Friday, August 21, 2015

American Heart Association's Cardiology Patient Page takes an uncritical view of chelation

The article opens:

Don’t cringe when you hear the term chelation (key-LAY-shun) therapy. If you have heard about it at all, you may have heard that it is alternative medicine, quackery, expensive, and even dangerous. New research funded by the National Institutes of Health is suggesting that this old treatment has some real life in it and that it may particularly benefit patients with diabetes mellitus and prior heart attacks.

The article goes on with more of the same credulity along with this little tidbit:

There are reasons to think that chelation to remove metals might treat or prevent heart disease.1 Some complications of diabetes mellitus may be caused by chemical reactions that happen to the excess sugar in the blood. These reactions are catalyzed, or facilitated, by metals. The environment is polluted with metals that are toxic to our systems. Lead (gasoline, plumbing), arsenic (well water, rice, apple juice), mercury (many fish), and cadmium (from rechargeable batteries) are among the top 10 most toxic substances listed by the US government. EDTA chelates lead and cadmium.

So now we're adding environmental toxins to the list of risk factors for cardiovascular disease.  I've been following this field closely for a long time and this is new to me.  Like mercury and autism I guess.    It is only the latest in a growing list of purported mechanisms by which chelation might “work.”  None of them have strong biologic plausibility.  It's interesting to me how the proponents have jumped from one to another over the years.

This is all based, of course, on TACT and its diabetes substudy.  For my own take on these two studies see here and here.  Suffice it to say for this post that, at least among highly publicized clinical trials, TACT is the most conflicted and flawed study I have been aware of in my career as a physician.  (It's too bad the article didn't cite this paper).

The article, though an AHA publication, departs from the AHA's official post-TACT position on chelation, which gives it only a IIb recommendation.   And now it appears that TACT 2, a follow up trial, is in the works.  I'm not sure what to think about this.  I guess that since TACT has changed the status of chelation, in the perception of the medical community, from that of “quackery” to “controversial treatment” another trial may have to be done.  But if its funding and conflicts are like those of TACT 1 I am not optimistic.

Tuesday, August 18, 2015

The obesity-asthma link

From a recent review:

Recent findings: Clinical and epidemiological studies indicate that obese patients with asthma may represent a unique phenotype, which is more difficult to control, less responsive to asthma medications and by that may have higher healthcare utilization. A number of common comorbidities have been linked to both obesity and asthma, and may, therefore, contribute to the obese–asthma phenotype. Furthermore, recently published studies indicate that even a modest weight reduction can improve clinical manifestations and outcome of asthma.

Summary: Compared with normal-weight patients, obese and overweight patients with asthma have poorer asthma control and respond less to corticosteroid therapy. Future studies focusing on the mechanism underlying both obesity and asthma including the obese–asthma phenotype are required to better characterize the link between the conditions and target the management of this patient group.

Of particular interest, the review suggests weight loss as a treatment modality.

Sunday, August 16, 2015

The emerging link between obesity and kidney disease

From a recent review:

It is well established that excessive caloric intake contributes to organ injury. The associated increased adiposity initiates a cascade of cellular events that leads to progressive obesity-associated diseases such as kidney disease. Recent evidence has indicated that adipose tissue produces bioactive substances that contribute to obesity-related kidney disease, altering the renal function and structure. In parallel, proinflammatory processes within the adipose tissue can also lead to pathophysiological changes in the kidney during the obese state.

Saturday, August 15, 2015

The asthma-COPD overlap syndrome (ACOS)

From a recent update:

Purpose of review: Some individuals share characteristics of asthma and chronic obstructive pulmonary disease (COPD). The asthma–COPD overlap syndrome (ACOS) has been defined as symptoms of increased variability of airflow in association with an incompletely reversible airflow obstruction. In this review, we present the latest findings in the diagnosis, characterization and management of ACOS.

Recent findings: Around 15–20% of COPD patients may have an ACOS. Patients with ACOS are characterized by increased reversibility of airflow obstruction, eosinophilic bronchial and systemic inflammation, and increased response to inhaled corticosteroids, compared with the remaining patients with COPD. Patients with ACOS have more frequent exacerbations, more wheezing and dyspnoea, but similar cough and sputum production compared with COPD.

Summary: The relevance of the ACOS is to identify patients with COPD who may have underlying eosinophilic inflammation that responds to inhaled corticosteroids. So far, the previous diagnosis of asthma in a patient with COPD is the more reliable criterion for ACOS. Ongoing studies will clarify if concentrations of blood eosinophils may be useful to identify this subgroup of patients with COPD. If this is the case, the interest of ACOS may shift to that of eosinophilic COPD, which is easier to diagnose and has clear therapeutic implications.

Friday, August 14, 2015

Strategies for reduction in hospital readmissions---what does the evidence say?

From a recent review (free full text):


› Use risk stratification methods such as the Probability of Repeated Admission (Pra) or the LACE index to identify patients at high risk for readmission. B
› Take steps to ensure that follow-up appointments are made within the first one to 2 weeks of discharge, depending on the patient’s risk of readmission. C
› Reconcile preadmission and postdischarge medications to identify discrepancies and possible interactions. B
Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Thursday, August 13, 2015

Proton pump inhibitors and esophageal varices

Data Synthesis: Of 1156 studies, 20 were included after assessment. There was wide methodological heterogeneity and moderately high risk of bias among studies. Level I evidence suggests that PPIs reduce esophageal ulcer size post–elective esophageal ligation; the clinical importance of such findings is not known given the self-limiting nature of esophageal ulcer. Available evidence does not support a role of PPIs for long-term prophylaxis of portal hypertension–related bleeding and high-dose infusion for acute management of GEV hemorrhage. Retrospective data demonstrate a potential increase in the incidence of spontaneous bacterial peritonitis in patients with cirrhosis receiving PPIs. Conclusions: The best available evidence supports the use of short-course (10 days) PPI post–endoscopic variceal ligation to reduce ulcer size if ulcer healing is a concern. Practices such as high-dose infusion and prolonged use should be discouraged until evidence of benefit becomes available.

Wednesday, August 12, 2015

Pneumonia as a cardiovascular risk factor

Pneumonia increased short and long term risk for cardiovascular events in two databases, published here.

This is not the first such report. See here.