A morning meal may lead to more exercise.

“The research about breakfast is so good if you eat the right breakfast that it is hard to find good negative articles. Add to breakfast doing several one minute strengthening exercises at the beginning of the day and a better day is guaranteed.” Bill Chesnut, MD
Breakfast bonus! A morning meal may lead to more exercise.

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Cleveland Clinic Wellness newsletter_March 13, 2016
“One thing leads to another” is more than a catchy song from an ’80s band (okay, we’ll give it to you: Pet Shop Boys). It’s a fact of life — and health. And sometimes the connections surprise you. Case in point: a compelling benefit of breakfast. No, your morning meal does not lead to immortality or hundred-dollar bills falling from the sky (sorry!), but research suggests that if you’re trying to be more active, eating breakfast may help. In a randomized, clinical trial studying people with obesity, researchers found that those who ate breakfast were more physically active during the day than those who fasted until lunch. Earlier research found similar benefits in people of normal weight. That’s a big deal, given the marked disadvantages of being sedentary. The study didn’t track what people ate, but that matters, too, of course. (In a nutshell, skip the sweet stuff and stripped carbs, and aim for whole foods, including protein.) You’ll probably notice more spring in your step! The possibilities are endless, and staying active is one of the pillars of good health.

 

Personal relationships with receiving and giving support are good for your health

“ Personal relationships with receiving and giving support are good for your health. They change your life experiences in great ways you cannot anticipate.” Bill Chesnut, MD

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Cleveland Clinic Wellness Newsletter.      March 12, 2016
Reach out and text someone? When you’re offering support, face-to-face contact can’t be beat.
Whether you view the Days Before Texting as the dark ages or as the good old days probably depends on your age. Teens and twentysomethings are mystified at how people socialized in the analog days (“Mom, did you ‘call and make plans,’ as you put it, before or after being chased by a saber-toothed tiger?”). But people of all ages are sliding along technology’s slippery slope. For instance, a national survey of texting behaviors in adults ages 50 to 64 found that they averaged more than 11 texts a day, but fewer than 9 calls. And overall, U.S. smartphone users are sending and receiving five times as many texts compared with the number of phone calls each day.

There are a lot of benefits to digital communication, from streamlining logistics to staying in touch with children and grandchildren, nieces and nephews, and far-flung friends. When reaching out to a friend in need, though, kick it old school if you can. Face-to-face support is much more effective than digital support, suggests new research. Alas, we are still social animals. You’ll never be able to order up Friend 6.0 from the tech store! Remember that the next time you need someone to lean on. Instead of seeking support via social media or texting, plan to meet a friend at a café for good old-fashioned face-to-face time (and not FaceTime!).

Working more than 45 work hours per week for at least 10 years may be an independent risk factor for CVD.

“ This research is a heads-up for hard working people. If you must, want to or just enjoy working more than 45 hours a week, counteract the risk factor by exercise, good consistent diet habits, stress control, good interpersonal relationships, mindfulness, good sleep habits and a regular lifestyle, not having wild variations in your weeks. This risk applies to most physicians in patient care; it is unavoidable. Their skills and knowledge are so needed, they have a strong reason to work excessively.” Bill Chesnut, MD.

Working long hours may be linked to higher risk of heart disease, study suggests

The New York Times (3/10, Bakalar) “Well” blog reports that research suggests “the more hours you work, the greater your risk for heart disease.” Investigators “found that for each additional hour of work per week over ten years, there was a 1 percent increase in the risk for heart disease.” The findings were published in the Journal of Occupational and Environmental Medicine. _________________Ama 3.10.1

Journal of Occupational & Environmental Medicine: ____March 2016 – Volume 58 – Issue 3 – p 221–226

 

Dose–Response Relation Between Work Hours and Cardiovascular Disease Risk: Findings From the Panel Study of Income Dynamics                 Conway, Sadie H. PhD; Pompeii, Lisa A. PhD; Roberts, Robert E. PhD; Follis, Jack L. PhD; Gimeno, David PhD

Objectives: The aim of this study was to examine the presence of a dose–response relationship between work hours and incident cardiovascular disease (CVD) in a representative sample of U.S. workers.

Methods: A retrospective cohort study of 1926 individuals from the Panel Study of Income Dynamics (1986 to 2011) employed for at least 10 years. Restricted cubic spline regression was used to estimate the dose–response relationship of work hours with CVD.

Results: A dose–response relationship was observed in which an average workweek of 46 hours or more for at least 10 years was associated with an increased risk of CVD. Compared with working 45 hours per week, working an additional 10 hours per week or more for at least 10 years increased CVD risk by at least 16%.

Conclusion: Working more than 45 work hours per week for at least 10 years may be an independent risk factor for CVD.

 

Immediate release opioids for pain control are a poorer choice than extended release

“I want to share my understanding of better ways to control pain with opioids. My comment here is not putting the post below in perspective, but a chance to share what I learned controlling acute and chronic pain by prescribing opioid medications. My comments are not research, just experience.

Immediate release (IR) opioids for pain control are the poorer choice when extended release (ER) forms of the same medication exist. The extended release drugs have a lower and slower rise in maximum blood level, do not have a trough of inadequate dose level and do not have frequency and severity of personality impairments seen with immediate-release medications. The lack of personality changes is with ER medications prescribed at drug levels controlling the pain adequately. The same degree of pain control with an IR drug can have personality changes. The personality side effects are especially concerning in co-morbidities such as depression. Ten percent of Americans studied have depression, often don’t get treatment, and are at risk for depressive exacerbations on pain control medication.

 Examples of ER medications that have been approved and used extensively are tramadol, both IR and ER, hydrocodone, both IR and ER, oxycodone IR and ER. The costs of the ER form is higher than IR of the same drug. Buprenorphine, Butrans, is available in an extended release patch that lasts a week.

 There are two factors that have delayed the more common use of ER opioids. First is the first formulations of ER drugs could be altered and injected by drug abusers. The new ER formulations are much harder to inject. They cannot be crushed by common methods using. They don’t dissolve to inject the drug intravenously and similar. The second factor is that the prescriber must create and submit a “prior authorization” form before you can get the ER medication. There are free software that makes obtaining the “prior auth” a matter of only a few keyboard clicks, if your provider uses them. I find using the software for prior authorizations and the software to look up your insurance drug formulary is efficient. It’s more work and time to get the ER form of an opioid than prescribing the IR form of the same drug.“ Bill Chesnut, MD.

To go back to New Health News: http://billchesnutmd.com/new-health-news

 Leading the News  AMA Morning Rounds 3.23.2016.    FDA to update warning for immediate-release opioids

The Washington Post (3/22, Bernstein) reports in “To Your Health” that the Food and Drug Administration announced that “it will require new warnings about the risk of addiction, abuse, overdose and death for short-acting opioid pain medications.” The boxed warning for immediate-release opioids “also will warn of the danger that chronic use of the drugs by pregnant women can result in…Neonatal Opioid Withdrawal Syndrome” in newborns. The new warnings “will emphasize that immediate-release opioids should be a last resort for severe pain.”

The New York Times (3/22, A13, Tavernise, Subscription Publication) reports that “the new labels also include ‘clearer instructions’ for directions like initial drug dose and dose changes during therapy.”

 

 

Exercise may slow mental decline by ten years.

“The Journal of the American Academy of Neurology reports a wonderful piece of news from the University of Miami. This long-term study of 876 participants found exercise can slow cognitive decline in older people by ten years. Keeping better brain function for years by exercising is a great cost/benefits ratio. In the eyes of an orthopedic surgeon, this finding is true and those who exercise have fewer painful bone fractures in the last decade. Major fractures in the elderly commonly prevent the injured to cover to the pre-injury quality of life. “  Bill Chesnut, MD

Study: Exercise may slow mental decline by ten years. MIAMI, March 25 (UPI) –.

