Laughter May Increase Appetite

A hearty laugh and a moderate workout may have more in common than anyone thought.

Both affect the appetite hormones in much the same way:

- When leptin goes down, it increases appetite
- When ghrelin goes up, it increases appetite

That is what typically happens after moderate exercise.

Leptin (from Greek, leptos, meaning thin) is a protein hormone that plays a key role in regulating energy intake and expenditure, including appetite and metabolism. Leptin acts on receptors in the hypothalamus of the brain where it inhibits appetite.

Ghrelin is a hormone that stimulates hunger. The name is based on its role as a growth hormone-releasing peptide, with reference to the root "ghre", meaning to grow. It is produced by the cells lining the fundus of the stomach and epsilon cells of the pancreas. It is considered the counterpart of the hormone leptin, produced by adipose tissue.

Twitter comments:

@LJaneTn Fat and Funny?

@doctorwhitecoat This explains why I'm always so hungry.

@scanman That explains why I eat too much when I party with friends.

References:
Laughter Affects Appetite Much Like a Workout Does. WebMD.

Image source: Wikipedia, public domain.

Anticancer effect of "5 a day" fruit and vegetable servings is negligible

It is widely believed that cancer can be prevented by high intake of fruits and vegetables. However, inconsistent results from many studies have not been able to conclusively establish an inverse association between fruit and vegetable intake and overall cancer risk.

People who eat more fruit and vegetables than average may have a slightly reduced risk of getting cancer, a big study concludes, but the benefit is much smaller than previous studies suggested.

The European Prospective Investigation Into Cancer and Nutrition (EPIC) was a 9 year prospective study of nearly 500 000 Europeans. It concluded that the protective effect of eating fruit and vegetables is “very small” (J Natl Cancer Institute 2010).

Associations between reduced cancer risk and increased intake of total fruits and vegetables combined and total vegetables for the entire cohort were similar (200 g/d increased intake of fruits and vegetables combined, HR = 0.97); 100 g/d increased intake of total vegetables, HR = 0.98); intake of fruits showed a weaker inverse association (100 g/d increased intake of total fruits, HR = 0.99).

The reduced risk of cancer associated with high vegetable intake was restricted to women (HR = 0.98). Stratification by alcohol intake suggested a stronger reduction in risk in heavy drinkers and was confined to cancers caused by smoking and alcohol.

References:

Study finds that anticancer effect of “5 a day” is less than expected. BMJ, 2010.
Fruit and vegetable intake and overall cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC). J Natl Cancer Inst. 2010 Apr 21;102(8):529-37. Epub 2010 Apr 6.

President Obama has been smoking for 30 years and managed to quit - and so can you

The White House says President Obama has kicked the habit and stopped smoking. "It's been probably about nine months since he last smoked a cigarette," says Robert Gibbs, the President's press secretary, in an interview with CNN. Mr. Obama, like a lot of smokers, has quit before and started back up again. This time may be different. Gibbs says this is the longest he's known the President to go without a cigarette. He quit by chewing Nicorette gum and exercising a lot of will power.

References:

Stop smoking: Follow the President's example. CNN.
The Presidents Club | Photos: Oval Office Secrets from Truman to Obama | TIME, 2012.

Cleverest women are the heaviest drinkers, according to Telegraph newspaper

Not sure if this is the best choice for a headline... This is the original source: Education, alcohol use and abuse among young adults in Britain. Soc Sci Med. 2010 Jul.

The findings come from a study carried out at the London School of Economics in which researchers tracked the lives of thousands of 34-year-old women and men, all born in the UK during the same week in 1970.

The report states: "The more educated women are, the more likely they are to drink alcohol on most days and to report having problems due to their drinking patterns.

"The better-educated appear to be the ones who engage the most in problematic patterns of alcohol consumption."

They may have more active social lives or work in male-dominated workplaces with a drinking culture. As girls, they may have grown up in middle-class families and seen their parents drink regularly.

According to the researchers, higher educational attainment is associated with increased odds of daily alcohol consumption and problem drinking. The relationship is stronger for females than males. Individuals who achieved high educational test scores in childhood are at a significantly higher risk of abusing alcohol across all dimensions.

References:
Cleverest women are the heaviest drinkers. Telegraph.

Education, alcohol use and abuse among young adults in Britain. Huerta MC, Borgonovi F. Soc Sci Med. 2010 Jul;71(1):143-51. Epub 2010 Mar 31.

Image source: Wikipedia.

Positive attitude and cheerfulness not related to college success

This study investigated the relation between positive affect and college success for undergraduate students matriculating at 21 colleges and universities in the United States.

Positive affect — cheerfulness — was positively related to students’ self-rated academic abilities, self-predicted likelihoods of various college outcomes, self-stated major and academic-degree intentions, and self-reported subjective college outcomes, but negatively related to most objective college-success variables (e.g., cumulative college grade-point average) recorded by the institution of matriculation, and not related to objective college outcomes reported by the student.

Positive affect was thus associated with “positive illusions” about college-success variables.

References:
Positive Affect and College Success. Journal of Happiness Studies - SpringerLink Journal, 2010.

Image source: OpenClipArt.org (public domain).

30 minutes is not enough - middle-aged need full hour of exercise to avoid gaining weight as they age

Middle-aged women need to get at least an hour a day of moderate exercise if they hope to ward off the creep of extra pounds that comes with aging.

According to JAMA, among women consuming a usual diet, physical activity was associated with less weight gain only among women whose BMI was lower than 25. Women successful in maintaining normal weight and gaining fewer than 2.3 kg over 13 years averaged approximately 60 minutes a day of moderate-intensity activity throughout the study.

Already, two-thirds of U.S. adults and nearly one in three children are overweight or obese.

Sheila Anderson, 50, works out at the fitness center three to four times a week, doing 45 minutes of cardiovascular training and a couple of hours a week of weight training.

"Does it strike me as too much?" she said of the finding. "Maybe. It sure is hard to fit in an hour each day. I could not come to the gym seven days a week," she said.

One hour per day of exercise is difficult to achieve. However, even 30 minutes is better than no exercise at all.



Dr. Michael Roizen, Cleveland Clinic Chief Wellness Officer, answers the question "How much exercise is enough?"

Three parts of exercise have been shown to be beneficial to health:

1. Moving the equivalent to 10,000 steps a day.
2. Resistance exercise for 30 minutes a week.
3. 20 minutes of cardiovascular exercise.

