Is 10 Minutes of Exercise Beneficial?

I read an article by Lauran Neergaard (Associated Press) recently about the benefits of ten minutes of exercise. It has been found that 10 minutes of exercise leads to metabolic change for more that an hour. Researchers are wondering what causes the health improvements of working out and eating well and whether some biologically pre-disposed to get more benefit?

These researches are from a new field that studies the unique chemical fingerprints that cellular processes leave behind.  They have measured biochemical changes in a variety of people during exercising and found changes in more than twenty metabolites that change during exercise. Naturually produced compounds involved in burning calories and fat and improving blood-sugar control.

The benefits are not limited to "healthy" individuals. Even those who are sick and weak from their illness or treatment can benefit from a little exercise.  Several personal trainers have developed workouts 10 - 15 minutes in duration.  Another article, by Landon Hill,  gives a few tips.

• Start out slowly. If you walk 15 minutes a day, add another 5 minutes.
• If you golf and usually ride in the cart, carry your bag once in a while.
• At work, take the stairs every now and then, or go across the office to talk to a colleague instead of e-mailing.
• Avoid boredom. Go for a walk at a different time of day, or try something new, like an aerobics class.
• There’s strength in numbers: Exercise with a group, or meet regularly to keep each other’s spirits up.
• Join, or start, an office or community “biggest loser” competition. My friend Dave mocked the one going on at his office, but he stepped on the scale anyway. He had ballooned to 248 pounds. Appalled, he eventually lost 60.
• Chronicle your goals, plans and progress in a journal. Or if you’re feeling bold, broadcast them on Facebook. Announcing a strategy makes it more real — there’s no turning back now — and you’ll find plenty of encouragement.
• Don’t push it early on. Allow for rest days between workouts.
• If you’re walking long distances or even running, go to a good running shop for shoes that match your physique and activity level.
• Join a gym. Get a free day pass or go as the guest of a member. If you don’t like the meat-market gyms, try Curves.

Avandia (Rosiglitazone) - Update

Initially the FDA recommended to allow Glaxo SmithKline (GSK) to continue their study which compares their drug Avandia to Actos a medication in the same class, but without the cardiovascular side effects. But on 21 July, the FDA announced that the study has been placed on a partial clinical hold (no new patients can be enrolled) until further notice.

In light of this action, the American Heart Association (AHA) recommends that patients not change or stop their medications without first consulting with their physician (s). They also recommend that physicians use Metformin as a drug of first choice in Type 2 Diabetes. The AHA also urges physicians to examine data relating to Avandia, diabetes, and heart disease and make an educated choice on whether or not to prescribe Avandia.

GSK continues to maintain the safety of Avandia, but will to follow the FDA's recommendations and will continue to work with the FDA in the best interest of diabetic patients.

Avandia (Rosiglitazone)

The diabetes drug Avandia (rosiglitazone) has been in the news recently as questions arise about its safety. The safety concern was brought into the public light after a study by Dr. Steven Nissen, a cardiologist at the Cleveland Clinic, showed that the drug increased heart attacks by 43 percent in patients given Avandia versus those given a placebo.

Avandia is a medication used in type II diabetes to control blood sugars by making the body more sensitive to insulin. It was approved by the FDA in 1999 based on the findings that it reduced blood glucose levels. There was no evidence that it reduced any known diabetes complications.

The study by Dr. Nissen was a meta-analysis of 42 previous studies. It revealed a significant increase in cardiovascular events (heart attack, heart failure, and stroke), an increase in risk of bone fractures and osteoporosis by interfering with the bone's process of replenishing bone cells. In addition, it has been shown to increase cholesterol and possibly the risk of liver failure.

In addition, a study performed by SmithKline Beecham (now Glaxo SmithKline) showed an increased risk of cardiovascular side effects, but the company did not report the results of this study as is required. According to a Glaxo SmithKline spokesperson, the study results were not provided because they did not contribute to any significant information.

One of the questions that faced the special advisory committee is to whether Avandia should be withdrawn from the market. Several questions need to be answered prior to making any decision.

1. How serious is the illness?
2. How big is the risk of continuing the medication?
3. How frequent do the risks occur?
4. Risks versus benefits
5. Are there safer alternatives?