Exercise can slow cognitive decline in older people by ten years, researchers at the University of Miami found in a recent study. People who reported little to no physical activity in the study saw a greater decline in brain aging than those who were active, the researchers report in the new study, published in the Journal of the American Academy of Neurology. A study released earlier this year by Boston University found increased blood flow resulting from physical activity protected brain volume, which also protects its ability to function properly. Physical activity is an attractive option to reduce the burden of cognitive impairment in public health because it is low cost and doesn’t interfere with medications, Dr. Clinton Wright, an associate professor of neurology at the University of Miami, said in a press release. For the study, researchers recruited 876 participants with an average age of 71, assessing their cognition in the Northern Manhattan Study based on processing speed, semantic memory, episodic memory and executive function, with 90 percent of participants reporting light exercise, and 10 percent reporting moderate to heavy levels of exercise. The participants were then assessed seven years later with the same tests, and again five years after that. Overall, the researchers report people without signs of cognitive impairment who exercised the least when the study started showed a more significant decline in brain function equivalent to about 10 years of aging. The number of people over the age of 65 in the United States is on the rise, meaning the public health burden of thinking and memory problems will likely grow, Wright said. Our study showed that for older people, getting regular exercise may be protective, helping them keep their cognitive abilities longer. .

 

Lifting Weights As You Age Cuts Your Risk Of Death By 46%

“Lifting weights is essential for bone health. Lifting weights have been shown to be at least as effective as taking Fosamax. From menopause to age 65 women without hormone replacement lose 25 percent of their bone mass.  I lift every day, and you should do. (Do I sound like your mother?).”     Bill Chesnut, MD.

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Lifting Weights As You Age Cuts Your Risk Of Death By 46%.   Discover the science of how strength training keeps you young.                     Men’s Health by  ALI EAVESWednesday, March 23, 2016.

The secret to a longer life may be a barbell: Strength training as you age reduces your risk of death, according to a new study from Penn State College of Medicine.

Researchers surveyed people age 65 or older about their exercise habits and then tracked them for 15 years. Nearly a third of the study participants died during that period.

Less than 10 percent of the subjects strength is trained, but those select few were 46 percent less likely to die during the study than everyone else.

Sure, you could say that older folks who lift must be in better health to begin with. But even after adjusting for BMI, chronic conditions like diabetes and hypertension, and habits like total physical activity, drinking, and smoking, lifting was linked to a 19 percent reduced risk of death.

Strength training can keep you active and independent in your golden years, says study author Jennifer Kraschnewski, M.D. Not only does it strengthen your muscles, resulting in better stamina and balance, but it also increases your bone density.

Postmenopausal bone loss is a major concern for orthopedic surgeons.

“Postmenopausal bone loss is a major concern for orthopedic surgeons. We know that 25% of a woman’s total bone mass before menopause is lost by age 65. There are a high emphasis and research trying to deliver methods to restore that bone loss or stop further loss. Some women have striking amounts of bone loss and pathological fractures. Fractures occurring from a standing height are called a “fragility fractures” whether it is the wrist, kneecap, hip or spine. A fragility fracture is an alarm to begin studies of bone mass and metabolism. The odds are high of another fragility fracture occurring without medical intervention.

 Developing methods to restore bone loss years after menopause is the late side of this problem. The early smart approach in medicine is to prevent the bone loss by methods in peri-menopausal women. Many studies were done relating to the safety of using some form of estrogen early in menopause. There are increased risks starting estrogen five years after menopause. These may be lessened by using Estriol, the weakest form of estrogen and avoiding giving the medication orally. By avoiding the oral administration, you avoid the “first pass” metabolism that affects the hormone.  Using estriol intravaginally has increasing research experience to show it does not cause hyperplasia of the endometrium. The data is increasing that it decreases urinary incontinence by its effect on the urethra and vaginal tissue. There have not been extensive studies of estriol vaginally yet. There is a reason to combine testosterone with the estriol vaginally for muscle strength and the bone strengthening result of getting more physical activity.

 Many practitioners are not aware of the most recent developments in my experience. My bigger concern is that so many people I have seen as patients were not aware they need to research safe hormone replacement early in menopause. I posted 14 articles related to postmenopausal hormone deprivation as a “category of posts” on the homepage.” Bill Chesnut, MD.  

To go back to New Health News: http://billchesnutmd.com/new-health-news

 Anti-Mullerian Hormone and Prediction of Trans-Menopausal Bone Loss                              The Endocrine Society 1016 meeting _ a presentation.  Friday, April 1, 2016          

Arun S Karlamangla*1, Albert Shieh1, Sherri-Ann M Burnett-Bowie2, Elaine W. Yu2, Gail A Greendale1, Patrick M. Sluss2, Deborah Martin3and Joel S Finkelstein2
1University of California, Los Angeles, CA, 2Massachusetts General Hospital, Boston, MA, 3University of Pittsburgh, Pittsburgh, PA
 

The menopause transition (MT) in women is a period of bone loss, with the most rapid declines occurring in a 3-year period bracketing the final menstrual period (FMP). This period of rapid bone loss has been called the trans-menopause, and the rate of BMD decline over this period varies substantially between women (1).  Circulating levels of Anti-Mullerian Hormone (AMH) made by ovarian granulosa cells also decline as women progress through the MT (2). We hypothesized that serum levels of AMH in women early in the MT will predict the rate of bone loss over the trans-menopause. We tested this hypothesis using data from The Study of Women’s Health Across the Nation, a 7-site, multi-ethnic study of the MT. At baseline, participants had to be 42 to 52 years old, pre- or early peri-menopausal, have an intact uterus with 1 or 2 ovaries, and not be taking exogenous sex steroid hormones. Enrollment began in 1996 and women were asked to return annually.  At each visit, blood was collected between 8:00 and 10:00 AM after a 12-hour fast, during the early follicular phase (cycle days 2–5) whenever possible, and serum was stored at -80F.  In all women who had a natural (non-surgical) MT and a dateable FMP, serum level of AMH was measured from frozen blood samples using a new high-sensitivity monoclonal ELISA with a detection limit of 2 pg/mL (Pico AMH, Ansh Labs, Webster, TX). BMD [bone mass density] in the lumbar spine and femoral neck was measured annually in 5 of the 7 study sites.  In 474 women who had AMH and BMD measurements between 2 and 4 years before the FMP, had a 2nd BMD measurement 3-4 years later, and had not taken any medications that affect bone prior to the 2nd BMD measurement, we examined the ability of AMH level to predict the annualized rate of BMD decline between the two visits (% decline per year). AMH inter-quartile range was [11,146] pg/mL. Median rate of BMD decline was 1.3% per year in the spine and 1.0% per year in the femoral neck. Adjusted for age, BMI, smoking, race/ethnicity, and study site, in multivariable linear regression, each 75% (or four-fold) decrement in AMH level was associated with 0.15% per year faster decline in spine BMD (p<0.001) and 0.13% per year faster decline in femoral neck BMD (p=0.005).  These associations persisted even after additional adjustment for time from FMP and serum levels of estradiol and FSH. In multivariable logistic regression, adjusted for age, BMI, smoking, race/ethnicity, and study site, each four-fold decrement in AMH level was also associated with 18% increase in the odds of faster-than-median decline in spine BMD (p=0.02) and 17% increase in the odds of faster-than-median decline in femoral neck BMD (p=0.02). These findings suggest that serum levels of AMH in women going through the MT can indeed predict the rate of trans-menopausal bone loss, and help identify the women at risk of most loss.  AMH levels appear to provide information about the rate of bone loss beyond that provided by serum levels of estradiol and FSH.

