20 July 2019 Blog Post: Recommendations for Japanese Encephalitis Vaccination

20 July 2019 Blog Post: Japanese Encephalitis Vaccination

The Centers for Disease Control today made new recommendations for Japanese Encephalitis vaccinations. Japanese Encephalitis virus is a mosquito borne illness. The map below shows that the affected area includes far more than Japan and extends from Asia to parts of the Western Pacific.

About 68,000 cases of Japanese encephalitis (JE) are estimated to occur each year. For travelers to Asia, the risk of JE is very low but varies based on season – usually after the monsoons except in tropical climates where there is year round transmission. Risk is likely to be higher for travelers with longer duration of travel (more than a month) or whose plans include extensive outdoor activities in rural areas.

The risk of acquiring Japanese encephalitis is still very low for most travelers β€” less than 1 case per million trips to Asia.

The vaccine (which is given as two doses) is recommended for the following groups:

1. People who are moving to a country where JE is regularly found
2. Those who will be traveling to JE area for a month or longer
3. Those who frequently travel to regions with JE
4. Lab workers with high exposure risk
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Additionally, the vaccine series should be considered for people traveling for less than 1 month who are at increased risk based on travel season, location, and activities, as well as those with uncertain travel itineraries. The vaccine is not recommended for low-risk travelers (e.g., those only traveling to cities for a short duration).
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Why is it called Japanese encephalitis if it is so widespread? Well – the first case of Japanese encephalitis viral disease (JE) was documented in 1871 in Japan.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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19 July 2019 Blog Post: Blood Pressure Measurements

19 July 2019 Blog Post: Blood Pressure Measurements

When it comes to blood pressure measurements, patients often ask me, “Which one matters? The top one or the bottom one?”
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One thing that Medicine is exceptional at doing is replacing simple terms with complex ones. Blood pressure measurement is no exception. The ‘top one’ is termed ‘systolic’ blood pressure and represents the amount of pressure in your arteries during the contraction of your heart muscle. The ‘bottom one’ is termed ‘diastolic’ blood pressure and represents the pressure when your heart muscle is relaxed between beats.
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Studies have gone back and forth about which one ‘matters’ (i.e. is more predictive of bad outcomes) more. Generally studies have shown a greater predictive value of the systolic blood pressure. However, the increased use of non-invasive or electronic blood pressure units (NIBP) may lead to inaccuracy. In 2013, a group of ICU researchers where they compared blood pressure from an invasive arterial line to NIBP readings, they determined that the NIBP significantly overestimated the systolic blood pressure when compared to the arterial line.
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A study published today in the New England Journal of Medicine shows that both matter, although systolic blood pressure (the top number) exerted a greater effect. The investigators looked at composite outcome of myocardial infarction (heart attack), ischemic stroke, or hemorrhagic stroke over a period of 8 years. Data from 1.3 million (!) adults was used in the analysis.
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Recently revised guidelines with two different thresholds (β‰₯140/90 mm Hg and β‰₯130/80 mm Hg) for treating hypertension. So now we know, both the top number and the bottom number matter.

Effect of Systolic and Diastolic Blood Pressure on Cardiovascular Outcomes 

Alexander C. Flint, M.D., Carol Conell, Ph.D., Xiushui Ren, M.D., Nader M. Banki, M.D., Sheila L. Chan, M.D., Vivek A. Rao, M.D., 
Ronald B. Melles, M.D., and Deepak L. Bhatt, M.D., M.P.H.

Abstract

Background:

The relationship between outpatient systolic and diastolic blood pressure and cardiovascular outcomes remains unclear and has been complicated by recently revised guidelines with two different thresholds (β‰₯140/90 mm Hg and β‰₯130/80 mm Hg) for treating hypertension.

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Methods:

Using data from 1.3 million adults in a general outpatient population, we performed a multivariable Cox survival analysis to determine the effect of the burden of systolic and diastolic hypertension on a composite outcome of myocardial infarction, ischemic stroke, or hemorrhagic stroke over a period of 8 years. The analysis controlled for demographic characteristics and coexisting conditions.

