It is not uncommon for me to see aspirin on the medication list of many of my older patients. It is most common with my well-controlled hypertensive or hyperlipidemia clients whom have no history of clinically evident cardiovascular (CV) disease. So when I ask them why they are on aspirin, the common reply is, “I read that it prevents heart attack and stroke so I started it on my own”, or “My husbands cardiologist suggested I take it after I took him in for a check up”. Two new studies in 2018 might shed some light on the subject.

In the ARRIVE trial, some 12,000 non-diabetic patients were randomized to 100mg of daily aspirin or placebo. Enrolled men were 55 years or older with 2 or more CV risk factors. Women in the study were at least 60 years old and had 3 or more CV risk factors. After a 5 year follow up aspirin had no CV benefit in reducing CV-related death, heart attack, unstable angina, stroke or transient ischemic events anymore than placebo. Those in the aspirin group had a slightly higher risk for gastrointestinal bleeding.

In the ASCEND trial, 15,000 middle aged or older diabetic patients were randomized to 100mg of aspirin daily or placebo. During average follow up of about 7 years, aspirin prevented 1 vascular event but caused 1 serious hemorrhage for every 100 treated patients.

So what does this mean…

Maybe we shouldn’t use aspirin as the magic prophylactic bullet for primary prevention that we once thought. Among diabetic patients, the trade off between a small benefit and harm are razor thin. And balancing one adverse event (CV event) against another adverse event (gastrointestinal bleed) is not straightforward. We cannot predict which of those outcomes would apply to any given patient. The other consideration is that a large proportion of patients in both studies were taking statins and antihypertensive drugs, and only a small proportion were current smokers. So you could conclude that these studies examined the incremental benefit of aspirin, added to other standard preventative treatments.

I like to individualize my healthcare with patients since outcomes in studies give us associations and not cause-and-effect results. One additional way to determine if a patient would benefit from aspirin is by performing a random urine test known as Aspirin Works. This measures 11-Dehydrothromboxane B2 in the urine which is produced from the breakdown of thromboxane A2. It is released by activated platelets (that cause our blood to clot) and urine levels can be used to monitor the response to aspirin therapy. This test may determine that you don’t need aspirin, or if on aspirin that your dose needs to be changed.

Ask your doctor or practitioner to perform this simple urine test to see if a daily aspirin would specifically benefit you.

Reference: Brett, A. Aspirin for primary prevention of cardiovascular events; JWatch.org, Oct 1, 2018, Vol. 38, No. 19.
NEJM JW Cardiol Oct 2018 and N Engl J Med 2018 Aug 26; [e-pub]

All medications have risks, whether they be a supplement or prescription drug. One example would be non-steroidal anti-inflammatory (NSAID) drugs such as Advil, Naproxen, Celebrex, or Diclofenac. Many people use these drugs long-term for menstrual cramps, headaches, aches and pains, arthritis or injuries. Long-term use can increase the risk for acute kidney injury or chronic kidney disease progression. They also raise the risk for cardiovascular events such as myocardial infarction (heart attack) and stroke. So it’s been suggested to avoid use of these medications for those with hypertension, heart failure or chronic kidney disease. This is difficult, especially for the elderly who typically have these health conditions but also need pain relief for treatment of osteoarthritis.

In a recent U.K. study, Diclofenac was associated with excess risk for myocardial infarction as opposed to Naproxen. Also, Ketorolac, another NSAID, can adversely affect kidney function more than other NSAIDs. Factor in dehydration, nausea, activity limitations especially after surgery, and acute kidney injury and you can see that the use of these meds can be a real danger.

With the opioid crisis in the forefront, nonnarcotic alternatives for pain control are in high demand. If you need to use an NSAID, there are some like Diclofenac that pose a higher risk for cardiovascular events and GI bleeding compared with other NSAIDs or Tylenol. There is little justification to use Diclofenac before trying other traditional NSAIDs. Better yet, it’s worth trying herbs such as Ginger, Curcumin and Boswellia (AKBA). Combining Boswellia’s activity with Curcumin and Tumeric can offer even higher levels of pain relief. CBD is also an amazing pain reliever if monitored well.
I always advocate plenty of fluids, avoiding food allergens and other inflammatory triggers and getting healthy sleep as the foundation for reducing pain and optimal wellness.

References: Dubreuil M et al. Risk of myocardial infarction with use of selected non-steroidal anti-inflammatory drugs in patients with spondyloarthritis and osteoarthritis. Ann Rheum Dis 2018 Aug; 77: 1137.
Schwenk, T. NSAID use in patients with hypertension, heart failure, or chronic kidney disease. Journal Watch 2018 Nov; Vol. 38 No. 22 p. 180.
Myers, C. Plants for pain relief. Health and Happiness 2019 Feb; p 12.