(1) Greendale GA et al., JBMR 2012; 27: 111-8. (2) Sowers MFR et al., JCEM 2008; 93: 3478-83.

 

Our Poached Eggs with Steamed Spinach and Red Pepper Pesto are bursting with flavor.

“I love these Cleveland Clinic recipes for their taste and simplicity of preparation. If you aren’t getting the Cleveland Clinic Wellness newsletter, try it. http://my.clevelandclinic.org/health/Cleveland_Clinic_Newsletters_Signup .”                                                                                      Bill Chesnut, MD

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Red, White, and Green! Our Poached Eggs with Steamed Spinach and Red Pepper Pesto are bursting with flavor.          Cleveland Clinic Wellness newsletter, March 24, 2016

Talk about nutrient-dense! Check out our rainbow-hued Poached Eggs with Steamed Spinach and Red Pepper Pesto. The all-star cast is led by eggs, rich in omega-3 fatty acids, B vitamins, important trace minerals like selenium, and, of course, protein. The poster child of dark leafy greens (thanks, Popeye!), the spinach is gently steamed to retain its abundant vitamins and minerals. And then there’s the gorgeous pesto! This particular version features roasted red peppers and almonds — in other words, amazing flavor along with nutritious fats and vitamin C. And the best part? Everything melds beautifully in this dish, which is sure to delight your family or guests.
You may also want to know:

You may also want to know:

Why eggs really are an incredible food choice 

Canker sores? You may be short on vitamin B12 and folate

What’s New in Adult Reconstructive Knee Surgery

“This is a review article from JBJS, a specialty update. These updates are yearly, cover the new developments and often mention consensus opinions. The comments about tibial osteotomy surgery for knee arthritis are important. In the national consensus, an osteotomy is one surgical choice that is not a knee replacement. The surgical technique for tibial osteotomy is significantly improved by the instruments developed by Arthrex, Naples Florida, in my opinion, based on personally performing many tibial osteotomies. If you need arthritis knee surgery, find a surgeon who offers tibial osteotomy as a choice.” Bill Chesnut, MD.

To return to New Health News for more news: http://billchesnutmd.com/new-health-news

What’s New in Adult Reconstructive Knee Surgery: Level I and II Studies.                                               OrthoBuzz Feb 26, 2016.

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in January 20, 2016 Specialty Update on adult reconstructive knee surgery:

Nonsurgical Management and Osteotomy

  • A Cochrane database review found that land-based therapeutic exercise programs were modestly beneficial to patients with knee arthritis. Individualized programs were more effective than exercise classes or home-exercise programs.1
  • A study comparing intravenous administration of tanezumab versus naproxen and placebo in patients with hip and knee osteoarthritis found that tanezumab effectively relieved pain and improved function at week 16.2
  • A comparison of platelet-rich plasma (PRP) injections and hyaluronic acid (HA) injections found both treatments to be equally effective in improving knee function and reducing symptoms as measured by the IKDC subjective score.3
  • A study comparing opening-wedge and closing-wedge high tibial osteotomy found that among patients who did not go on to conversion to TKA, there were no between-group differences in clinical or radiographic outcomes at six years of follow-up.

Implants, Instrumentation, and Technique

  • A comparison of highly cross-linked and conventional polyethylene in posterior cruciate-substituting TKA found no differences in pain, function, and radiographic outcomes at a mean of 5.9 years.
  • A randomized study of 140 patients that compared the use of patient-specific instrumentation (PSI) and conventional instrumentation found no differences in clinical, operative, and radiographic results.4
  • In a randomized trial of 200 patients, the use of electromagnetic computer navigation resulted ininsignificantly fewer outliers from the target alignment, compared with the use of conventional instrumentation. There were no between-group differences in clinical outcomes.5
  • In a prospective randomized trial, the use of computer-assisted navigation during TKA resulted in lower systemic embolic loads, compared with TKA performed using conventional intramedullary instrumentation.
  • A randomized controlled trial comparing kinematically and mechanically aligned TKA found that kinematic alignment with patient-specific guides provided better pain relief and restored better function and range of motion than mechanical alignment using conventional instruments.6
  • A randomized study of selective patellar resurfacing in 327 knees followed for a mean of 7.8 years found higher satisfaction among patients with a resurfaced patella.7

Pain and Blood Management:    A randomized controlled trial comparing femoral and adductor canal blocks found that adductor canal blocks decreased time to discharge readiness without an increase in narcotic consumption.8

  • A trial comparing periarticular injections (PAIs) of liposomal bupivacaine with conventional bupivacaine PAI found no between-group differences in VAS pain scores 72 hours postoperatively orin patient narcotic consumption.9
  • A double-blinded randomized trial comparing topical versus intravenous administration of tranexamic acid found no significant differences in estimated blood loss or complications.

Rehabilitation and Complications

  • A randomized trial of 205 post-TKA patients found no differences in WOMAC scores for pain, function, and stiffness in groups thatreceivedtelerehabilitation or face-to-face home therapy.
  • A randomized trial found that Kinesio Taping helped reduce postoperative pain and swelling and improved knee extension during early postoperative rehabilitation.10
  • A trial comparing oral edoxaban and subcutaneous enoxaparin for post-TKA thromboprophylaxis found that edoxaban wasthe more effective agent. The incidence of bleeding events was similar in both groups.11

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Reoperation Rate For Breast Cancer Is Nearly Halved When MRI Findings Are Included in Planned Surgical Treatment

“Using bilateral MRI when planning surgery for breast cancer improved results in 1,926 patients.” Bill Chesnut, MD

To return to New Health News: http://billchesnutmd.com/new-health-news

s

Reoperation Rate Is Nearly Halved When MRI Findings Are Included in Planned Surgical Treatment       Doctors Guide News__March 8, 2016    By Jenny Powers

VIENNA, Austria — March 8, 2016 — A comparison between two cohorts of patients who did and did not receive magnetic resonance imaging (MRI) in addition to mammography or ultrasound before breast cancer surgery revealed that MRI detected additional contralateral lesions and provided information that significantly altered surgical plans, researchers reported here on March 3 at the 2016 Annual European Congress of Radiology (ECR).

The study included women with newly-diagnosed breast cancer who were not candidates for neoadjuvant therapy. Surgical treatment was pre-planned for all women in the study based on mammography and or ultrasound, but one cohort received an MRI prior to surgery and one group did not.

To date 4,295 women have been enrolled in the ongoing study. The current analysis included data from 1,926 women aged 18 to 80 years, of whom 972 received MRI and 954 did not.

“The cohorts were not homogenous and significant differences in age and breast density were seen in the groups,” noted Giovanni Di Leo, MD, Radiology Unit, IRCCS Policlinico, Milan, Italy.

Patient age was 56 years in the MRI group versus 61 years in the non-MRI group and ACR breast density was 12% versus 18%, respectively (P < .001 for both).

The mastectomy rate was significantly higher in patients having MRI in addition to mammography or ultrasound (20.1% vs 14.0%; P < .001).

Pre-planned breast conserving surgery based upon MRI results was unchanged in 74% of women in the MRI cohort, altered to less extensive surgical treatment in 13%, and to a broader surgical treatment in 13% of women.

The rate of MRI-detected new contralateral cancers was (2%).

Importantly, the number of subsequent surgeries was significantly reduced in patients receiving MRI. The reoperation rate for positive margins was 7% in the MRI group compared with 13% in the non-MRI group (P < .001).