References:

Hour of exercise may be too much for busy U.S. women | Reuters.

JAMA 2010;303[12]:1173-1179

Sitting on a patient’s bed, by visitors or doctors, is prohibited by infection control

Iona Heath, general practitioner from London comments on this issue in BMJ:

"I learnt recently from senior nursing colleagues that sitting on a patient’s bed, by either visitors or clinicians, is now also prohibited, apparently in the interests of infection control. A quick internet search of "sitting on the bed" and "infection control" produces a huge list of leaflets from a variety of hospitals, each reinforcing the prohibition.

Doctors should never be discouraged from sitting, because patients consistently estimate that they have been given more time when the doctor sits down rather than stands. Standing makes the conversation seem hurried even when it is not; and, in the hospital setting, sitting on the chair does not seem to work nearly as well, because the levels are somehow all wrong."

Sitting on a chair next to the patient's bed is the best approach.

References:
Do not sit on the bed -- Heath 340: c1478 -- BMJ.

Image source: OpenClipArt.org, public domain.

Correcting Vitamin D Deficiency May Decrease Risk of Heart Disease

Vitamin D is a steroid hormone and a component of a complex endocrine pathway sometimes called 'vitamin D endocrine system' (Medscape, 2012).  In a recent study, 9,400 patients had an average vitamin D level of 19.3 nanograms per milliliter - levels of 30 are generally considered "normal". At their next follow-up visit, 50% of patients had raised their vitamin D levels to above 30 nanograms per milliliter.

Compared with patients whose vitamin D levels were still low, patients who raised their vitamin D levels were 33% less likely to have a heart attack, 20% less likely to develop heart failure, and 30% less likely to die between the two visits (source: WebMD).

"While normal has generally been considered to be 30, some people have suggested 40 or 50 is better. People who increased their vitamin D blood level to 43 nanograms per milliliter had the lowest rates of heart disease and stroke. But increasing it beyond that, say to 60 or 70, offered no greater benefit."

One of the BMJ blogs calls vitamin D "the elixir of life", but it all starts to sound a bit too good to be absolutely true.

What is the best test to diagnose vitamin D deficiency?

Serum 25(OH)D.

The circulating half-life of 25(OH)D is 2 weeks. This is the best test to determine vitamin D status. A 25(OH)D level of less than 32 ng/mL is considered vitamin D insufficient because intestinal calcium absorption is optimized at levels above 32 ng/mL.

A 25(OH)D level of less than 15 or 20 ng/mL have been used to define vitamin D deficiency.

Parathyroid hormone levels start to rise at 25(OH)D levels below 31 ng/mL, which is another marker of vitamin D insufficiency. Although not always required for the diagnosis of vitamin D insufficiency, a serum PTH may be used to help establish the diagnosis of vitamin D insufficiency.

The word vitamin was originally derived from Funk's term "vital amine."

A vitamin D3 dosage of 800 IU/d increased serum 25-(OH)D levels to greater than 50 nmol/L in 97.5% of women http://bit.ly/GzBCcA 

References:
Vitamin D Supplements Lower Heart Disease Risk. WebMD.

Low vitamin D levels in children associated with higher plasma glucose and lower HDL

Vitamin D deficiency occurs frequently in COPD and correlates with severity

Image source: Wikipedia, public domain.

COPD patients with anxiety have a higher risk of exacerbations

Psychological functioning is an important determinant of health outcomes in chronic lung disease.

COPD was associated with a greater risk of anxiety in multivariable analysis (OR 1.85). Among patients with COPD, anxiety was related to poorer health outcomes including worse submaximal exercise performance (less distance walked during the 6-min walk test) and a greater risk of self-reported functional limitations.

Subjects with COPD with anxiety had a higher risk of COPD exacerbations.

COPD is associated with a higher risk of anxiety. Once anxiety develops among patients with COPD, it is related to poorer health outcomes.

References:

Influence of anxiety on health outcomes in COPD. Eisner et al. Thorax 2010;65:229-234 doi:10.1136/thx.2009.126201

Chronic Obstructive Pulmonary Disease (COPD). AllergyCases.org.

Action plan is a key component of self-management programs in patients with COPD. Thorax, 20111.

Image source: Enlarged view of lung tissue showing the difference between healthy lung and COPD, Wikipedia, public domain.

Comments:

Dr RW: I don't have the full text of this paper, and I wonder if they controlled for continued smoking. Nicotine is a powerful anxiolytic for some COPD patients.

16% of motorists may be under the influence of drugs during weekends - one in six cars

Motorists under the influence of drugs are a growing threat on U.S. roads. If you think about driving on a Friday or Saturday evening about 16% of the vehicles - one in six of the cars - the driver will be under the influence of an illicit or licit drug.

"Drugged driving" hampers judgment, reaction time, driving skills and memory.

Video: "Fall down alcohol test".

References:

U.S. says drugged driving growing threat. Reuters.

Am I driving a car? Drunk motorist stuns police http://goo.gl/D9NOa
Drunk Driving, Distracted Driving, Moralism, and Public Health - NEJM
30% of U.S. adults have been arrested by age 23: study. Reuters, 2011.

Following DASH Diet Improves Brain Activity in Overweight Adults

A new study suggest that the DASH diet in combination with regular exercise improves mental activity by 30% in overweight adults compared with those who didn’t diet or exercise. The DASH diet was developed for the Dietary Approaches to Stop Hypertension (DASH) study and emphasizes low-fat dairy products and low-cholesterol foods as well as carbohydrates and fruits and vegetables.

Researchers say high blood pressure affects about 50% of adults aged 60 and older and increases the risk of Alzheimer’s disease and other forms of mental decline like dementia.

These are 5 healthy lifestyle factors associated with a lower risk of developing high blood pressure:

1. Healthy weight: body mass index (BMI) of less than 25.

2. Daily exercise: average of 30 minutes of vigorous exercise per day.

3. Heart-healthy diet (DASH).

4. Moderate alcohol use.

5. Use non-narcotic pain relievers less than once per week.

References:

DASH Diet Fuels the Brain - WebMD.

6 healthy lifestyle factors associated with a lower risk of developing high blood pressure

A table to show the impact of lifestyle interventions on blood pressure http://bit.ly/johjzs - Great for patient education.

Related: What is the best diet in the world? DASH Diet, according to the latest review. TIME, 2011.
The long history of dieting fads: "soap should be eaten for its diuretic properties", wrote a prominent surgeon in 1810. Lancet, 2012. 

