Coke Zero, how could you? (artificial sweeteners and glucose intolerance)

mouse and aspartame

 

In theory, artificial sweeteners were created to help consumers avoid traditional sugar in an attempt to avoid caloric intake and curb the metabolic consequences, such as obesity and diabetes. However, a recently published study in Nature suggests otherwise.

Sugar substitutes such as saccharin might aggravate these metabolic disorders by acting on bacteria in the human gut, according to a study published by Nature this week (J. Suez et al. Nature http://dx.doi.org/10.1038/nature13793; 2014). Smaller studies have previously purported to show an association between the use of artificial sweeteners and the occurrence of metabolic disorders. This is the first work to suggest that sweeteners might be exacerbating metabolic disease, and that this might happen through the gut microbiome, the diverse community of bacteria in the human intestines. “It’s counter-intuitive — no one expected it because it never occurred to them to look,” says Martin Blaser, a microbiologist at New York University.

A team led by Eran Elinav of the Weizmann Institute of Science in Rehovot, Israel, fed mice various sweeteners — saccharin, sucralose and aspartame — and found that after 11 weeks, the animals displayed glucose intolerance, a marker of propensity for metabolic disorders.

To simulate the real-world situation of people with varying risks of these diseases, the team fed some mice a normal diet, and some a high-fat diet, and spiked their water either with glucose alone, or with glucose and one of the sweeteners, saccharin. The mice fed saccharin developed a marked glucose intolerance compared to those fed only glucose. But when the animals were given antibiotics to kill their gut bacteria, glucose intolerance was prevented. And when the researchers transplanted faeces from the glucose-intolerant saccharin-fed mice into the guts of mice bred to have sterile intestines, those mice also became glucose intolerant, indicating that saccharin was causing the microbiome to become unhealthy.

So his team recruited seven lean and healthy volunteers, who did not normally use artificial sweeteners, for a small prospective study. The recruits consumed the maximum acceptable daily dose of artificial sweeteners for a week. Four became glucose intolerant, and their gut microbiomes shifted towards a balance already known to be associated with susceptibility to metabolic diseases, but the other three seemed to be resistant to saccharin’s effects. “This underlines the importance of personalized nutrition — not everyone is the same,” says Elinav.

He does not yet propose a mechanism for the effect of artificial sweeteners on the micro­biome. But, says Blaser, understanding how these compounds work on some species in the gut might “inspire us in developing new therapeutic approaches to metabolic disease”.

Portions of this post are reprinted by permission from Macmillan Publishers Ltd: Nature, advance online publication, volume: 513, pages: 290. 18 September 2014(doi: 10.1038/513290a)

 

Vasculitis update

During intern chart conference, Dr. Kazi referenced an article that summaries the 2012 update on the nomenclature and definitions of the different vasculidities. The prior consensus conference was held in 1994 and since then we have had many advances in our knowledge and understanding of vasculitis. Below is a table showing the different classifications but I also highly recommend also checking out the definitions on Table 3! Here’s the link to read the whole article:

http://onlinelibrary.wiley.com/doi/10.1002/art.37715/pdf

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“Could you patent the sun?”

This famous quote is by Dr. Jonas Salk (1914-1995) who was an American virologist and discovered and developed the first inactivated vaccine against polio. By the 1950’s, polio was one of the biggest public health problems in the world with many epidemics occurring. Dr. Salk tested the vaccine nationally on 1 million children who were referred to as Polio Pioneers as results showed the vaccine to be safe and effective. Dr. Salk was asked why he didn’t patent the vaccine and potentially earn billions of dollars to which he responded, “Could you patent the sun?” Today marks Dr. Salk’s 100th birthday as he passed away in 1995 at the age of 80. Check out the link below from The Salk Institute to learn more about Dr. Salk and his work.

http://www.salk.edu/about/jonas_salk.html

Epididymitis

Today at VA Morning Report we talked about epididymitis with Dr. Cuttrell from the infectious disease division. Below are some key points from our discussion and from the Johns Hopkins Antibiotic Guide:

  • Acute epididymitis is defined as < 6 weeks of duration.
  • Common presentation: pain, swelling, and inflammation
  • Men < 35 years old: Usual causative organisms are C. trachomatis (CT) and N. gonorrhoeae (GC)
  • Men > 35 years old: Most common pathogens are enteric (E. coli, Klebsiella) and P. aeurginosa but gonorrhea and chlamydia must also be considered
  • Diagnostic Test: GC and CT nucleic acid amplication tests, gram stain and culture of urethral secretions, test for other STD such as syphilis and HIV, ultrasound exam to exclude torsion
  • Empiric Therapy for men <35 years old and STD suspected: Ceftriaxone 250mg IM x 1 plus doxycyline 100mg PO bid for 10 days
  • Empiric Therapy for men >35 years old and enteric organisms suspected: Ofloxacin 300mg PO bid x 10 days or levofloxacin 500mg daily for x 10 days
  • Supportive therapy consits of bed rest, ice, scrotal elevation, analgesics
  • If swelling and tenderness persists after completion of antibiotics, comprehensive reevaluation is warranted and consider other etiologies such as tumor, abscess, infarction, TB, fungal infection

Also, check out this review article from the AAFP, Epididymitis and Orchitis: An Overview:

http://www.aafp.org/afp/2009/0401/p583.html

 

Dying in America

Dying

The Institute of Medicine recently released a report, titled “Dying In America.”