Here are the top 10 Health Breakthroughs of 2018:

10. Synthesized Antibiotics- There is a real concern regarding drug-resistant bacteria strains such as MRSA. Researchers in Britains University of Lincoln discovered a synthesized form of the antibiotic texiobactin that has already been used to treat infections in mice. The next step could be commercial drug use for humans to battle the growing epidemic of drug resistance.
9. Senescence Drugs- Some drugs are now being tested to kill old cells called “senolytics”. This will help extend our quality of life, not just our years.
8. Semiconductor technology- This can read the bodies vital signs on the skin. A thin plastic material laid over the skin can check heart rate, blood sugars and other readings that can be displayed on your Smart phone or sent directly to your medical professional.
7. CRISPR genome- Targeting the RNA of diseased cells has become more accurate and safe. Salk Institute scientists tested their technology against dementia which effectively restored healthy levels of proteins to the neurons affected by the disease.
6. Cancer vaccine. Human trials have been underway to treat patients with lymphoma which could present an all new treatment for the eradication of cancer.
5. Brain implants- A pacemaker for the human brain, or deep-brain stimulator, creates electrical impulses that could boost the memory of sufferers of epilepsy, Parkinson’s, and Alzheimer’s disease.
4. Ingestible Sensors: Track your gut health. This ingestible sensor developed by Australia’s RMIT University can measure the gases in your intestine that could help to diagnose gastrointestinal issues way before patients are symptomatic.
3. Cloning Monkeys- It’s been over 20 years since researchers cloned Dolly the sheep. Now China has cloned 2 monkeys which is the first time this technique has been used in primates. DNA was taken from fetal cells into eggs that had had their DNA removed, stimulated the eggs to develop embryos, and implanted them in female surrogates. Two female identical-twin long-tailed macaques’s were born. This could revolutionize research on disease.
2. Treating Muscular Dystrophy- Scientists corrected a gene mutation behind a form of muscular dystrophy in dogs. Duchenne muscular dystrophy is caused by a gene mutation that prevents the body from producing dystrophin, a protein required for strong muscle fibers. By using gene-editing technology we hope the same can be done in humans very soon.
1. Helping Paraplegics Walk- Having worked in the Neuro ICU treating para and quadriplegics, this is such a huge discovery! Researchers implanted tiny electrodes between patients’ vertebrae of paraplegics below the injury and delivered a weak electrical current to help amplify signals to the brain. After months of intensive physical therapy, one patient Jered Chinnock, could walk the length of a football field with assistance. “It feels,” he said, “like science fiction.”

Wishing all of you a Healthy and Joyful 2019!

References: The Week, December21/December 28, 2018. Pages 28-29.
Interesting Engineering.com. The 16 Most Remarkable Healthcare Innovations, April 7, 2018.

We are finding that “Age” is the most common risk factor for many diseases. So the older we get, the more likely we are to get heart disease, neurological conditions, diabetes and cancers. That puts us in a tough position. Of course we want to live a long life, but we want to do what we can to stay healthy and ideally avoid illness and disease.

So the question is, is aging a condition in itself that can be reset? Currently the oldest person on record is a French woman who died in 1997 at the age of 122! It is predicted that by 2040, Spain will have the longest-lived citizens reaching the average age of 86 years.

Scientists have used animal studies to better understand the cellular and molecular processes that cause the deteriorations of aging. There are 4 broad groups according to Tamara Tchkonia and Dr. James L. Kirkland of the Mayo Clinic. These groups include chronic inflammation, cell dysfunction, changes in stem cells that make them fail to regenerate disease, and cellular senescence, the accumulation in tissue of aging cells that accompanies disease.

Researchers have found that old cells secrete proteins, lipids and other substances that increase inflammation and cause destruction of tissues. Apparently, healthy young people have few of these aging cells, but after age 60, they begin to accumulate and their increasing quantity correlates with the disabilities of old age.

Could there be a remedy that removes these old cells while leaving young cells? Well, we’re getting closer.
In one study with mice, old cells were sensitive to a combination of 2 drugs; dasatinib, a cancer drug, and quercetin, a plant flavonoid. They improved cardiac function and exercise capacity in old mice delaying the symptoms of osteoporosis and prolonged healthy old age. I mean isn’t that what we all want?! Healthy quality years as we age.