“The order for an MRI was made by a radiologist in 67% of the cases and by a surgeon in 40% of cases,” said Dr. Di Leo. “More mastectomies had already been planned on the basis of mammography or ultrasound in patients receiving MRI; this higher rate is due to a selection bias. One could say MRI is a confirmation tool for mastectomy.”

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Make sleep #1 at night and be #1 all day!

“Creating and maintaining a healthy sleep pattern is deliberate. It involves several important steps including decreasing stimulation in the evening, increasing exercising in the day and learning to concentrate on the act of falling asleep.” Bill Chesnut, MD

To return to New Health News: http://billchesnutmd.com/new-health-news

Make sleep #1 at night and be #1 all day!    Cleveland Clinic Wellness newsletter_ March 7, 2016.   Sleep and technology go together like oil and water. And by oil, we mean the midnight oil that’s far too easy to burn when you get caught up in texting your BFF, catching up on social media, and other online pursuits. Numerous studies show that staying e-connected interferes with sleep. And new research shows that the reverse is true, too: Sleeping badly may make you more likely to check Facebook compulsively the next day. Can you say vicious cycle? The explanation has to do with a lack of focus.

Sleep and technology go together like oil and water. And by oil, we mean the midnight oil that’s far too easy to burn when you get caught up in texting your BFF, catching up on social media, and other online pursuits. Numerous studies show that staying e-connected interferes with sleep. And new research shows that the reverse is true, too: Sleeping badly may make you more likely to check Facebook compulsively the next day. Can you say vicious cycle? The explanation has to do with a lack of focus.

When you don’t sleep well, you tend to be more distracted and distractible. And what are social media and the Internet in general if not distraction’s dream come true! By prioritizing your sleep at night, you’ll improve your focus and productivity by day.

Start by getting back to basics: For starters, keep a consistent bedtime and wake time, avoid screens for an hour prior to bedtime, avoid caffeine in the afternoon and evening, and keep your room a sleep haven. Create a relaxing bedtime routine that includes dimming the lights (or switching to red wavelength lights only), keeping the temperature of your room cool, taking a bath or shower, meditating, doing gentle stretching, and…turning off your devices. To avoid temptation, keep them out of the bedroom. They’ll be there in the morning, we promise!

Return to New Health News, http://billchesnutmd.com/new-health-news

Higher percent of body fat may be linked to higher risk of dying early

“This important article studies the body fat percentage and not the BMI index. This is more specific research than articles using the BMI to determine results. Men with highest body fat percent had a 60 percent higher risk of mortality. A warning here for the wise.” Bill Chesnut, MD

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Higher percent of body fat may be linked to higher risk of dying early, study suggests

The AP (3/7, Neergaard) reports that research published in Annals of Internal Medicine suggests that “a higher percent of body fat, independent of” a “person’s BMI,” may be “linked to reduced survival.”

STAT (3/7, Anyaegbunam) reports that investigators “examined the medical charts and X-rays of people…who had gotten osteoporosis screenings between 1999 and 2013.”

TIME (3/7, Park) reports that when the researchers “looked at how body fat correlated with early death,” they “found that people with the lowest BMI had a 44% to 45% higher risk of dying early – likely because they were malnourished or otherwise ill – than those with more average BMI.” Individuals “with the highest body fat composition, regardless of their BMI, also had the highest risk of dying early – women with more body fat showed a 19% increased risk of early death while men had a 60% higher risk of mortality.”

The Los Angeles Times (3/7, Healy) reports on the study, and also reports on a separate study published in the Annals of Internal Medicine, which “found that in a group of more than 1.5 million Swedish military recruits, men who had poor physical fitness at age 18 were three times more likely to develop Type 2 diabetes in midlife than were those who had been highly fit on the cusp of adulthood.” AMA News.

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A veggie-centric breakfast of champions!

“I enjoy these healthful recipes from Cleveland Clinic. They are tasty with a different fresh taste. The Cleveland Clinic Wellness newsletter is a free email. They have several newsletters at this link.” Bill Chesnut,MD http://my.clevelandclinic.org/health/Cleveland_Clinic_Newsletters_Signup

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Rise and shine…with a veggie-centric breakfast of champions   ____Cleveland Clinic Wellness  newsletter_March 6, 2016
“So many vegetables, so little time,” goes the produce lover’s lament. But hold the tissues. There’s more time than you think! Since most of us eat two-thirds of our daily veggies at dinnertime, and the rest at lunch, our morning meal is ripe for veg-ifying. (Don’t look for that word in Webster’s…yet!) “When we think of produce in the morning, we tend to think of fruit,” notes Cleveland Clinic nutritionist Amy Gannon, R.D. But adding veggies at breakfast ups your intake of all those health-promoting phytonutrients as well as fiber, and it sets you up for stable blood sugars all through the day.

The classics. Egg white omelets and frittatas (try scrambled tofu or tempeh for vegan versions) are great vehicles for spinach, tomatoes, onions, peppers, or leftover roasted veggies. Our Frittata with Baby Greens and Feta will get you started.

Oatmeal, the next generation. Brown sugar and pancake syrup aren’t the only game in town. Savory steel cut oatmeal is delicious, says Gannon, who enjoys oatmeal stir-ins such as steamed kale, tomatoes, mushrooms, and fresh herbs.

Veggie-rific yogurt. “Long ago, my father taught me to add cucumbers and tomatoes, diced very small, to my yogurt every morning,” says Cleveland Clinic Wellness Enterprise medical director Roxanne Sukol, MD. And we promise you — it’s absolutely delicious.

Dinner for breakfast! Try a breakfast salad with greens, avocado, walnuts, and berries. Or set aside a roasted sweet potato at dinner, and top it with almond butter or Greek yogurt for breakfast. Leftovers such as veggie-filled soups can also be a breakfast of champions. Just reheat and victory is yours!

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Surgeons Get Graded: Report Card Is Online

“Transparency of complications is increasing. You can go to the Surgeon Scorecard to see the complication rates of your surgeon and your hospital compared to other surgeons and hospitals. Refreshing.” Bill Chesnut, MD

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 Surgeons Get Graded: Report Card Is Online

The ProPublica “Surgeon Scorecard” has been available online since July 15. If any AAOS members haven’t yet checked out this tool, it might be a good idea to look yourself up. The scorecard details complication rates for individual surgeons who perform any of eight different procedures, five of which are orthopaedic (hip and knee replacement, cervical spine fusion, and anterior and posterior column lumbar fusion).

ProPublica, founded in 2007, describes itself as “an independent, nonprofit newsroom that produces investigative journalism in the public interest.” Although it accepts advertising, major funding comes from philanthropic organizations.

To create the Surgeon Scorecard, ProPublica analyzed Medicare billing records for nearly 17,000 surgeons and identified 66,569 complications over 5 years (2009–2013). Complications were reported if the patient was readmitted to the hospital within 30 days of the index procedure. The cost of these readmissions was estimated at $645.3 million.  AAOS 2015.

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MRI for the evaluation of knee pain: comparison of ordering practices of primary care physicians and orthopaedic surgeons.

“If you have knee pain and are considering a knee MRI, see an orthopedic surgeon first. This study shows the differences in treatment if the orthopedic surgeon orders the MRI compared to another specialty. Emphasis added is mine.” Bill Chesnut, MD

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 MRI for the evaluation of knee pain: comparison of ordering practices of primary care physicians and orthopaedic surgeons.

BACKGROUND: Knee pain is one of the most common reasons for outpatient visits in the U.S. The great majority of such cases can be effectively evaluated through physical examination and judicious use of radiography. Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. We hypothesized that MRIs ordered by orthopaedic providers were more likely to result in changes in diagnoses and/or plans for care than those ordered by non-orthopaedic providers.