Be lucky - it's an easy skill to learn, says researcher

From Telegraph:

The study findings have revealed that although unlucky people have almost no insight into the real causes of their good and bad luck, their thoughts and behaviour are responsible for much of their fortune.

Personality tests revealed that unlucky people are generally much more tense than lucky people, and research has shown that anxiety disrupts people's ability to notice the unexpected.

Unlucky people miss chance opportunities because they are too focused on looking for something else. They go to parties intent on finding their perfect partner and so miss opportunities to make good friends.

Lucky people generate good fortune via 4 principles:

1. They are skilled at creating and noticing chance opportunities.
2. Make lucky decisions by listening to their intuition.
3. Create self-fulfilling prophesies via positive expectations.
4. Adopt a resilient attitude that transforms bad luck into good.

Unlucky people often fail to follow their intuition when making a choice, whereas lucky people tend to respect hunches.

Unlucky people tend to be creatures of routine. Lucky people tend to see the positive side of their ill fortune.



References:

Be lucky - it's an easy skill to learn - Telegraph.co.uk.

Image source: OpenClipArt.org, public domain.

Low risk of transmission of influenza on the plane: 3.5% if sitting within 2 rows of infected passengers

This BMJ study assessed the risk of transmission of pandemic A/H1N1 2009 influenza (pandemic A/H1N1) from an infected high school group to other passengers on an airline flight and the effectiveness of screening and follow-up of exposed passengers.

The design was a retrospective cohort investigation using a questionnaire administered to passengers and laboratory investigation of those with symptoms.

The setting was in Auckland, New Zealand, with national and international follow-up of passengers. The participants were passengers seated in the rear section of a Boeing 747-400 long haul flight that arrived on 25 April 2009, including a group of 24 students and teachers and 97 (out of 102) other passengers in the same section of the plane who agreed to be interviewed.

9 members of the school group were laboratory confirmed cases of pandemic A/H1N1 infection and had symptoms during the flight. Two other passengers developed confirmed pandemic A/H1N1 infection. Their seating was within two rows of infected passengers, implying a risk of infection of about 3.5% for the 57 passengers in those rows.

A low but measurable risk of transmission of pandemic A/H1N1 exists during modern commercial air travel. This risk is concentrated close to infected passengers with symptoms.

Video: "How to Sneeze" Demonstrated by the U.S. Health and Human Services Secretary Kathleen Sebelius. She shows NBC’s Chuck Todd the “Elmo way” to sneeze.

Don't forget to get your influenza immunization (flu shot or spray) this season. The CDC video embedded below clearly explains why this is extremely important.


CDC video: Why Flu Vaccination Matters: Personal Stories from Families Affected by Flu.

References:

Transmission of pandemic A/H1N1 2009 influenza on passenger aircraft: retrospective cohort study. BMJ 2010; 340:c2424 doi: 10.1136/bmj.c2424 (Published 21 May 2010).

Diagram of influenza virus nomenclature. Image source: Wikipedia, GNU Free Documentation License.

Five faces of life with HIV - Chicato Tribune video

The World AIDS Day is December 1. Video source: Chicago Tribune.

How primary care doctors choose the specialists to refer their patients

Dr. Kirsch, a blogging gastroenterologist lists some of the reasons why certain medical specialists are chosen:

- Reciprocity - patients are referred in both directions
- Personal relationships
- Corporate enforcement keeping consultations within the network
- Economic pressure exerted by consultants to maintain referrals. I have seen this happen.
- Specialist willingness to do tests and procedures on request
- Habit
- Patient or family request

References:
How doctors choose which specialists they refer to. KevinMD.com

Image source: OpenClipArt.org, public domain.

The Lancet: Commonest cause of maternal death is post-partum haemorrhage - one woman dies every 7 minutes

99% of all deaths in childbirth are in the least developed countries - 45 million women deliver without a skilled birth attendant every year, a situation in which the greatest number of maternal deaths occur.

The commonest single cause of maternal death is from post-partum haemorrhage, from which one woman dies every 7 minutes.


Health Technologies to Save Mothers. PATH.org video.

References:
Maternal mortality: one death every 7 min. The Lancet, Volume 375, Issue 9728, Pages 1762 - 1763, 22 May 2010.

Acupuncture Is Popular with Patients but Insurance Does Not Cover It

From the NYTimes:

Because her insurer did not cover acupuncture, Ms. Kumar had to pay for the $70 weekly treatments she hoped would put her cycle on a more normal schedule.

Acupuncture remains a largely out-of-pocket form of health care. Sessions with an acupuncturist run about $65 to $120, depending on where you live (and some leading acupuncturists charge as much as $300). Most ailments require at least three treatments, while some chronic issues like arthritis might require biweekly or monthly sessions, depending on the situation.

In a 2007 survey, 3.1 million adults reported using acupuncture in the previous 12 months, up from 2.1 million in a 2002 survey.

References:

Patient Money - Acupuncture May Help, but You’ll Need to Pay - NYTimes.com.

Acupuncture can spread serious diseases: bacterial infections, hepatitis B and C, even HIV
Does traditional Chinese medicine have a place in the health system? http://goo.gl/RH04o

Image source: Needles being inserted into a patient's skin, Wikipedia, public domain.

"Choose primary care, give up $2.5 million"

Researchers at Duke University modeled the earning potential of cardiologists and primary care physicians between the ages of 22 and 65, taking into account medical school debt, earning potential and the age at which doctors begin earning an income. They conducted similar analyses for the average b-school, physician assistant and college graduate.

Over a career, a typical cardiologist earns more than $5 million, primary care physicians earn $2.5 million and business school grads earn $1.7 million. Meanwhile, physician assistants earn about $846,000 and college graduates earn about $340,000.

References:

Choose primary care, give up $2.5M. MedCityNews.

Primary Care Doctors Make $3 Million Less Than Cardiologists Over The Course Of Their Careers. Kaiser Health News' Daily Report.

Image source: OpenClipArt.org, public domain.

What the Average American Consumes in a Year

Average size

The average American is 36.6 years old and eats 1,996.3 lbs. of food per year. The average man is 5’9” and weighs 190 lbs. The average woman is 5’4” and weighs 164 lbs.