Some drugs are now being tested to kill old cells called “senolytics”. For example a drug called Metformin which has been used for 60 years to treat diabetes has been shown to be effective against several age-related diseases. Maybe we can prevent a host of age-related diseases- cardiovascular, cancer, dementia- that can help us not only live longer but with fewer disabilities related to aging.

Of course healthy eating, exercise, inner and outer connection through friends, family, community, religion or spiritual practices are the foundation of health. But maybe certain medicines can optimize and prolong good health. There are trials underway in humans looking at drugs and nutrients that will tackle all of the difficult causes of aging to help extend our health span so we can live healthier in our older years.

NYT – How Long Can People Live?

Many of us have experienced that annoying buzzing sound known as tinnitus. It’s thought of as more of a symptom than as a diagnosis. It affects more than a million people worldwide and has been chronicled as far back as the first century AD. Only 20% of people with tinnitus seek treatment. That is most likely due to the fact that most tinnitus comes and goes and is tolerated to a degree in which we can function. Although in the United States, almost one third of patients who request treatment report symptoms that are debilitating.

Tinnitus is variable with the quality and loudness of the buzz, hiss or ringing that is often described. Prevalence increases with age, smoking, male gender and ethnicity, with the non-Latino white population statistically at greater risk. Some conditions such as diabetes and other autoimmune diseases are risk factors for tinnitus. A history of loud sound, which can be recreational (those crazy late night concerts!), occupational or environmental also can predispose a person to tinnitus.

The majority of tinnitus cases are considered Primary which is defined as having no identifiable cause. On the other hand, Secondary tinnitus has an identifiable cause which can include a long list of conditions such as certain medications (NSAIDS, chemotherapy, antibiotics), inner and outer ear disturbances, neurological and vascular causes, infections and nutrient deficiencies. Persistent tinnitus (lasting more than 6 months) can impact ones quality of life and can lead to depression, anxiety, insomnia and neurocognitive decline. It can really be devastating!

The cause of tinnitus is alittle more complicated than we once thought. It is not simply a cochlear (inner ear) phenomenon. It has to do with the damaged stereocilia (inner ear organelles of hair cells) located in the cochlea that exhibit an increase in a spontaneous firing rate in response to lost frequencies which are relayed to higher structures in the brain. It appears to be a maladaptive neural plasticity as it results in increased spontaneous firing rates and synchrony among neurons in central auditory structures, according to research by Shore and colleagues (Shore, SE, Roberts LE, Langgguth B. Maladaptive plasticity in tinnitus- triggers, mechanisms and treatment. Nat Rev Neurol. 2016;12(3):150-160.

So, what to do?
First, lab testing should be done to rule out causes of tinnitus. Imaging is usually unnecessary unless one questions a tumor or vascular cause. When no underlying pathology is identified for tinnitus, then a patient should be sent for a full audiology evaluation. Management involves treatment of perceived loudness and treatment of comorbid symptoms such as depression, anxiety, sleep disturbance, etc.
The leading recommendation made by The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) is cognitive behavioral therapy (CBT). The sound cannot be eliminated but the patient’s response to the sound can be modified. Tinnitus Retraining therapy (TRT) is another form of habituation therapy that has been successful. Unlike CBT, which is the idea that behaviors are modifiable thoughts that can be changed by teaching coping mechanisms such as relaxation, TRT aims to eliminate the perception of sound. A patient wears a device similar to hearing aids using broadband noise that closes the gap between silence and the perception of tinnitus. This device is worn for 6 hours a day for 12 months.

Other alternative non-medical therapies include Chinese herbal medications such as Ginko biloba, vitamins, zinc, manganese, and melatonin. Cannabinoids, which is a plant that contains hundreds of chemicals that each act differently on the brain may have an inhibitory effect on neurotransmitter release. Other modalities such as yoga, meditation, physical therapy and mindfulness have helped patients feel more relaxed but they had no effect on the severity of tinnitus.

Of course prevention cannot be underestimated. Occupational noise and recreational use of music devices put people at heightened risk for hearing loss and tinnitus. If you are suffering from tinnitus, see a practitioner for evaluation to help your symptoms.

Reference: Gillian Ross, W, Danielsen, R. What’s the Buzz? Treatment Strategies in Chronic Subjective Tinnitus. Clinician Reviews. September/October 2018/Vol 28,NO 10. p. 34-41.

Alcohol use has a complicated association with health. It tends to follow a “U” shape curve. Some research suggests that low levels of alcohol consumption give some protection against heart disease, diabetes and several other conditions. Too much alcohol on the other hand, can lead to adverse effects on organs and tissues leading to injuries, poisoning, potential self-harm or violence. So there’s a “sweet” spot.