METHODS: We reviewed the charts of all consecutive new patients seen at our orthopaedic outpatient office between January 1, 2010, and December 31, 2011, with International Classification of Diseases, Ninth Revision (ICD-9) codes for meniscal or unspecific sprains and strains of the knee. A total of 1592 patients met our inclusion criteria and were divided into two groups: those initially evaluated and referred by their primary care physician (PCP) (n = 747) and those initially evaluated by one of our staff orthopaedic surgeons (n = 845).

RESULTS: MRI-ordering rates were nearly identical between orthopaedic surgeons and PCPs (25.0% versus 24.8%; p = 0.945). MRIs ordered by orthopaedic surgeons, however, resulted in significantly more arthroscopic interventions than those ordered by PCPs (41.2% versus 31.4%; p = 0.042). Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention, including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001), patients with acute symptoms (39.3% versus 22.2%; p < 0.001), and patients with a history of trauma (49.3% versus 36.2%; p = 0.019). Finally, orthopaedic surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048).

CONCLUSIONS: MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention.  Author: Timothy T Roberts;Natalie Singer;Shazaan Hushmendy;Ian J Dempsey;Jared T Roberts;Richard L Uhl;Paul E M Johnson

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In-Home Telerehabilitation Compared with Face-to-Face Rehabilitation After Total Knee Arthroplasty

In-Home Telerehabilitation Compared with Face-to-Face Rehabilitation After Total Knee Arthroplasty: A Noninferiority Randomized Controlled Trial.

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BACKGROUND: The availability of less resource-intensive alternatives to home visits for rehabilitation following orthopaedic surgeries is important, given the increasing need for home care services and the shortage of health resources. The goal of this trial was to determine whether an in-home telerehabilitation program is not clinically inferior to a face-to-face home visit approach (standard care) after hospital discharge of patients following a total knee arthroplasty.

METHODS: Two hundred and five patients who had a total knee arthroplasty were randomized before hospital discharge to the telerehabilitation group or the face-to-face home visit group. Both groups received the same rehabilitation intervention for two months after hospital discharge. Patients were evaluated at baseline (before total knee arthroplasty), immediately after the rehabilitation intervention (two months after discharge), and two months later (four months after discharge). The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire at the last follow-up evaluation. Secondary outcome measures included the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, functional and strength tests, and knee range of motion. The noninferiority margin was set at 9% for the WOMAC.

RESULTS: The demographic and clinical characteristics of the two groups of patients were similar at baseline. At the last follow-up evaluation, the mean differences between the groups with regard to the WOMAC gains, adjusted for baseline values, were near zero (for 182 patients in the per-protocol analysis): -1.6% (95% confidence interval [CI]: -5.6%, 2.3%) for the total score, -1.6% (95% CI: -5.9%, 2.8%) for pain, -0.7% (95% CI: -6.8%, 5.4%) for stiffness, and -1.8% (95% CI: -5.9%, 2.3%) for function. The confidence intervals were all within the predetermined zone of noninferiority. The secondary outcomes had similar results, as did the intention-to-treat analysis, which was conducted afterward for 198 patients.

CONCLUSIONS: Our results demonstrated the noninferiority of in-home telerehabilitation and support its use as an effective alternative to face-to-face service delivery after hospital discharge of patients following a total knee arthroplasty.

LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

 

Testing for calcium in the arteries can help predict heart disease

“The Miami Herald article below is from the AMA News 3.6.16, and I include it for it tells the point about cardiac CT well. There are low-grade heart scans that show calcium score and high-grade coronary artery angiogram CT. The message here is the inexpensive calcium score scan may avoid having to take statin drugs. Statins have many side effects, more than listed here. They can cause significant muscle pain and damage. If you are 40-50 and are taking statins, consider getting a calcium heart scan to see if there are any calcium plaques. You may be able to stop  taking statin drugs. I had this scan done when it became available and had an average calcium score. When the more sensitive coronary angiogram heart CT became available, I had that  because of the calcium score. It showed my coronary arteries were excellent with no stenosis. As my cholesterol is normal, I did not require statin cholesterol-lowering drugs.” Bill Chesnut, MD.

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Testing for calcium in the arteries can help predict heart disease      AMA Morning Rounds 3.6.16.

1.      The typical patient to be scanned is in their 40s or 50s whose cholesterol is a tad high and who has family history of heart attacks

2.    The scan is not covered by most insurance, and costs $75 to $100
3.    It exposes the patient to about the same radiation as a mammogram

Mila Veledar, 61, of Miami learned she had high cholesterol 10 years ago. She started taking statins, which reduced her cholesterol, but raised her liver enzymes. For a few years, she went on and off the medicine.

In 2014, Veledar underwent a coronary calcium scan, also known as a heart scan, which looks for calcium deposits in the arteries and is a predictor of heart disease. Because she had no calcium deposits, her doctor took her off statins.

“My doctor told me my risk of having cardiac problems in the next 10 years was 2 percent. If I take statins, it lowers it to 1.6 percent,” Veledar said.

She stopped taking the statins, which had raised her liver enzymes and brought on headaches and insomnia.

A coronary calcium scan is a CT scan that detects small flecks of calcium in the arteries, said Dr. Gervasio Lamas, chief of the Columbia University Division of Cardiology at Mount Sinai. During the scan, the calcium is quantified and given a score. The lower the score, the better.

“The more calcium you have, the more likely you are to have a heart attack, but it goes beyond being a predictor because it tells you that you have coronary heart disease,” Lamas said. “At some point or another you had a fatty plaque and then your body’s own healing response deposited a little calcium there. The more times your body has had to do that, the more likely you are in the future to have a heart attack.”

“A score of zero means there is no calcium in the coronary arteries, but the scores do increase with age, so there are ‘age-adjusted normals,’” he said. “For an 85-year-old, a calcium score of 40 or 50 may be OK, whereas that score in a 30-year-old would be very concerning.”

The problematic range is anything over 400, with numbers over 1,000 being at extreme risk, Hendel said. “Between 100 and 400 is a gray zone that identifies hardening of the arteries, but it’s a continuum. As the score increases, so does the risk.”

Who should be scanned__The best candidate is someone with moderate risk of heart disease, Lamas said.

“The typical patient that I scan is in their 40s or 50s whose cholesterol is just a little high. They take care of themselves, maybe there was heart attack in a family member years ago,” he said.

A doctor might look at the cholesterol and recommend a statin, Lamas said, but the patient wants another opinion. A scan can give more information to determine if a statin is necessary.

Generally, the criteria for taking statins are high-risk factors such as cholesterol and weight. “Then you are prescribed a lifelong pill to reduce the risk,” said Dr. Khurram Nasir, medical director for the Center for Healthcare Advancement & Outcomes at Baptist Health South Florida. “But emerging evidence is suggesting that people we thought are high risk are actually low risk, and we never had a way of identifying them.”

A study led by Nasir found that about two-thirds of adults 45 and older with no established cardiovascular disease are eligible to take lifelong statins.

“But when we did heart scans, about half of the individuals had no calcium scores, and their 10-year risk was below the level at which you should consider taking a statin,” he said. “The scan is providing patients more information so they can make a better judgment of whether the risk is high enough to take a pill for the next 10 years.”

The heart scan is not a routine test, and there’s a controversy about whether it should become one, Hendel said. “Many physicians think it should. Currently, the American Heart Association and the American College of Cardiology have taken a conservative stand, not recommending it as a routine screening measure,” he said.