Meat consumption

Each year, Americans eat 85.5 lbs. of fats and oils. They eat 110 lbs. of red meat, including 62.4 lbs. of beef and 46.5 lbs. of pork. They eat 16.1 lbs. of fish and shellfish and 32.7 lbs. of eggs.

Americans eat 31.4 lbs. of cheese each year and 600.5 lbs. of non-cheese dairy products. They drink 181 lbs. of beverage milks. They eat 141.6 lbs. of caloric sweeteners, including 42 lbs. of corn syrup.

Fruit and vegetables

Americans consume 56 lbs. of corn each year and eat 415.4 lbs. of vegetables. Americans eat 273.2 lbs. of fruit each year.

Coffee

Every year, Americans consume 24 lbs. of coffee, cocoa and nuts. Americans consume 0.2 lbs. of caffeine each year, about 90,700 mg.

Fast food

The foods include 29 lbs. of French fries, 23 lbs. of pizza and 24 lbs. of ice cream. Americans drink 53 gallons of soda each year, averaging about one gallon each week.

They eat an average of 2,700 calories each day.

Salt

Americans consume 2.736 lbs. of sodium, which is 47 percent more than recommended. Some pizzas are 'saltier than the sea' (NHS blog).

References:
Food Consumption in America - VisualEconomics.com.

The Stroke Robot Will See You Now - Mayo Clinic Video

Mayo Clinic — April 30, 2010 — Imagine this: you're eating dinner with your family and suddenly your left arm feels numb. Your speech is slurred. It could be a stroke, so you've got to get to the hospital fast. But what if your hospital doesn't have a stroke specialist or what if that doctor is out of town? The answer may be telemedicine. Doctors at Mayo Clinic are using a telemedicine robot that allows them to be face to face with patients who are miles away.

Are doctors required to get patient permission to use non-identifiable X-rays, CTs, EKGs for medical education online?

Sam Ko, MD, MBA asked this pertinent question on Twitter. My answer is below. Feel free to correct me and please provide references for your opinion.

Question: "Are Drs required to get Pt permission to use non-identifiable images for medical education?"

Answer: According to most journals, no.

The NEJM policy is here:

"If a photograph of an identifiable patient is used, the patient should complete and sign our Release Form for Photographs of Identifiable Patients. Any information that might identify the patient or hospital, including the date, should be removed from the image."

This is the BMJ policy:

Images – such as x rays, laparoscopic images, ultrasound images, pathology slides, or images of undistinctive parts of the body – may be used without consent so long as they are anonymised by the removal of any identifying marks and are not accompanied by text that could reveal the patient’s identity through clinical or personal detail.

Case Reports and HIPAA

Physicians must assure that the case report does not contain any of the 18 health information identifiers noted in the HIPAA regulations, unless authorization from the individual (s) has been obtained. The authorization is not required if neither of the 18 identifiers below are used in the case report.

List of 18 Identifiers:

1. Names;

2. All geographical subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code, if according to the current publicly available data from the Bureau of the Census: (1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000.

3. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older;

4. Phone numbers;

5. Fax numbers;

6. Electronic mail addresses;

7. Social Security numbers;

8. Medical record numbers;

9. Health plan beneficiary numbers;

10. Account numbers;

11. Certificate/license numbers;

12. Vehicle identifiers and serial numbers, including license plate numbers;

13. Device identifiers and serial numbers;

14. Web Universal Resource Locators (URLs);

15. Internet Protocol (IP) address numbers;

16. Biometric identifiers, including finger and voice prints;

17. Full face photographic images and any comparable images; and

18. Any other unique identifying number, characteristic, or code (note this does not mean the unique code assigned by the investigator to code the data)

References:

Author Center - NEJM Images in Clinical Medicine.

Patient confidentiality. BMJ.

Case Reports and HIPAA Rules

The Human Research Protection Program - UCSF.edu.
HIPAA Resources - The Privacy Rule - NIH.gov.
Single Case Report Policy - Johns Hopkins Medicine.
Medical Case Report Policy - Louisville.edu.
Privacy of Individually Identifiable Health Information. Code of Federal Regulations.

Image source: Bone fracture, from Wikipedia, the free encyclopedia (public domain).

Marathon-associated ailments: “too hot,” “too cold,” “too dry,” “too wet” and “wobble and fall down”

According to the NYTimes, the most common and potentially life-threatening marathon-associated ailments are “too hot,” “too cold,” “too dry,” “too wet” and “wobble and fall down”. These translate into heat stroke, hypothermia, dehydration, low blood sodium and collapse, respectively.

The medical professionals at this year's NYC marathon had ice-water dunk tanks to treat runners who developed high fevers. Handheld i-Stat machines enabled them to analyze the chemistry of the runners’ blood, then dispense the right amounts of intravenous fluids, salts and sugar.



Understanding the Heart Hazards of Marathon Running - Video - TIME.com.

References:
Doctor Prepared for the Worst at Marathon. NYTimes.
Faces at the Finish - Interactive Feature - NYTimes.
Running With the Elites - Slide Show - NYTimes.

What's new in nephrology and hypertension

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in nephrology and hypertension:

Glomerulonephritis

In idiopathic membranous nephropathy, among patients with protein excretion less than 8 grams/day, treatment with an ACE inhibitor or ARB increased the probability of remission.

Hypertension

There was no difference in the rate of myocardial infarction, stroke or death from cardiovascular causes between the intensive versus standard hypertension therapy groups, nor in the all-cause mortality rate. ('ACCORD BP trial'). Intensive therapy included goal systolic blood pressure less than 120 mmHg, standard therapy included goal systolic blood pressure less than 140 mmHg.

Hyponatremia

Tolvaptan is a vasopressin receptor antagonists. The long-term administration of tolvaptan appears to be safe and effective among patients with chronic hyponatremia. Responses were similar in heart failure and SIADH, and more modest in cirrhosis.

Transplantation

An increased incidence of angioedema has been noted in patients administered angiotensin-converting enzyme (ACE) inhibitors plus either sirolimus or everolimus.

Autosomal dominant polycystic kidney disease (ADPKD)

Activation of the mammalian target of rapamycin (mTOR) protein may contribute to cyst growth in autosomal dominant polycystic kidney disease (ADPKD). The inhibition of mTOR with rapamycin preserved renal function and inhibits epithelial cell proliferation and fibrosis in a mouse model of ADPKD. In a human trial, cyst volume was stable on rapamycin.

The long-acting somatostatin octreotide decreased liver volume by 5% in patients with autosomal dominant polycystic liver disease.