After reviewing over 1000 pages of information and over 12 speakers, the FDA, in a split decision, voted to keep Avandia on the market. The committee concluded that there was sufficient evidence of a concern for increased cardiovascular risk, but stated that there was no conclusive evidence that it increases overall risk of death.  A significant number (twelve) voted to remove Avandia from the market, but the majority voted to keep it on the market. Ten voted for stronger black box warning, sales restrictions and closer supervision of administration. Seven voted for only a stronger black box warning, three voted to keep on the market with any change in status. One member abstained from voting.  A final decision is pending.

The FDA also recommended that Glaxo SmithKline be allowed to continue a large international study that compares Avandia to Actos (pioglitazone) an Avandia alternative with a similar clinical effect without the cardiovascular side effects. Critics say this raises an ethical question as patients will be given a medication with known safety concerns.

The FDA also have recommendations for patients:

• Do not stop taking their medication without talking with their healthcare professional.
• Discuss any questions or concerns they have about rosiglitazone with their healthcare professional.
• Read the Medication Guide that comes with each rosiglitazone prescription to better understand the risks and benefits of their medication.
• Report any side effects with rosiglitazone to FDA's MedWatch program using the information at the bottom of the page.

and for healthcare professionals:

• Follow the recommendations in the drug label when prescribing rosiglitazone. This includes a Boxed Warning stating that:
  • Use of rosiglitazone in patients with established NYHA Class III or IV heart failure is contraindicated. Further, rosiglitazone is not recommended in patients with symptomatic heart failure.
  • Rosiglitazone causes or exacerbates congestive heart failure in some patients. Healthcare professionals should monitor for the signs and symptoms of heart failure (including excessive, rapid weight gain, difficulty breathing, and/or swelling) after starting treatment and after dose increases of rosiglitazone. If heart failure signs and symptoms occur, the heart failure should be managed appropriately and discontinuation or dose reduction of rosiglitazone must be considered.
  • Available data on rosiglitazone and risk of myocardial ischemia are inconclusive. A meta-analysis of 42 clinical studies (mean duration 6 months; 14,237 total patients), most of which compared rosiglitazone to placebo, found an association between rosiglitazone use and an increased risk of myocardial ischemic events such as angina or heart attack. Three other studies (mean duration 41 months; 14,067 total patients), comparing rosiglitazone to other oral diabetes medications or placebo, have not confirmed or excluded this risk. The recently completed RECORD study, currently being reviewed by FDA, is one of these three studies.
• Discuss with patients the risks of rosiglitazone treatment, taking into account the clinical utility of rosiglitazone, the risks/benefits of other anti-diabetic medications, and the risks associated with poorly controlled blood glucose.
• Discuss with patients the importance of adhering to their diabetes medication regimen.
• Report any adverse events associated with the use of rosiglitazone to FDA's MedWatch program.

Back Pain in Kids and Teens

One of my kids has been complaining of back pain off and on. She did a search on the subject  and found that her problem probably began with band camp last summer (August 2009) and has been aggravated by her other activities throughout the school year (marching band, winter color guard). I read the article and it appears to go a great job of covering all the possibilities.  The article found on Healthcare South and written by Julian Huang, MD.  The article, Back Pain in Kids and Teens, is reproduced in its entirety below.

While back pain is very common for adults, kids are much more resilient and flexible and do not suffer the same types of back injuries to which adults are subject. In fact, medically significant back pain in children and teens is infrequently encountered, with even fewer cases in younger children.

Because children rarely suffer from back pain, any complaint by a child or teenager about acute or chronic back pain is taken very seriously by Pediatricians, and usually will result in a detailed consultation that will include a review of the child’s medical history and a physical exam.
Suspicious episodes of pain, or any concerning features of the pain, will result in radiological studies (such as an x-ray or MRI scan) and possibly a referral to a specialist for further examination and diagnostic tests.

The most common causes of back pain in children and teens tend to be somewhat age-dependent:
Younger children are less likely to be putting their spine under the same severe stresses as older children and adults. Thus, for the most part younger children do not have medically significant back pain and their discomfort tends to be short-lived. Also, younger children tend to self-limit their activity, choosing not to repeat painful activities, which aids in their recovery if an episode of back pain does occur.

At a young age, if a child has back pain there is greater concern for the possibility of a serious condition, such as a spinal tumor, growth, or an infection of the spine.
Therefore, if the pain persists in a younger child despite a lack of re-injury, or if there are other symptoms suggestive of a more insidious process (infection or tumor), the child’s condition will most likely be considered atypical, and therefore, further work-up and medical examination will be indicated.