Read more here: http://www.miamiherald.com/living/health-fitness/article62723472.html#storylink=cpy

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Nasal irrigation helps control allergies was washing out the allergens in the nasal passages

“Nasal irrigation helps control allergies was washing out the allergens in the nasal passages. Repeated and chronic allergies lead to the tissue overgrowth, new growths of polyps which can obstruct the small openings of the sinus cavities of the skull. In some sensitive people, the polyps become so bad, extensive surgery is required. If you are prone to upper respiratory allergies, explore nasal irrigation.” Bill Chesnut, MD

Breathe more easily this spring! Two tools to counteract seasonal allergies.      Cleveland Clinic Wellness newsletter 3.6.16.

Spring is coming, with its lush grass, swaying trees, and rainbow of fragrant blossoms. And then, for some, the ultimate buzzkill: watery eyes, an itchy nose, and sneezing fits that feel strong enough to shift the jet stream. Seasonal allergies can do a number on your enjoyment of the great outdoors. Using the right medications and avoiding allergy triggers can do a lot to help you feel better through the season. So can these low-tech strategies:
Nasal irrigation, the practice of using warm, sterile salt water to rinse nasal passages, can help to ease allergy symptoms. The practice may feel odd at first, but that’s because your sinuses are still irritated. As they heal, you should be able to tolerate the practice much better.
Give stress a little credit. Emotional stress has real, physical effects, including raising levels of epinephrine, a type of adrenaline that your body makes to fend off allergies. When you’re perpetually stressed, soaring epinephrine levels can make it hard to recognize allergens. “Think of it like a body that’s cried wolf too often,” says Michael Roizen, MD, Chief Wellness Officer and Chair of the Wellness Institute. “When a real danger comes along, there’s no response.” Take stress management seriously by exercising regularly and incorporating a mindfulness practice such as meditation, deep breathing, or yoga into your routine.

Long-term Use of Aspirin and the Risk for Cancer

 

 

“This is part of an abstract of original research publish in the Journal of American Medical Association (JAMA)  Oncology. The researchers studied 136,000 healthcare professionals for 26 years. Keep in mind there are side effects of chronic aspirin intake in some people. Consult your primary care physician about taking aspirin chronically if you have other health conditions.” Bill Chesnut, MD

 Population-wide Impact of Long-term Use of Aspirin and the Risk for Cancer

Two large US prospective cohort studies, the Nurses’ Health Study (1980-2010) and Health Professionals Follow-up Study (1986-2012), followed up 135 965 health care professionals (88 084 women and 47 881 men, respectively) who reported on aspirin use biennially. The women were aged 30 to 55 years at enrollment in 1976; the men, aged 40 to 75 years in 1986. Final follow-up was completed on June 30, 2012, for the Nurses’ Health Study cohort and January 31, 2010, for the Health Professionals Follow-up Study cohort, and data were accessed from September 15, 2014, to December 17, 2015.

Key Points

  • Question: What are the potential benefits of aspirin for the prevention of cancer?
  • Findings: In 2 large, prospective cohort studies, regular use of low doses of aspirin for at least 6 years was associated with a significantly lower risk for overall cancer, primarily tumors of the gastrointestinal tract. Although aspirin may prevent colorectal cancers irrespective of screening, substantially more cases appear to be prevented among those who do not undergo screening.
  • Meaning: Long-term aspirin use was associated with a modest but significantly reduced risk for cancer, especially gastrointestinal tract cancer, and may complement the benefits of colorectal cancer screening.

TXA , Tranexamic Acid, Reduces Postoperative Morbidity in Foot and Ankle Surgery Patients

“TXA, tranexamic acid, is a drug that decreases bleeding. It is another breakthrough in surgery. It can be given orally, injected into the wound during surgery and used intravenously before, during and after surgery. It’s first highly successful orthopedic use is decreasing bleeding in total knee replacement. Less wound bleeding during and after surgery means a lower incidence of almost all complications in the operated leg. If you are having invasive extremity surgery, ask about it. Ask about it as about TEA, the acronym more commonly used.” Bill Chesnut, MD

Study: TXA Reduces Postoperative Morbidity in Foot and Ankle Surgery Patients

The results of a prospective randomized controlled trial—presented in Poster P206 on display in Academy Hall C—indicate that preoperative administration of 1 gram of tranexamic acid (TXA) significantly reduced blood loss, pain, and swelling in patients undergoing foot and ankle surgery. The abstract of the study, conducted by Nicholas A. Abidi, MD; Ashish Govan, BS; Clay Christensen, BS; and Jess Gifford, BS, reads as follows:

Introduction
Previously published papers have demonstrated that administration of TXA prior to skin incision during hip and knee arthroplasty has resulted in significant reduction of blood loss, pain, and swelling. This prospective randomized trial sought to determine whether there were demonstrable reductions in postoperative ecchymosis, erythema, edema, pain, and incisional bleeding in patients who received TXA prior to incision for foot and ankle surgical procedures.

Methods
In this trial, 100 consecutive patients undergoing foot and ankle surgery by one surgeon were randomized into two groups: Group I and Group II. In Group I, 50 patients were administered 1 gram of TXA intravenously 20 minutes prior to skin incision. In Group II, 50 patients did not receive TXA. Demographics were obtained along with preexisting medical conditions and medications for each group. The reviewer was blinded as to the treatment groups. The reviewer was asked to rate patients’ pre- and postoperative foot and ankle images for ecchymosis, edema, erythema, and degree of fresh blood on the postoperative incision and first postoperative dressings using a scale of 0 to 3. These results were ranked and compared. Patients were also administered a Foot Function Index survey preoperatively and postoperatively at each visit.

Results
A combination of patients undergoing forefoot, midfoot, hindfoot, and ankle surgeries qualified for the study. Data analysis showed statistically significant reductions in postoperative ecchymosis, edema, erythema, and bleeding at 2 and 6 weeks in patients who received 1 gram of TXA 20 minutes prior to skin incision, with P values of < 0.05 and F values greater than 1.0. There was one complication in the non-TXA group; one patient with excessive swelling underwent amputation of the tips of toes 2+3 after forefoot reconstruction. There were no medical complications in the TXA group. Foot function index pain scores were lower between weeks 2 and 6 postoperatively in patients who received TXA preoperatively than in patients who had not received TXA.

Conclusion
Preoperative administration of 1 gram of TXA significantly reduced blood loss, pain, and swelling in patients undergoing foot and ankle surgery. Patients experienced no deleterious detectible medical side effects from administration of TXA. Further studies with more patients are warranted to elaborate on these preliminary results.

 

Using Aspirin for DVT Chemoprophylaxis Increases Non-Unions

“The study shows that taking aspirin to decrease deep vein thrombosis (DVT) in tibial shaft and distal plafond fractures:

  • Does not decrease DVT.
  • Increases non-union incidence significantly.
  • Slows cortex union in those fractures that do heal.

Cigarette smoking, diabetes, and type of fracture did not significantly affect any outcome measure.  These complications are statistically significant. Do not take aspirin to prevent DVT secondary to a lower leg fracture. The bold emphasis is mine.” Bill Chesnut, MD.

 Using Aspirin for DVT Chemoprophylaxis Increases Non-Unions in Tibial Shaft, Plafond Fractures__DG News online _March 3, 2016__By Jill Stein

ORLANDO, Fla — March 3, 2016 — Using aspirin for deep vein thrombosis (DVT) and pulmonary embolism (PE) chemoprophylaxis for tibial shaft and plafond fractures delays fracture healing and increases non-unions, according to a study presented here on March 1 at the 2016 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS).

John P. Eggers, MD, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, and colleagues examined the medical records of 162 patients who received their index treatment for tibial shaft and plafond fractures over a recent 9-year period at a single centre. Patients were skeletally mature at the time of their injury and their fracture was non-pathologic.