References:
What's new in nephrology and hypertension. UpToDate.

Twitter comments:

@kidney_boy (Joel Topf): UpToDate seems to be misrepresenting the ADPKD mTOR data. See my interpretation here: More ADPKD and sirolimus data: More definitive; less encouraging

Liraglutide (Victoza) superior to sitagliptin (Januvia) for reduction of HbA1c in diabetics

Action of DPP-4 inhibitors. Note that DPP-4 normally inactivates GLP-1. DPP-4 inhibitors block DPP-4 which in turn leaves GLP-1 active. Click to enlarge the figure. Created with Gliffy.

What is Glucagon-like peptide-1 (GLP-1)?

Glucagon-like peptide-1 (GLP-1) is a GI peptide that stimulates insulin secretion (similar to sulfonylureas). GLP-1 also inhibits glucagon release, gastric emptying and food absorption. GLP-1 and another similar peptide are called incretins. As noted above, incretins have a dual action which leads to lowering blood glucose:

1. Stimulate insulin release
2. Inhibit glucagon release

Exenatide (Byetta) is a GLP-1 receptor agonist approved for adjunctive therapy for patients with DM 2 who are not well controlled on oral agents. It is available only as injections and has to be administered twice daily.

DPP-4 inhibitors, or gliptins, increase GLP-1 levels by blocking the enzyme which inactivates GLP-1. The enzyme is called DPP-4 (dipeptidyl peptidase-4). They act similarly to Byetta (see figure above) but have the big advantage to be available in oral form (pills). Gliptins used for treatment of DM2 include sitagliptin (Januvia) and vildagliptin (Galvus).

What is Liraglutide?

Liraglutide (Victoza) is a long-acting glucagon-like peptide-1 (GLP-1) analog that was developed by Novo Nordisk for the treatment of type 2 diabetes. Liraglutide has a half-life after subcutaneous injection of 11–15 hours, making it suitable for once-daily dosing (in contrast to Byetta's twice daily).


Liraglutide. Image source: Wikipedia, public domain.

Liraglutide (Victoza) superior to sitagliptin (Januvia) for reduction of HbA1c in diabetics

This Lancet study assessed the efficacy and safety of the human GLP-1 analogue liraglutide versus the DPP-4 inhibitor sitagliptin, as adjunct treatments to metformin, in individuals with type 2 diabetes who did not achieve adequate glycaemic control with metformin alone.

More than 600 participants (aged 18—80 years) with type 2 diabetes mellitus who had inadequate glycaemic control (glycosylated haemoglobin [HbA1c] 7·5—10·0%) on metformin (more than 1500 mg daily) were enrolled.

Participants were randomly allocated to receive 26 weeks' treatment with 1·2 mg or 1·8 mg subcutaneous liraglutide once daily, or 100 mg oral sitagliptin once daily.

Greater lowering of mean HbA1c (8·5% at baseline) was achieved with 1·8 mg liraglutide (−1·50%) and 1·2 mg liraglutide (−1·24%) than with sitagliptin (−0·90%).

Nausea was more common with liraglutide (27%) on 1·8 mg. Minor hypoglycaemia was recorded in about 5% of participants in each treatment group.

Liraglutide was superior to sitagliptin for reduction of HbA1c, and was well tolerated with minimum risk of hypoglycaemia. These findings support the use of liraglutide as an effective GLP-1 agent to add to metformin.

References:

Liraglutide versus sitagliptin for patients with type 2 diabetes who did not have adequate glycaemic control with metformin: a 26-week, randomised, parallel-group, open-label trial. The Lancet, Volume 375, Issue 9724, Pages 1447 - 1456, 24 April 2010.

In-flight exercises help during plane travel

Prolonged immobilization can cause circulatory stasis which is one of the predisposing factors for DVT described by Virchow in his famous triad: endothelial injury, stasis and hypercoagulability.

In a trial of previously healthy patients who traveled at least 8 hours per flight (median duration 24 hours), duplex ultrasound showed an asymptomatic DVT in 10 % of participants. In other studies, the reported risk of symptomatic DVT after flights of more than 12 hours was 0.5%. According to a 2006 Lancet study, activation of coagulation occurs in some individuals after an 8-hour flight.

This Chicago Tribune article lists some useful in-flight exercises:

In-flight exercises for beginners

- Shoulder shrugs, shoulder rolls. Ten each.
- Short sets of bending and straightening the elbows and knees.
- Walk through the plane every two hours.
- March your knees up and down in your seat.
- Lift and lower your feet on tiptoes to work the calves.

Advanced In-flight exercises

- Neck stretches; hold on each side for 15 to 20 seconds.
- If you can find space (near an exit), work the core with yoga stretches. Pigeon pose — an intermediate move of folding one leg under the body while stretching the back leg out — is an in-flight favorite of hers.
- In your seat, lift your arms over your head, grip your hands together and lean from side to side for a few seconds on each side. Repeat.
- Walk the length of the plane every hour, incorporating deep lunges. Unless you want air marshals on your case, it might be wise to notify a flight attendant.
- Put a small flight pillow in small of back to keep posture upright.

References:
Midair exercise makes for happier landings. Chicago Tribune, 10/2010.

Prolonged immobilization increases risk of DVT -- how do you define prolonged immobilization?

"Avoiding Airport Germs and Healthy Plane Travel Tips" by WebMD http://goo.gl/rLO2h

The risk of VTE (blood clots) is 3 times higher in passengers on long-distance flights than in the general population http://goo.gl/Tk45Z
Exercises for air travel — Cleveland Clinic Journal of Medicine, 2011.

Will Airplane Air Make Me Sick? No, but proximity to the other passengers very well might. WebMD, 2011.

Happiest people are 22% less likely to develop heart disease

From WebMD:

Happiest people were 22% less likely to develop heart disease over the 10 years of follow-up than people who fell in the middle of the negative-positive emotion scale.

People with the most negative emotions had the highest risk for heart disease and people who scored highest for happiness had the lowest risk.

Possible explanations for how happiness may protect the heart:

- Healthier lifestyle: Happy people tend to sleep better, eat better, smoke less, and get more exercise.
- Physiological impact: Happiness may produce a host of positive chemical changes -- such a reduction in stress hormones.
- Genetic influences: It could be that people who are predisposed to happiness are also predisposed to have fewer heart attacks.