Older children tend to be more aggressive in their activities and sports, thereby increasing the risk of injury to the bones, nerves and soft tissues in the spine. Teenagers are also more likely to test the limits of their bodies, often being exhorted by commercial advertising and/or peer pressure to push the envelope.

At this point, compression fractures are more commonplace, and we begin to see occasional disc injuries. Older pediatric patients also can injure the joints between vertebral bones, causing painful stress injuries. Only very rarely do the nerve roots become compromised.
lightly older children can be convinced to minimize their activity to speed up healing times, but then they frequently return to the same injurious behavior that caused the initial damage. Here, older kids may also find themselves the victims of their own intermittent inactivity and suffer overuse injuries, similar to an adult who is a “weekend warrior”. For most injuries, the treatment of choice is usually a short period of rest with an eye towards developing and maintaining physical conditioning.

Tumors and infection of the spine may occur in teens, but it is more common for back pain to be caused by sports injuries or overuse syndromes.

Scoliosis
While scoliosis (curvature of the spine) is not an uncommon diagnosis among teenagers, it is very rare that scoliosis will cause back pain. Teens with scoliosis may develop back pain, just as other teenagers, but it has not been found that people with adolescent idiopathic scoliosis are any more likely to develop back pain than the rest of the population.

Potential causes of back pain in children and teens
While adults can have vertebral disc injuries involving rupture, protrusion or slipping, and compression, these problems are uncommon in children. However, as kids age and their bodies mature, it becomes more likely that an injury to the spinal discs may occur and cause pain.

Causes of back pain that tends to occur older children
Spondylolysis
As kids’ sporting events become more competitive and the activities more specialized, certain types of injuries tend to arise. Spondylosis, a defect of the joint between vertebral bones, is commonly found in those who tend to hyperextend their backs (bend backwards), such as gymnasts. This injury may actually represent a stress fracture and the period of rest and recuperation may be extensive – up to 4 to 6 weeks.

Spondylolisthesis
Occasionally, further injury can be found as spondylolisthesis, a “slipping” of one vertebra upon another. This condition can progress through adolescence, and if it results in instability and pain it may require spinal fusion surgery at a later point.

Disc Injuries and vertebral fractures
Teens who tend to punish their spines through gymnastics or extreme sports (such as skateboarding, in-line skating, and vert biking) will frequently land very hard on their feet or buttocks. Either way, the force is transmitted to their vertebrae, which can result in a vertebral fracture and/or damage to the intervertebral discs.

If the disc material is extruded out or herniated, the spinal cord nerve roots leaving the cord can be compressed. This causes the sensation of pain along the path of that nerve. A well-known version of this is sciatica, which presents as buttock pain radiating down the back of a leg. Conservative measures are usually the first line of treatment for this type of pain (such as physical therapy, medications, osteopathic or chiropractic manipulation). If these treatments do not provide sufficient pain relief, patients may require surgery (e.g. a microdiscectomy or discectomy) to relieve pressure on the nerve.

Causes of back pain that may occur in younger or older children:
Infection
Of constant concern to physicians is the diagnosis of infection of the spine (discitis) in children. An infection of the spine is of great consequence and requires prompt diagnosis. Diagnosis of an infection is usually made with the assistance of a good physical exam and laboratory data. Signs of inflammation may be present (e.g. redness, swelling) even to the level of the skin. Radiographic studies are frequently normal. Treatment may consist of antibiotics if bacteria are found to be the cause of the infection. Again, prolonged rest is the primary treatment.

Tumor
Another major concern for pediatricians is potential for a tumor in the spine in children. Luckily, this is a very rare occurrence. As with infection of the spine, the diagnosis hinges on obtaining a good medical history, physical exam, and the suspicious nature of physicians when they cannot get an otherwise satisfactory diagnosis to explain the child’s symptoms. Treatment once again depends upon the final diagnosis and the skills of several subspecialties.

Backpacks

Importantly, pediatricians are starting to see a new form of injury in school-age children and teens become more common: overuse injuries and back strain caused by carrying back packs that are too heavy.

Often, backpacks may equal 20% to 40% of the child’s own body weight (equivalent to a 150-pound adult carrying a 30 to 60-pound back pack around 5 days a week). This amount of weight understandably creates a great deal of strain on the child’s spine. Additional strain is caused when children and teens carry the backpack over one shoulder, causing an uneven load on the spine.

Summary
As you may have noted, rest and careful monitoring of symptoms seems to be the answer for most diagnoses. This is because the vast majority of back pain problems in children are related to soft tissue damage (such as muscles, ligaments and tendons), which is often caused by overuse or strain.