While patients frequently receive chemoprophylactic anticoagulation for prevention of DVTs and PEs for tibial and plafond fractures, aspirin’s effects on non-unions and delayed healing for these fractures have not been previously studied in humans, noted Dr. Eggers said.

Overall, 104 patients received aspirin, while 58 patients did not receive aspirin. Results showed that tibial shaft and plafond non-unions occurred in 19% of patients in the aspirin group compared with 6% of patients in the non-aspirin group. Composite events occurred in 42% and 20% of the 2 groups, respectively.

Aspirin, compared with no-aspirin, significantly increased non-unions (P = .04) and composite events (P = .01).

Open tibial shaft and plafond fractures had significantly increased delayed unions (P = .004) and composite events (P = .023) compared with closed fractures.

Cigarette smoking, diabetes, and type of fracture did not significantly affect any outcome measure.

There was no statistical difference in DVT formation between aspirin and other forms of anti-coagulation.

Excluding non-unions, mean radiographic healing of 3 cortices comparing aspirin and no aspirin was 133 and 96 days (P ˂ .01), respectively.

Dr. Eggers acknowledged that the study had multiple limitations. For example, the study was a retrospective review that used an electronic medical record (EMR) with multiple treating physicians. Patients who were prescribed medication outside the EMR may have received medication that could not be reviewed.

In addition, several patients were lost to follow-up, although loss to follow-up was equal in the 2 groups.

The researchers recommend that physicians use an alternative to aspirin for DVT and PE chemoprophylaxis for tibial shaft and plafond fractures due to aspirin’s deleterious effects on healing.

[Presentation title: Aspirin Utilized for DVT Chemoprophylaxis Increases Non-Unions in Tibial Shaft and Plafond Fractures. Abstract P525]

 

Nut Butter is effective in cutting heart disease risk, reducing belly fat accumulation, and helping to control diabetes.

“The good news of eating nuts is discussed here. I am including this to bring attention to avoiding nut butters that added sugar, palm oil or hydrogenated oils, and skip the reduced fat nut butter. Interesting recipe ideas.” Bill Chesnut. MD.

Get nutty! Protein, fiber, nourishing fats…nut butters have it going on.  Cleveland Clinic Wellness newsletter_3.3.16
It’s high time to go nuts…in a good way! There’s a world of nutritious, delicious nut butters out there beyond the children’s classic. No offense, PB&J, but we’re ready to spread our wings and our celery sticks with almond butter, walnut butter, and cashew butter, for starters. “Across the board, tree nuts and nut butters are a superduper source of nutritious fats, fiber, and vitamins and minerals,” says Cleveland Clinic nutritionist Amy Gannon, RD. Cases in point: Walnut butter boasts lots of omega-3 fatty acids, and almond butter is a go-to for vitamin E. These and other little nutritious nuggets can making a big difference for health by (1) cutting heart disease risk, (2) reducing belly fat accumulation, and (3) helping to control diabetes. When shopping, look for products that contain simple ingredients: “just nuts and perhaps salt,” says Gannon. Steer clear of nut butters that contain added sugar, palm oil, or hydrogenated oils, and skip the reduced-fat nut butters, which often replace nutritious fats with sugar and other fillers. If you have a high-power blender or food processor, you can whip up your own nut butter from walnuts, pecans, macadamia nuts, almonds, or hazelnuts — or try a delicious combo. As for how to use nut butter, the sky (er, the tree?) is the limit! Add it to homemade muffins and pancakes, blend it into smoothies, or add a dollop to a baked sweet potato. Try blending some nut butter into Greek yogurt for breakfast or a fruit-and-veggie dipping sauce. Create luxurious sauces, such as a cashew curry or Far-East-inspired almond soy sauce. Because sometimes you feel like a nut…butter!
You may also want to know:

Go nuts! People who eat nuts may live longer

Weight Bearing After Ankle Fracture Surgery is OK.

“This article is posted in American Academy of Orthopaedic Surgeons Now publication March 1, 2016. The find is common sense research, close monitoring and accurate observation of patients you treat. There is a lot of good in learning from “best practices” methods. The bold text is my emphasis.” Bill Chesnut, MD

Study: Weight Bearing OK After ORIF for Ankle Fracture

A study to be presented today found that for patients who underwent open reduction and internal fixation (ORIF) for an ankle fracture, weight bearing as tolerated (WBAT) was safe, regardless of the fracture pattern.

The study, to be presented by Fernando A. Peña, MD, of the University of Minnesota, compared functional results and level of complications seen with immediate WBAT after ORIF in 159 patients versus 222 patients treated with ORIF and a traditional postoperative protocol of non–weight bearing (NWB) for 6 weeks after surgery. Those in the WBAT group had an average time to weight bearing (WB) of 2.6 weeks, and at 6 weeks they showed a higher level of function compared to the NWB group (P = 0.04); no significant differences in bother or functional indices were seen at all other time points.

In the paper reporting the study, the authors commented: “An extended period of NWB can have a significant impact on patient satisfaction as well as significant social implications including potentially lost productivity and income for the patient. NWB can also cause transportation challenges for patients, which can cause work limitations, and may increase other indirect costs of these injuries. Despite the importance of this decision, the ideal time of NWB for various injuries has not been established in the literature, although several studies have compared varying periods of NWB.”

Dr. Peña said that the findings confirm the hypothesis that he and his colleagues formulated: that patients could safely bear weight shortly after surgery, with no more adverse consequences than those who kept weight off the foot for the traditional period. He said that this hypothesis emerged from clinical experience and patient behavior; his team undertook the study “to find out if patients were right—some of them were walking after surgery against medical advice—or ‘we’ were right.”

The results demonstrate, Dr. Peña said, “that it is perfectly safe to walk after surgery for an ankle fracture. Patients with normal sensation on their ankles/feet are safe to walk after an ankle fracture.”

Limitations of the study include nonstandardized surgical techniques, the authors noted. However, they wrote, “all patients underwent surgery at the same facility and fracture fixation techniques are similar between all surgeons in the study. Additionally, while the study was prospective in nature, there was no randomization performed; however, because patients who were NWB were part of a consecutive series, and patients who were treated with WBAT were part of a consecutive series, this is similar to the limitations of all other WB studies after ankle fracture in the literature, and is something that should be considered in future studies.”

Below is the abstract for the study, which will be presented at 8:30 a.m. in room W304A.

Introduction: Numerous postoperative protocols are utilized after ORIF of ankle fractures. Increasing emphasis on early return to activity and the value of early rehabilitation have led to protocols allowing earlier weight bearing after ankle fracture. The purpose of this project was to determine if immediate WBAT after ORIF of an ankle fracture provided the same functional results and level of complications as a more traditional postoperative protocol of NWB for 6 weeks after surgery.

Material and Methods: Patients who underwent ORIF of a unilateral ankle fracture with no concomitant injuries were eligible for the study. Ankle fractures included single lateral, medial, and posterior malleoli fractures or any combination of the three. Patients with a decreased sensory exam were excluded from the study in both groups. For both groups comorbidities such as smoking, diabetes, use of insulin, anticoagulation treatment, use of nonsteroidal anti-inflammatory medication, were assessed. Short Musculoskeletal Functional Assessment (SMFA) scores were collected 6 weeks and 6 months postoperatively. Time to WB from the time of surgery for the WBAT group was also collected.