Devote 15-20 minutes a day to doing something enjoyable and relaxing.

Strategies that could help naturally negative people become happier:

- Express gratitude on a regular basis.
- Practice being optimistic.
- Engage in frequent acts of kindness.
- Visualize one's best self.
- Savor joyful events.
- Practice forgiveness.

Regular exercise, sexual activity and good sleep are associated with increased self-reported happiness.

References:

Study: Happiness Good for the Heart. WebMD.

Experienced happiness is largely set by personality, it will temporarily respond to changing circumstances. The Lancet, 2010. http://goo.gl/ot3Kx

What's the best exercise for heart health? A combination of weight training and aerobic exercise http://goo.gl/h1YKD and bit.ly/on9sNn

Image source: OpenClipArt.org, public domain.

What's new in gastroenterology and hepatology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in gastroenterology and hepatology:

Hepatitis C virus (HCV) infection

Peginterferon alfa-2a was superior to peginterferon alfa-2b with regard to virologic response rates in patients with chronic hepatitis C virus infection, genotypes 1, 2, 3, or 4. Patients being treated for chronic hepatitis C virus infection should receive peginterferon alfa-2a rather than peginterferon alfa-2b.

72 weeks of therapy with peginterferon alfa-2a plus ribavirin in patients with HCV genotype 1 or 4 was not better than 48 weeks.

Chronic use of proton pump inhibitors (PPIs)

Chronic use of proton pump inhibitors (PPIs) may lead to an increased risk of fractures. FDA recommends that healthcare professionals who prescribe proton pump inhibitors should consider whether a lower dose or shorter duration of therapy would adequately treat the patient's condition.

Ulcerative colitis

Once daily dosing of delayed-release mesalamine (Asacol 400 mg tablets) 1.6 to 2.4 g/day was as effective as twice daily dosing for maintenance of clinical remission in patients with ulcerative colitis. Remission rates were 85% in both groups.

Crohn's disease

Capsule endoscopy was not a cost-effective third test for establishing the diagnosis of Crohn's disease after a negative ileocolonoscopy and either a CT enterography or small bowel follow-through x-ray.

Azathioprine in combination with infliximab or infliximab alone had a higher rate of glucocorticoid-free clinical remission than those treated with azathioprine alone. Combination therapy and infliximab monotherapy led to significantly more complete bowel healing than azathioprine alone.

Obscure gastrointestinal bleeding

Double balloon enteroscopy (DBE) detected bleeding sources in 78% of patients with obscure gastrointestinal bleeding. Small intestinal ulcers and erosions were the most common findings.

References:
What's new in gastroenterology and hepatology. UpToDate.

Lowering Triglycerides With Exercise - Mayo Clinic Video

Mayo Clinic | October 22, 2010: Instead of taking medicine to lower triglycerides, most people can lower that number simply by moving more.

"Talk to Frank" - British government website for drug abuse prevention and treatment

Talk to Frank" is a British government-funded website for drug abuse prevention and treatment tips for the general public available at http://www.talktofrank.com

The "A to Z" list of substances explains appearance and use, effects, chances of getting hooked, health risks and the UK law. It also includes information on peer pressure, etc.

Statins Use in Presence of Elevated Liver Enzymes: What to Do?

The beneficial role of statins in primary and secondary prevention of coronary heart disease has resulted in their frequent use in clinical practice.

However, safety concerns, especially regarding hepatotoxicity, have driven multiple trials, which have demonstrated the low incidence of statin-related hepatic adverse effects. The most commonly reported hepatic adverse effect is the phenomenon known as transaminitis, in which liver enzyme levels are elevated in the absence of proven hepatotoxicity.

"Ttransaminitis" is usually asymptomatic, reversible, and dose-related.


Lovastatin, a compound isolated from Aspergillus terreus, was the first statin to be marketed for lowering cholesterol. Image source: Wikipedia, public domain.

The increasing incidence of chronic liver diseases, including nonalcoholic fatty liver disease and hepatitis C, has created a new challenge when initiating statin treatment. These diseases result in abnormally high liver biochemistry values, discouraging statin use.

A PubMed/MEDLINE search of the literature (1994-2008) was performed for this Mayo Clinic Proceedings review. The review supports the use of statin treatment in patients with high cardiovascular risk whose elevated aminotransferase levels have no clinical relevance or are attributable to known stable chronic liver conditions.

References:
Statins in the Treatment of Dyslipidemia in the Presence of Elevated Liver Aminotransferase Levels: A Therapeutic Dilemma. Rossana M. Calderon, MD, Luigi X. Cubeddu, MD, Ronald B. Goldberg, MD and Eugene R. Schiff, MD. Mayo Clinic Proceedings April 2010 vol. 85 no. 4 349-356.

What's new in obstetrics and gynecology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in obstetrics and gynecology:

Obstetrics

Influenza vaccination with inactivated vaccine is recommended for pregnant women, regardless of the stage of pregnancy. The 2010-2011 influenza vaccine is trivalent and includes antigens from both the 2009 pandemic H1N1 influenza virus and seasonal influenza viruses.

Use of acetaminophen during pregnancy was associated with a reduction in neural tube defects, as well as cleft lip/palate and gastroschisis. These data support the safety of acetaminophen for relief of fever and pain.

Gynecology

Like CA 125, human epididymal secretory protein E4 (HE4) is a promising biomarker for ovarian cancer. In contrast to CA 125, HE4 levels do not appear to be elevated in women with endometriosis, and thus can be useful to rule out ovarian cancer in patients with endometriosis and a pelvic mass suspected to be an endometrioma.

Sterilization does not impact sexual function. Sexual function appears to be unchanged or improved in women following tubal sterilization.

Botulinum toxin may be useful for overactive bladder syndrome (onabotulinumtoxinA, Botox®). Detrusor injection of botulinum toxin (BoNT) had a transient effect. The average time between injections was 8 to 12 months.

References:
What's new in obstetrics and gynecology. UpToDate.

Image source: Wikipedia, GNU Free Documentation License.

Stelara (ustekinumab) and Remicade (infliximab) are effective if Enbrel (etanercept) stops working in psoriasis

About 7.5 million Americans suffer from psoriasis, a lifelong disorder characterized by inflammation of skin and, often, the joints.



Stelara, Remicade, and Enbrel are all biologics -- drugs made of genetically engineered proteins -- that are generally used to treat patients who aren't responding to traditional therapies such as light therapy and methotrexate.



