for the entire 30% reduction in crude breast cancer deaths after 1994.
In contrast, regular mammograms exposed women to the risks of overdiagnosis and treatment, and at least one in three women diagnosed with mammography screening were overdiagnosed, meaning the cancer would have never gone on to cause harm, Professor Burton said.
A large portion of women with early breast cancer receive postoperative external beam radiation therapy (EBRT), which comes with risks of potentially fatal cardiac events.
This could have resulted in 54 extra deaths in 2004 and 78 extra deaths in the five years after 2013, said Professor Burton.
But the 30% figure for overdiagnosis was much higher than Cancer Australia figures, which suggested it might be more like 11 to 19%, Professor Bruce Mann member of BreastScreen Victoria’s Clinical Reference Group and tumour stream director at the Victorian Comprehensive Cancer Centre, said.
He hit back at the latest paper, saying it was based on a number of flawed assumptions.
“The reason that the outcomes from breast cancer have improved over the last 20 to 25 years is a combination of early diagnosis and treatment,” he said.
“The idea that it’s one or the other is a false dichotomy.”
Professor Mann thinks the apparent increase in advanced cancers is due to a change in the definition of “stage 3”, which now requires four or more involved lymph glands rather than “matted” axillary lymph glands prior to 2006.
Professor Mann said that BreastScreen helped women identify cancers earlier, allowing them to be treated less invasively than if they were caught later. He pointed to research showing women diagnosed with the screening program had half as many mastectomies (35% vs. 17%), fewer axillary dissections (43% vs. 21%) and less chemotherapy (65% vs. 41%).
Focusing on death rates alone missed this reduction in morbidity, he said.
He also pushed back on the level of harm the paper claimed women were exposed to from treatment, saying radiation technology had improved “dramatically”.
“Saying that the morbidity from radiation from the 1970s or the 1980s still applies to those diagnosed and treated now is misleading,” he said.
Similarly, those overdiagnosis figures didn’t tell the whole story, because the low risk women wouldn’t be recommended to have chemotherapy and mastectomy, he said.
“This is a dangerous paper, because it may discourage women from participating,” Professor Mann said.
“Sure, there are ways breast screening could be further improved, but to suggest that it is harmful is mischievous at best.”
However, Professor Burton said there was a growing body of evidence casting doubt on the benefits of population screening in asymptomatic women.
Conflicting information was discarded by proponents of BreastScreen because it had become a big industry, supporting many people’s livelihoods, Professor Burton said, likening it to the military-industrial complex.