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Results:

The burdens of systolic and diastolic hypertension each independently predicted adverse outcomes. In survival models, a continuous burden of systolic hypertension (β‰₯140 mm Hg; hazard ratio per unit increase in z score, 1.18; 95% confidence interval [CI], 1.17 to 1.18) and diastolic hypertension (β‰₯90 mm Hg; hazard ratio per unit increase in z score, 1.06; 95% CI, 1.06 to 1.07) independently predicted the composite outcome. Similar results were observed with the lower threshold of hypertension (β‰₯130/80 mm Hg) and with systolic and diastolic blood pressures used as predictors without hypertension thresholds. A J-curve relation between diastolic blood pressure and outcomes was seen that was explained at least in part by age and other covariates and by a higher effect of systolic hypertension among persons in the lowest quartile of diastolic blood pressure.

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Conclusions:

Although systolic blood-pressure elevation had a greater effect on outcomes, both systolic and diastolic hypertension independently influenced the risk of adverse cardiovascular events, regardless of the definition of hypertension (β‰₯140/90 mm Hg or β‰₯130/80 mm Hg). (Funded by the Kaiser Permanente Northern California Community Benefit Program.)

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18 July 2019 Blog Post: Takotsubo Syndrome / Broken Heart Syndrome

18 July 2019 Blog Post: Takotsubo Syndrome / Broken Heart Syndrome

Have you ever heard of Takotsubo Syndrome (TTS)? Probably not. How about broken heart syndrome? Maybe that rings a bell?
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A report today published in Journal of the American Heart Association shows elevated cancer rates in patients with Takotsubo Syndrome (or ‘broken heart syndrome’). I found the article to be timely as I have had some clinical experience with TTS.
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Takotsubo syndrome is a weakening of the left ventricle, the heart’s main pumping chamber, usually as the result of severe emotional or physical stress, hence the term ‘broken heart syndrome.’ Stressors range from sudden illness, the loss of a loved one, a serious accident, or a natural disaster such as an earthquake.
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This condition causes similar symptoms as a heart attack but is different from one because there is evidence on an angiogram of blockages in the coronary arteries. However, patients can have typical EKG changes of a heart attack as well as a rise in cardiac biomarkers (substances released into the blood when the heart is damaged). This makes it difficult to distinguish from a heart attack until an angiogram is performed.
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The syndrome was first described in 1990 in Japan and has since been increasingly recognized around the world. It is much more common in women than men and occurs predominantly in older adults. The term “takotsubo” is taken from the Japanese name for an octopus trap used by fisherman, which has a shape that is similar to that of a heart affected by TTS.
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Most of the abnormalities in heart function clear up in one to four weeks, and most patients recover fully within two months. However, this latest study indicates that alignancy rates were significantly higher among TTS patients than among similar patients with acute coronary syndrome – or a typical heart attack – (18% vs. 11%). The most common malignancies in TTS patients were breast and gastrointestinal cancers.
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The authors point out: “History of malignancy might increase the risk for TTS, and therefore, appropriate screening for malignancy should be considered in these patients.”
Clinical Features and Outcomes of Patients With Malignancy and Takotsubo Syndrome: Observations From the International Takotsubo Registry

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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16 July 2019 Blog Post: On Alzheimer’s Dementia

16 July 2019 Blog Post: Alzheimer's Dementia

One common question I get from patients who are in for an annual examination is if there are any strategies or lifestyle approaches that will reduce one’s risk of developing dementia. This is a very reasonable question given that in 2019, an estimated 5.8 million Americans of all ages are living with Alzheimer’s dementia. One in 10 people age 65 and older has Alzheimer’s dementia and women are disproportionately affected (even when accounting for their higher average lifespan) – almost two-thirds of Americans with Alzheimer’s are women.

As the number of older Americans grows, so too does the number of new and existing cases of Alzheimer’s. By 2050, the number of people age 65 and older with Alzheimer’s dementia is estimated grow to a projected 13.8 million.

Typically my response regarding approaches that may be protective against dementia is based on a series of studies published by The Research Network on Successful Aging (funded by the MacArthur Foundation). The purpose of this series of studies was to to discover and study the factors that enable people to maintain good mental and physical functioning into old age. It demonstrated that there are a number of important factors that are associated with successful aging – most notably: increased physical activity, intellectual engagement and social interaction.