Remicade and Enbrel both block tumor necrosis factor-alpha (TNF-alpha), a chemical produced by immune cells that fuels inflammation, much like gas on a fire. Stelara targets two proteins, interleukin 12 and interleukin 23, that also drive the inflammatory process.



References:

Study Shows Stelara and Remicade Are Both Effective if Enbrel Stops Working. WebMD, 2010.

Ustekinumab is a Strong Option for Moderate to Severe Psoriasis - anti-IL12/23 monoclonal antibody with NNT of 2 http://goo.gl/gbXSJ

Image source: Crystal structure of human IL-12, Wikipedia, public domain.

In Adolescents, Gratitude Leads to More Success Than Materialism

Materialistic youth seem to be languishing while grateful youth seem to be flourishing.

In this study, 1,000 high school students completed measures of materialism, gratitude, academic functioning, envy, depression, life satisfaction, social integration, and absorption.

Gratitude, controlling for materialism, predicted all outcomes considered: higher grade point average, life satisfaction, social integration, and absorption, as well as lower envy and depression.

In contrast, materialism, controlling for gratitude, uniquely predicts three of the six outcomes: lower grade point average, as well as higher envy and life satisfaction.

References:
Gratitude and the Reduced Costs of Materialism in Adolescents. Jeffrey J. Froh1 , Robert A. Emmons2, Noel A. Card3, Giacomo Bono4 and Jennifer A. Wilson1. Journal of Happiness Studies, 2010.
http://www.springerlink.com/content/21616624m5621673/

Comments from Twitter:

@drjohnm RT @DrVes: In Adolescents, Gratitude Leads to More Success Than Materialism >>It also much better for the heart.

Tom Jones at 70: "I will sing as long as I possibly can. My enemy is time"

He's sold over 150 million records, but Sir Tom Jones has confessed that he dreads the day that he can no longer sing.

The 70-year-old veteran -- whose latest album 'Praise and Blame' is a meditative collection of gospel and blues songs dealing with spirituality and mortality -- was speaking to CBS News when he revealed his fear.

"I dread the day. Time is my enemy. Time will catch up with me vocally. And I dread that,' he said. "I dread to think about life without singing because I can express myself, it's a great release, it's a wonderful feeling to get on stage and pour all this stuff out and for people to go, 'Yeah!'''

From the comments on the YouTube video:

catcando75: I grew up listening to this man who belted out a song like no other & always did it in skin tight pants! His voice was clear & crisp yet deep & raspy. When you watched him you knew he loved every note because he wore it like a banner on his face. He pushed tv limits without a pause, his charisma was strong. This is a man so in love with music he knows no boundaries...

References:
Tom Jones: Time Is My Enemy. CBS.
'Time is my enemy': Tom Jones confesses to US TV network CBS that he 'dreads' the thought of retirement. Daily Mail.

Tom Jones: 'I Want to Live Forever' (video) http://goo.gl/UZ2jX

Free Medical Education Resources by the Association of American Medical Colleges (AAMC)

Head, Neck and Oral Cancer Examination

This 40-minute video is intended for practitioners of dentistry, medicine, nursing and public health who are responsible for diagnosing and referring patients with head and neck and oral cancer.

Emergency Medicine Ultrasound Simulation (U/SS) Case Scenario Package

This resource consisit of a modular package containing 5 high-fidelity full-body simulation case scenarios with supplemental bedside Emergency Department Ultrasound videos (de-identified) to assist in EM decision-making training.

Disclosing Medical Errors To Patients

This is a standardized patient case, which has been used to assess the communication skills of radiology residents when disclosing a medical error to a patient. The case content can be modified for use in other specialties. The checklist for the standardized patient and the self-evaluation checklist for the resident can be used without modification by all residencies.

Introduction to Effective Communication Skills

This PowerPoint with audio program covers the relevance and basic concepts of communication and interpersonal skills as they apply to general dentistry.

The Study Skills Workshop

The Study Skills Workshop was introduced to guide and promote 1st year Medical Students towards effective ways of learning in medicine. It is hoped that through the workshop the students are able to identify their individual learning styles and approaches. Thus they can find out self-improvement strategies to enhance their learning in medicine.

Image source: OpenClipArt.org, public domain.

What's new in endocrinology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in endocrinology:

Osteoporosis

Denosumab (Prolia)

Denosumab is a fully human monoclonal antibody that specifically targets a ligand known as RANKL (that binds to a receptor known as RANK) which is a key mediator of osteoclast formation, function, and survival. Denosumab was approved for the treatment of postmenopausal women with osteoporosis at high risk for fracture (history of osteoporotic fracture, multiple risk factors for fracture) or patients who have failed or are intolerant of other available osteoporosis therapies. Denosumab inhibits the formation, function, and survival of osteoclasts. It decreases bone resorption, increases bone mineral density (BMD), and reduces the risk of fracture.

Teriparatide (Forteo)

Teriparatide (parathyroid hormone) did not accelerate fracture healing in postmenopausal women with distal radial fractures.

Transdermal teriparatide patch worked as well as teriparatide injection in postmenopausal women with osteoporosis.

Orlistat (Xenical, Alli) in obesity

Severe liver injury has been reported rarely with the use of orlistat (13 reports). Over the ten year period of the review, an estimated 40 million people worldwide used orlistat.

References:
What's new in endocrinology and diabetes mellitus. UpToDate.

Image source: Flickr, Creative Commons license.

Physicians as a group are leaner, fitter and live longer than average Americans

From the WSJ:

Physicians as a group are leaner, fitter and live longer than average Americans. Male physicians keep their cholesterol and blood pressure lower.

However, doctors are less likely to have their own primary care physician—and more apt to abuse prescription drugs.

Lifestyle habits

Exercise: Many physicians say they "embed" it into their lives, making it a non-negotiable part of their daily routine, often early in the morning before demands pile on. One doctor says he gets up at 4:45 a.m. virtually every morning to train for marathons he runs. "But by 8:30 at night, I have the IQ of a zucchini," he says.

Smoking: Only 2% to 4% of physicians smoke cigarettes, compared to roughly 24% of the U.S. population.

Stress: For all their good habits, it's no secret that doctors are under enormous pressure.

References:

What Patients Can Learn from the Ways Physicians Take Care of Themselves. WSJ.
Chicago doctors talk about healthy habits in their own lifestyle - not surprisingly ladies do a lot better than the guys http://goo.gl/jFf7w

Image source: OpenClipart.org, public domain.