Results: There were 381 consecutive patients who were included in the final analysis.  Of these, 222 consecutive patients with ankle fractures were treated with ORIF and NWB for 6 weeks and were compared to another group of 159 consecutive patients with ankle fractures who were treated with ORIF and immediate WBAT. Both groups had similar demographics with an average age of 37 years for both groups, body mass index of 27.8 for the WBAT group and 28.7 for the NWB group, and 39 percent incidence of comorbidities for the WBAT group versus 39 percent for the NWB group. The WBAT group had 1 superficial infection and one deep infection requiring an irrigation and debridement (I & D), (0.01%). The NWB patients had 5 superficial infections and 4 deep infections, requiring I & D (0.04%). No fracture in either group required a reoperation to address the fixation or reduction of the fracture. Average time to WB in the WBAT group was 2.6 weeks. Analysis showed a statistically significant difference in functional index from the SMFA at 6 weeks (P = 0.04) but failed to show statistically significant difference in bother or functional indices at all other time points.

Conclusions: In patients with a normal sensory exam, it is safe to allow WBAT after undergoing ORIF of an ankle fracture regardless of the fracture pattern. A higher level of function is acquired at an earlier time of the recovery when compared to a protocol of NWB for 6 weeks.

Coauthors of “Weight Bearing After Open reduction and Internal Fixation of Ankle Fractures” are Jordan Hauschild, MD; Robby Sikka, MD; and Megan Reams, MA/OTR/L.

Details of the authors’ disclosure as submitted to the Orthopaedic Disclosure Program can be found in the Final Program; the most current disclosure information may be accessed electronically at www.aaos.org/disclosure

 

Foot and Ankle Surgery Patients are Better with Tranexamic acid.

“TXA, tranexamic acid, is a drug that decreases bleeding. It is another breakthrough in surgery. It can be given orally, injected into the wound during surgery and used intravenously before, during and after surgery. It’s first highly successful orthopedic use is decreasing bleeding in total knee replacement. Less wound bleeding during and after surgery means a lower incidence of almost all complications in the operated leg. If you are having invasive extremity surgery, ask about it. Ask about it as about TEA, the acronym more commonly used.” Bill Chesnut, MD

Study: TXA Reduces Postoperative Morbidity in Foot and Ankle Surgery Patients

The results of a prospective randomized controlled trial—presented in Poster P206 on display in Academy Hall C—indicate that preoperative administration of 1 gram of tranexamic acid (TXA) significantly reduced blood loss, pain, and swelling in patients undergoing foot and ankle surgery. The abstract of the study, conducted by Nicholas A. Abidi, MD; Ashish Govan, BS; Clay Christensen, BS; and Jess Gifford, BS, reads as follows:

Introduction
Previously published papers have demonstrated that administration of TXA prior to skin incision during hip and knee arthroplasty has resulted in significant reduction of blood loss, pain, and swelling. This prospective randomized trial sought to determine whether there were demonstrable reductions in postoperative ecchymosis, erythema, edema, pain, and incisional bleeding in patients who received TXA prior to incision for foot and ankle surgical procedures.

Methods
In this trial, 100 consecutive patients undergoing foot and ankle surgery by one surgeon were randomized into two groups: Group I and Group II. In Group I, 50 patients were administered 1 gram of TXA intravenously 20 minutes prior to skin incision. In Group II, 50 patients did not receive TXA. Demographics were obtained along with preexisting medical conditions and medications for each group. The reviewer was blinded as to the treatment groups. The reviewer was asked to rate patients’ pre- and postoperative foot and ankle images for ecchymosis, edema, erythema, and degree of fresh blood on the postoperative incision and first postoperative dressings using a scale of 0 to 3. These results were ranked and compared. Patients were also administered a Foot Function Index survey preoperatively and postoperatively at each visit.

Results
A combination of patients undergoing forefoot, midfoot, hindfoot, and ankle surgeries qualified for the study. Data analysis showed statistically significant reductions in postoperative ecchymosis, edema, erythema, and bleeding at 2 and 6 weeks in patients who received 1 gram of TXA 20 minutes prior to skin incision, with P values of < 0.05 and F values greater than 1.0. There was one complication in the non-TXA group; one patient with excessive swelling underwent amputation of the tips of toes 2+3 after forefoot reconstruction. There were no medical complications in the TXA group. Foot function index pain scores were lower between weeks 2 and 6 postoperatively in patients who received TXA preoperatively than in patients who had not received TXA.

Conclusion
Preoperative administration of 1 gram of TXA significantly reduced blood loss, pain, and swelling in patients undergoing foot and ankle surgery. Patients experienced no deleterious detectible medical side effects from administration of TXA. Further studies with more patients are warranted to elaborate on these preliminary results.

 

Surgery, Anesthesia Not Linked to Long-Term Cognitive Impairment in Older Adults

“Postoperative confusion does not mean there is long-term dementia because of the operation. The result is a significant finding. Many patients and providers discourage surgery in the elderly based on old data. Our techniques are now so improved that this study of 8,500 operated cases with general anesthesia found are no increased incidence of cognitive impairment in the Denmark. Research of this type from the Scandanavian countries has extra validly with me because they can track their patients more carefully. Patients return for follow-up care as directed better than in American” Bill Chesnut, MD

AAOS Now online edition _March 1, 2016  __SOURCE: American Society of Anesthesiologists

CHICAGO — March 1, 2016 — New research suggests that older patients should not feel reluctant to have quality of life enhancing surgeries due to concerns that undergoing anaesthesia may boost their risk of developing cognitive issues.

In a study of more than 8,500 middle-aged and elderly Danish twins published in Anesthesiology, researchers found no clinically significant association between major surgery and general anaesthesia with long-term cognitive decline.

“Our use of twins in the study provides a powerful approach to detect subtle effects of surgery and anaesthesia on cognitive functioning by minimising the risk that the true effects of surgery and anaesthesia are mixed-up with other environmental and genetic factors,” said lead author Unni Dokkedal, MD, University of Southern Denmark, Odense, Denmark. “We found no significant cognitive effects related to surgery and anaesthesia in these patients, suggesting that other factors, such as preoperative cognitive levels and underlying diseases, are more important to cognitive functioning in aging patients following surgery.”

The researchers examined the association between exposure to surgery and level of cognitive functioning in a sample of 4,299 middle-aged twins aged younger than 70 years and 4,204 elderly twins aged 70 years or older.

Results from cognitive tests of twins who had either major, minor, hip, and knee replacement or other surgery within 18 to 24 years before cognitive examination were compared with the cognitive results of a reference group, comprised of twins who had no surgical procedures. Test results were also compared in an intra-pair analysis of twins, one of whom was exposed to surgery while the other was not, to assess genetic and shared environmental confounding.

Twins who had undergone major surgery had slightly lower cognitive scores, compared with the reference group, but when compared to their twin, when genetic and shared environmental factors were adjusted, no association was observed.

Interestingly, twins who had undergone hip and knee replacement surgery had slightly higher cognitive scores, but the difference was not statistically significant.

No differences were found in the minor or other surgery group when compared with the reference group.

The authors also analysed data for patients who had undergone surgery from 3 months to 2 years before cognitive examination and found no effect of the short time interval between surgery and cognitive examination on cognitive function.

The results suggest preoperative cognitive functioning and underlying diseases are more important for cognitive functioning in mid- and late life than surgery and anaesthesia.

“It is important to know whether surgery and anaesthesia have any negative effects, especially with regard to preoperative counselling of the patient,” said Dr. Dokkedal. “This research has the potential to become a key piece of this very complex research puzzle.”

In an accompanying editorial, Michael S. Avidan, MD, and Alex S. Evers, MD, Washington University School of Medicine, St. Louis, Missouri, wrote: “On the basis of a growing body of evidence, of which the study by Dokkedal et al is symbolic, older patients should today be reassured that surgery and anaesthesia are unlikely to be implicated in causing persistent cognitive decline or incident dementia. The large number of patients and the use of rigorous longitudinal cognitive testing in the study increased the reliability of the findings.”