Two studies published this week in JAMA and its related publication JAMA Neurology reiterate this seminal findings in a groups of higher risk adults. In the first study of nearly 200,000 adults found that a ‘healthy lifestyle’ was associated with a 65% risk reduction in dementia. A healthy lifestyle consisted of 3 of 4 of the following:

1. Not currently smoking
2. Regular physical activity (e.g., 150 min/week of moderate or 75 min/week of vigorous activity)
3. Healthy diet
4. Low-to-moderate alcohol intake (0-1 standard drink for women, 0-2 drinks for men)
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The second study of 1600 adults demonstrated up to a 39% risk reduction among those who participated in stimulating mental and social activities over a lifetime. These activities include reading, volunteering, eating at restaurants, traveling, visiting friends and family. All of which also sound enjoyable.
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One caveat to note from the first very large study is that all of the participants were Caucasian. This is a significant limitation and an important one to highlight as African-Americans are about twice as likely to have Alzheimer’s or other dementias as older whites. Further, those of Hispanic origin are about one and one-half times as likely to have Alzheimer’s or other dementias as older whites.
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The most common follow-up question I get is, “how do I know if I am developing dementia?” The link below highlights 10 early signs of Alzheimer’s published by the Alzheimer’s Association.
10 Early Signs and Symptoms of Alzheimer's

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12 July 2019 Blog Post: PrEP (a daily pill to prevent HIV infection termed pre-exposure prophylaxis)

12 July 2019 Blog Post: PrEP (a daily pill to prevent HIV infection termed pre-exposure prophylaxis)

In most cases a report showing that the use of a particular medication has soared 500% would not be good news. However, in the case of PrEP (a daily pill to prevent HIV infection termed pre-exposure prophylaxis) this is welcome finding. More than a third of people at risk of HIV infection are now protected with the medication, which is more than 90% effective, according to a CDC report published today.

Some of my patients may already know that my interest in medicine first germinated in the early 1990s when I spent the better part of a year working at the Fenway Community Health Center in Boston while an undergraduate. There I worked on two HIV/AIDS studies and never imagined a time when there would be a effective treatment, much less a mechanism that could end HIV.

By routinely testing patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in ending the HIV epidemic. Dr. Kenneth Mayer (who oversaw the studies I had the good fortune to work on while at Fenway) has been a tremendous advocate for PrEP. His article in JAMA in 2018 (linked below) highlights this 90% efficacy.

My patients who take PrEP already know (since I tell them) that it is “my favorite medication to prescribe.”

Changes in HIV Preexposure Prophylaxis Awareness and Use Among Men Who Have Sex with Men β€” 20 Urban Areas, 2014 and 2017

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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10 July 2019 Blog Post: Fish Oil

10 July 2019 Blog Post: Fish Oil

One difficulty physicians often encounter is reconciling clinical studies that reach contradictory conclusions. Just this week I have seen the following ‘conclusions’ about fish oil.
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1. An impressive sounding article published by the New York Times on July 1st entitled “10 Medical Myths We Should Stop Believing. Doctors, Too.” Myth #2, in bold print, “Fish oil does not reduce the risk of heart disease.” The NYT article cites a single trial involving 12,500 people at risk for heart trouble, daily omega-3 supplements did not protect against heart disease.
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2. An article published today in the Annals of Internal Medicine showed the exact opposite. This study looking at the risk of heart disease encompassed a total of 277 trials, 24 interventions, and 992,129 participants. It considered a variety of supplements and interventions (including multivitamins; vitamins A, C, and E; vitamin D alone; reduced saturated fat intake; and the Mediterranean diet). This study showed with “low-certainty” that omega-3 long-chain polyunsaturated fatty acid was associated with reduced risk for myocardial infarction (heart attack) and coronary heart disease.
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So who do you believe? At first blush, a study involving nearly a 1,000,000 participants seems a lot more compelling than one involving 12,500. But sample size alone may not make it a ‘better’ study (although it certainly has more statistical power). However, these two seemingly contradictory studies may in fact be studying different things. The trial cited by the NYT is among individuals “at risk of heart trouble”. The second article considered a wider segment of the population.
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So what do you do? A reasonable conclusion for the general public is that based on the evidence for effects on risk factors and clinical events, and (importantly!) no evidence to suggest harm, most adults should consume at least one to two servings per week of oily fish. Those who do not eat this much fish may consider taking a daily fish oil supplement (about 1 g/day).
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Further, it seems to me that “This Week In Fish Oil” also is a cautionary tale against headlines labeling supplements or interventions as a “myth” when previous evidence was simply contradictory. It also argues against a notion of a single definitive study as compared to a broader analysis of existing information. In this case, the fish oil “myth” was instead supported with compelling evidence only 8 days later.
Effects of Nutritional Supplements and Dietary Interventions on Cardiovascular Outcomes

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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8 July 2019 Blog Post: Breast Cancer