Comments from Twitter:

@IrfanDhalla (Irfan Dhalla): Wonder if they still would be after adjusting for income? MT @DrVes: Physicians as a group are fitter and live longer goo.gl/b5C3

New CPR Guidelines - Hands Only - Use "CAB" Instead of "ABC" While Singing "Stayin' Alive"

The American Heart Association is adopting new cardiopulmonary Resuscitation (CPR) guidelines that do away with mouth to mouth resuscitation and focus on chest compressions. Do fast, forceful compressions; the beat of "Stayin' Alive" is the right pace - 100 beats per minute. Queen's "Another one bites the dust" was rejected as an alternative song choice.

Currently, this recommendation only applies to laymen CPR. The professional rescuers (EMTs, doctors, etc.) should use the previous approach with a compression-breathing (ventilation) ratio of 30:2.

However, “chest compression only” CPR is recommended if the rescuer is not trained (for example, in dispatcher assisted CPR) or is not willing to give rescue breaths. The aim is now to compress the chest to a depth of 5-6 cm (rather than 4-5 cm). This recommendation is based on several studies showing that deeper compressions were associated with improved short term outcomes.


Dr. Sanjay Gupta shows Matthew McConaughey the new way of doing CPR on Larry King Live.


Bee Gees - Stayin' Alive.

References:

New CPR is spelled C-A-B. CNN.
New international guidelines on resuscitation. BMJ, 2010.

Related reading:

Dangers of unrecognized heart disease: Husband dies while giving wife CPR (both found dead, age 60, 59) http://goo.gl/LZ39U
British Heart Foundation is urging people to forget "mouth-to-mouth" during CPR: 'no kissing, just hard CPR'. BBC, 2011.

Stereotypes in medical photographs

From BMJ:

If you search "medicine" on Google Images, you get a hundred million photographs.

The most common image is a stethoscope. The next is a bottle of pills (or, sometimes, red and black capsules). The next is a surgeon, masked and gowned, slicing skin with a scalpel.

Try "patient" and you will find lots of people in stripy pyjamas, lying obediently in bed, often with a spotty rash or a leg strung up in an orthopaedic hoist.

New images are needed to break the century-old stereotypes in medical photographs.

References:
New images needed: stereotypes in medical photographs. BMJ 2010;340:c1524.

Why doctors should use social media: it benefits their patients enormously

Wendy Sue Swanson, who blogs as Seattle Mama Doc, is a pediatrician in Seattle who recently gave a keynote at the Swedish Medical Center as part of their 2010 Health Care Symposium. See for yourself why doctors must use social media to stay uptodate and educate the public:



Link via KevinMD

Gonorrhea Getting Harder to Treat - Antibiotic Resistance Pushing Gonorrhea Toward Superbug Status

Gonorrhea is a common sexually transmitted bacterial infection. If left untreated, gonorrhea can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility in women. Treatment for gonorrhea usually consists of a single dose of one of two antibiotics, cefixime or ceftriaxone.

The current drugs of choice, ceftriaxone and cefixime, are still very effective but there are signs that resistance, particularly to cefixime, is emerging and soon these drugs may not be a good choice.

Only one remaining class of antibiotics is recommended for the treatment of gonorrhea - cephalosporins. Historically, gonorrhea has progressively developed resistance to the antibiotic drugs prescribed to treat it. Thus, it is critical to continuously monitor antibiotic resistance in Neisseria gonorrhoeae.

As a side note that highlights the prevalence of the problem, there are at least 10 songs titled "Gonorrhea" by various artists in the Amazon.com MP3 music store.



CDCStreamingHealth | April 16, 2010: This video, produced by Be Smart. Be Well., raises awareness of Sexually Transmitted Diseases (STDs): 1) What are they? 2) Why they matter? and, 3) What can I do about them? Footage courtesy of Be Smart. Be Well. http://www.besmartbewell.com, featuring CDC's Dr. John Douglas, Division of Sexually Transmitted Disease Prevention.

References:

Gonorrhea Getting Harder to Treat. WebMD.
Sex infection gonorrhea risks becoming "superbug". Reuters.
Antibiotic Resistant Gonorrhea. CDC.

Sexually Transmitted Diseases (STDs) - Diagnosis and Management Slideshow from Medscape http://goo.gl/uzwA

10 risk factors are associated with 90% of the risk of stroke

The Lancet reported that in 3000 patients with stroke (78%, with ischaemic stroke; 22%, with intracerebral haemorrhagic stroke) and 3000 controls, significant risk factors for all types of stroke were:

- history of hypertension (OR 2·64)

- current smoking (2·09)

- waist-to-hip ratio (1·65)

- diet risk score (1·35)

- regular physical activity (0·69)

- diabetes mellitus (1·36)

- alcohol intake (1·51)

- psychosocial stress (1·30)

- depression (1·35)

- cardiac causes (2·38)

- ratio of apolipoproteins B to A1 (1·89)

Collectively, these risk factors accounted for 88·1% of the PAR for all strokes. When an alternate definition of hypertension was used (history of hypertension or blood pressure higher than 160/90 mm Hg), the combined PAR was 90·3% (85·3—93·7) for all stroke.

These risk factors were all significant for ischaemic stroke, whereas hypertension, smoking, waist-to-hip ratio, diet, and alcohol intake were significant risk factors for intracerebral haemorrhagic stroke.

Ten risk factors are associated with 90% of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the burden of stroke.

References:

Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. The Lancet, Volume 376, Issue 9735, Pages 112 - 123, 10 July 2010

Stroke Risk Calculator http://goo.gl/elmc
Image source: BP device used for measuring arterial pressure. Wikipedia, GNU Free Documentation License.

Distracted Walking Featured in the New Windows Phone Ads

Distracted driving has gained much attention lately because of the inflated crash risk posed by drivers using cellphones to talk and text. But phones aren't just distracting drivers; they make pedestrians inattentive too.

Distracted walking combines a pedestrian, an electronic device and an unseen crack in the sidewalk, the pole of a stop sign, a toy left on the living room floor or a parked (or sometimes moving) car.

There are plenty of examples of the dangers of distracted walking in the two videos embedded in this page. These are also examples of "distracted life" in general:



References:
Forget Gum. Walking and Using Phone Is Risky. NYTimes.
Video: Stop texting while driving. Terrifying. All drivers should watch this.