Surgery for back pain in children is very rare, and is usually only considered for the more severe cases. If the child’s pain is severe, and he or she is having difficulty functioning, then surgery may be considered.

Most importantly, a careful process of elimination of medically more significant causes of back pain (such as tumor, infection, fracture) should always precede any therapeutic plan.

Julian Huang, MD
July 10, 2002

Do I Still Need a Pap Smear?

This question stems from an article I saw in a Dr. Gott newspaper column. The question was posed from a woman who stated that she had a "complete" hysterectomy.  Her question to Dr. Gott was whether she still needed to have pap smears done.

There are two types of hysterectomies: total and partial. In a total hysterectomy both the uterus and the cervix are removed. In a partial hysterectomy only the uterus is removed. In either case, the the ovaries and fallopian tubes may or may not be removed. I believe her when she stated she had a complete hysterectomy, I believe she meant a total hysterectomy.

What is a pap smear? A pap smear is a screening test for cervical cancer based on the examination of cervical cells under the microscope.

According to the American Cancer Society (ACS) Guidelines, pap smears should begin at age 18 or after becoming sexually active, which ever comes first. You are to have a pap smear yearly. Your physician may extended these to every 2 or every 3 years you have had a normal test for 3 consecutive years and if she/he feels the risk is low enough. The ACS states you may stop having pap smears after the age of 70 years old if the last 3 pap smears are normal AND if there are no abnormal pap smears in the past10 years.

Other recommendations include resuming screening pap smears  (after 70 years old) if you have a new sexual partner. Also the ACS continues to recommend yearly overall exams and breast exams yearly.

The Little Pink Pill - Part 2

Since my initial blog article (The Little Pink Pill), the US Food and Drug Administration's (FDA) Reproductive Health Drugs Advisory Committee voted 10 to 1 on June 18 that flibanserin, 100 mg (Girosa; Boehringer Ingelheim), was not significantly better than placebo for hypoactive sexual desire disorder (HSDD); they also voted unanimously that the benefits did not compensate for its adverse effects, which may include loss of consciousness and depression.

Even before the advisory committee’s meeting debate was triggered whether this is a long sought step toward equality for women or is it the pharmaceutical industry’s fabrication of a questionable “disorder” (see below) in order to sell unnecessary and potentially dangerous drugs?

The disorder is Female Dysfunctional Syndrome (FDS) also called Hypoactive Sexual Desire Disorder (HSDD).  It is a deficiency or absence of sexual fantasies and desire for sexual activity, as defined by the American Psychiatric Association (APA). The women are not averse to sex. They just they don’t care about it and stop thinking about it.  They have problems with sexual desire, arousal, or orgasm and unexplained loss of sexual thoughts, fantasies and desire. They also have a low sex drive and a slow response to stimulation. Some complain of an inability to experience an orgasm. Researchers suggest that approximately 10% of women suffer from this disorder.

Because the definition is vague and there are significant differences in sexual interest levels and in sexual functioning among women; the question is what is normal?  Another question may be what led to this change? Many say that a decreased sex drive in a woman may be a normal part of aging, a dysfunctional relationship (i.e., an abusive partner), stress, a lack of exercise, diet or other medical problems.

Is this a real syndrome and if so does it need to be treated with medication? Many say that the pharmaceutical industry has played a central role in defining FSD/HSDD as an official psychiatric disorder and has exaggerated its scope by funding key research.

What do you think?

I have been training over the past two days in travel medicines an independent contractor and evaluating pilots and flight attendants for travel to Ghana.

There are numerous vaccinations required for anyone who will be traveling to this country.  Other countries have similar measures although the vaccination regimen may be different. For Ghana, one will need vaccinations for yellow fever, Hepatitis A, Hepatitis B, Meningococcal Meningitis,Cholera, Tetanus/Diphtheria/Pertussis, Polio and medication to prevent Malaria.

The Centers of Disease Control has all the information you will need know prior to an international trip. In regard to Ghana, they recommend adults get the intramuscular form of polio as immunity appears to wane with oral polio.  Also, they recommend that adult who have received Tetanus & Diphtheria receive the Tetanus, Diphtheria, and Pertussis as the latter is a significant problem in Ghana. Tuberculosis also appears to be prevalent and travelers are instructed how to avoid placing themselves at risk.

In addition to the medical information, immunizations, and medications, they receive a travel advisory which includes information on the country's political situation, personal safety, travel conditions (auto) in the area and other social situations.