8 July 2019 Blog Post: Breast Cancer

I thought that I would start a larger conversation regarding breast cancer risks and screening recommendations (this has been requested by several patients so thank you for your patience!) by highlighting a recent article about alcohol intake as a risk factor for breast cancer.
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According to a June 19th, 2019 British Medical Journal article, only 20% of women (and only 50% of medical staff at mammography sites!), knew that alcohol was a risk factor for breast cancer.
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A variety of factors contribute to one’s breast cancer susceptibility. Breast cancer is the most frequently diagnosed malignancy and the leading cause of cancer death in women. The probability of developing breast cancer in one’s lifetime from birth to death is 12.4% (1 in 8 women).
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Established high risk factors include (this is not an exhaustive list but highlights major modifiers):
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1. Advancing age
2. Female gender (breast cancer occurs 100 times more frequently in women than in men),
3. White race (highest rate of breast cancer occurs among white women, although breast cancer remains the most common cancer among women of every major ethnic group),
4. Weight and body fat (A higher BMI and/or perimenopausal weight gain have been consistently associated with a higher risk of breast cancer among postmenopausal women although an increased BMI is associated with a lower risk of breast cancer in premenopausal women),
5. Tall stature ( In one study, women who were >175 cm (69 inches) tall were 20 percent more likely to develop breast cancer than those <160 cm (63 inches) tall),
6. Estrogen levels (High endogenous estrogen levels increase the risk of breast cancer),
7. Earlier menarche and later menopause (Early age at menarche is associated with a higher risk of breast cancer. In addition, later age at menopause increases breast cancer risk),
8. Nulliparity (Nulliparous women are at increased risk for breast cancer compared with parous women),
9. Increasing age at first full term pregnancy ( Women who become pregnant later in life have an increased risk of breast cancer),
10. Personal history of breast cancer ( A personal history of ductal carcinoma in situ (DCIS) or invasive breast cancer increases the risk of developing an invasive breast cancer in the contralateral breast),
11. Family history of breast cancer (The risk associated with a positive family history of breast cancer is strongly affected by the number of female first-degree relatives with and without cancer and the age at diagnosis),
12. Alcohol (Alcohol consumption is associated with an increased risk of breast cancer development),
13. Smoking (Although results have not been uniform, multiple studies suggest there is a modestly increased risk of breast cancer in smokers),
14. Night shift work (Night-shift work is recognized by the International Agency for Research on Cancer and the World Health Organization as a probable carcinogen, although evidence is mixed).
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It is sometimes frustrating to be confronted with a myriad of risk factors, some of which are out of our control. The good news is that there are some demonstrated protective factors that reduce the risk of breast cancer. These include:
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1. Breast feeding (A protective effect of breastfeeding has been shown in multiple case-control and cohort studies and meta-analyses),
2. Physical activity (regular physical exercise appears to provide modest protection against breast cancer, particularly in postmenopausal women).
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And several factors have been identified that do not influence breast cancer risk, including: abortion, tubal ligation, caffeine, cosmetic breast implants, electromagnetic fields, electric blankets, and hair dyes – these have not been associated with breast cancer risk.
Most Women Don't Realize Alcohol Is a Risk Factor for Breast Cancer

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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8 July 2019 Blog Post: Synthetic Cannabinoids

8 July 2019 Blog Post: Synthetic Cannabinoids

As an adult practitioner, it is sometimes difficult to keep up with trends in recreational drug use. An interesting article was published in Pediatrics highlighting the risks of synthetic cannabinoids in teenagers, a substance with which I have little clinical experience. Chemical analogues of THC, called “synthetic cannabinoids” may have been available in Europe as early as 2004, and were first reported in the United States in December 2008.
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Synthetic cannabinoids are chemicals similar to those found in the marijuana plant that are either sprayed on dried, shredded plant material so they can be smoked or sold as liquids to be vaporized and inhaled in e-cigarettes and other devices.
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According to this recently published study, synthetic cannabinoids are significantly more likely than traditional cannabis to lead to seizures and coma. Specifically, coma or occurred more often among patients exposed to synthetic cannabinoids versus cannabis (29% vs. 11%), as did seizures (19% vs. 6%).
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I remind my adult patients that the potency of even naturally occurring (non-synthetic) cannabis has increased around the world in recent decades. This increased potency may have contributed to increased rates of cannabis-related adverse effects. However, unlike synthetic cannabinoids, serious cannabis intoxication is rare in adolescents and adults.
Neuropsychiatric Sequelae in Adolescents With Acute Synthetic Cannabinoid Toxicity

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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