The Global Burden of Disease Study 2016 collected data from developed and developing nations, involving 195 countries and territories, from 1990-2016. It is one of the largest studies of its kind looking at the association between population-wide consumption of alcohol to population wide trends. This study published in the Lancet concluded that alcohol consumption is involved in 2.8 million deaths worldwide annually. This makes it the 7th leading risk factor for death and disability.
The bottom line in this study was that alcohol use (10 grams of pure ethyl alcohol = 3.4 ounces of red wine at 13% alcohol, 12 ounces of beer at 3.5% alcohol or 1 ounce of 80-proof whiskey) is a leading risk factor for global disease burden and causes substantial health loss and the level of consumption should be zero!

OK…so that doesn’t sit well with many of us. So lets look deeper in the study.
First of all, the researchers relied on sales of alcohol and surveys to estimate the prevalence of drinking in each country. They linked consumption data to 23 health outcomes which included car accidents, suicides, tuberculosis, liver cirrhosis, cardiovascular disease and cancers.
Rates of alcohol consumption vary greatly by country. Plus, this was a meta-analysis, which means it is a collection of many observational studies in which the data is then combined into mathematical models to predict the harm from alcohol consumption worldwide. The problem is, observational data can miss other causes of the problem. Examples are: Do those who drink have other health problems, such as smoking tobacco? Do those that drink alcohol have an unhealthy diet or live in poorer neighborhoods? These could be more of the cause of death and disability, and the studies that were analyzed did not look at these variables.

Second, looking at the health outcome of tuberculosis (TB) is interesting. According to the World Health Organization, over 95% of cases and deaths of TB are in developing countries and those that are infected with HIV are 20-30 times more likely to develop active TB. Again, this could be a confounding factor as I described above because the causes of death in developing countries are different than in developed nations. TB was the major cause of death in young adults, and we know alcohol can raise the risk for TB activation. This may show a statistical significant change in the data but gives an overall bias in the clinical importance.

Third, this is a world wide study, but the results are being interpreted at an individual level. The 23-alcohol related health issues are not experienced at the same rate. For instance, the rate of heart disease and diabetes actually go down with light or moderate drinking. The risks for cancer and tuberculosis can go up for some people (depending on many circumstances). It’s not clear that everyone is at the same risk in real life.
So if 0 drinks is ideal, what is the risk at 1 drink per day? Well, if you don’t drink, 914 for every 100,000 people can expect to experience one of the 23-alcohol related problems in any given year. Having 1 drink per day, that number goes to 918 per 100,000. That means 99,082 are unaffected. So the risks in the study present themselves as much bigger than they really are. Don’t get me wrong…I’m not advocating drinking, but there is a balance and we shouldn’t interpret these results individually to induce panic or fear to change policy. We have enough of that right now.

So we need better studies. More likely a large randomized control trial looking at light to moderate drinking, to get the best perspective on the harms and benefits of alcohol consumption. This may give us more answers on the way most people consume alcohol and perhaps give us insight on more specifics such as cultural, age and gender differences.

https://www.nytimes.com/2018/08/27/health/alcohol-drinking-health.html

The prescription anti-nausea medication Ondansetron (Zofran) is the first line drug for nausea in the emergency department (ED) for non-cancer patients. Now, an alternative option, inhaled isopropyl alcohol, has shown promise. Yes, this is your typical rubbing alcolhol that you may have in your bathroom cabinet.

A recent trial involved 120 ED adult patients with nausea and vomiting who did not need IV (intravenous) medications or fluids. They were randomized to receive inhaled isopropyl alcohol in the form of alcohol swabs plus 4 mg of oral ondansetron, inhaled isopropyl alcohol plus an oral placebo, or inhaled saline plus 4 mg oral ondansetron. Patients could sniff the alcohol or saline repeatedly.

Results showed a significant decrease in nausea in the alcolhol/ondansetron and alcohol/placebo groups than in the saline/ondansetron group. Patients in the alcohol groups also had better nausea control at the time of discharge.

For patients who do not require IV therapy, consider repeated inhalations of isopropyl alcohol swabs (which you can buy at your local pharmacy). We don’t know the mechanism of action, but it is simple and safe to try. Call your doctor or get to the ED if your symptoms worsen. And maybe don’t eat the old leftovers in the frig next time…

Reference: April MD et al. Aromatherapy vs oral ondansetron for antiemetic therapy among adult emergency department patients. A randomized control trial. Ann Emerg Med 2018 Aug; 72-:184.
Photo by Internet Archive Book Images

Photo by Internet Archive Book Images