The report suggests that the first end-of-life conversation could coincide with a cherished American milestone: getting a driver’s license at 16, the first time a person weighs what it means to be an organ donor. Follow-up conversations with a counselor, nurse or social worker should come at other points early in life, such as turning 18 or getting married. The idea, according to the IOM, is to “help normalize the advance care planning process by starting it early, to identify a health care agent, and to obtain guidance in the event of a rare catastrophic event.”

The IOM plans to spend the next year holding meetings around the country to spark conversations about the report’s findings and recommendations. “The time is now for our nation to develop a modernized end-of-life care system,” said Dr. Victor Dzau, president of the IOM.

The 21-member IOM committee that authored the report grappled with the fact that most Americans have not documented their wishes for end-of-life care. A national survey in 2013 found that 90 percent of Americans believed it was important to have end-of-life care discussions with their families, yet less than 30 percent had done so. Those who have had the discussions tend to be white, higher-income, over 65, and have one or more chronic condition.

In response to these statistics, the IOM offers a new “life-cycle model of advance care planning” that envisions people having regular planning conversations as part of their primary care, and at the diagnosis of any chronic illnesses or genetic conditions. The conversation would continue at various turning points of a disease, when spiritual counseling might be offered, and then again in the final year of expected life.

The report also found that the American health care system is poorly equipped to care for patients at the end of life.  Despite efforts to improve access to hospice and palliative care over the past decade, the committee identified major gaps, including a shortage of doctors proficient in palliative care, reluctance among providers to have direct and honest conversations about end-of-life issues, and inadequate financial and organizational support for the needs of ailing and dying patients.

“We all share in common one reality: We’re all going to die,” said Dr. Philip Pizzo, co-chair of the committee, at the public release of the report Wednesday. “We have the ability to accomplish [a strong end-of-life care system], but we have a long way to go.”

Just talking about death and dying can ignite fear and controversy: Five years ago, the health law’s proposal for Medicare to reimburse doctors for counseling patients about living wills and advance directives became a rallying cry for Republican opponents of the law who warned about so-called “death panels.” The reimbursement provision was removed from the Affordable Care Act before it passed.

The IOM argues that the country cannot afford to wait any longer to have a less heated conversation, especially as the number of elderly Americans continues to grow with the aging of the baby boom generation.

“At a time when public leaders hesitate to speak on a subject that is profoundly consequential for the health and well-being of all Americans, it is incumbent on others to examine the facts dispassionately, assess what can be done to make those final days better, and promote a reasoned and respectful public discourse on the subject,” write Dzau and Dr. Harvey Fineberg, the former president of the IOM, in a forward.

The report also addresses how to make palliative care – care that focuses on quality of life and pain control for people with serious illnesses – more prevalent and available to all patients.

Over the past decade, palliative medicine has become a widespread specialty.  But while 85 percent of hospitals with more than 300 beds now have palliative care services, many patients still may not have access to a specialist, including those who are not hospitalized or who live in rural areas.

To address the shortage, the committee writes, all clinicians regardless of specialty “should be competent in basic palliative care, including communication skills, interprofessional collaboration, and symptom management.” Medical schools are currently required to cover end-of-life care as part of their curriculum, but they offer an average of just 17 hours of training over all four years. And end-of-life care is not one of the crucial 15 topic areas for Step 3 of the medical licensing exams, the final step to becoming a practicing physician.

The committee calls for medical schools, accrediting boards and state regulatory agencies to bolster their end-of-life training and certification requirements.

Some private insurance plans have already started adopting some of the practices recommended in the report. “It’s not entirely altruistic,” said David Walker, co-chair of the committee. Private payers have the data to know that palliative and hospice care can save money at the end of life.

The IOM is an influential body that is the health arm of the National Academy of Sciences. Its mandate is to provide objective information to advise the public and policy makers. IOM reports are sometimes undertaken at the request of Congress, which can also fund the work. “Dying in America” was funded privately, however, by “a public-spirited donor” who wishes to remain anonymous, according to Dzau and Fineberg.

Reproduced with permission from Kaiser Health News.

Fever, anemia, renal failure, low platelets…this sounds familiar

Today at VA Morning Report we talked about thrombotic microangiopathy (TMA) and its various forms including TTP and HUS. The New England Journal of Medicine has a great review article about thrombotic microangiopathies.

Key Points:

  • TMA include disorders that are acquired and inherited.
  • All disorders involve arteriolar and capillary thrombosis due to vascular damage with endothelial and vascular wall damage.
  • Common disorders associated with acquired microangiopathic hemolytic anemia and thrombocytopenia include systemic infection, cancer, severe hypertension, hematopoietic stem cell and organ transplantation, HELLP, autoimmune disorders.

Check out the link below:

NEJMmicro

Which test should I get to rule out latent TB?

JAMA has been doing a fantastic series called “JAMA Diagnostic Test Interpretation” in which authors present a clinical case that highlights the utility of a particular test. In the October 8th issue of JAMA, Dr. Blumberg and Dr. Kempker review interferon-gamma release assays in the evaluation of tuberculosis infection.

Key Points:

  • There is no actual gold standard test for latent TB infection.
  • Tuberculin skin testing (TST) has a specificity over 95% but decreases to 60% in patients with a history of BCG vaccination.
  • Interferon-gamma release assays are preferred over TST in patients with history of BCG vaccination or unlikely to return for TST interpretation.
  • If a patient tests positive for latent TB infection, active infection must be ruled out before starting treatment for latent TB.

Check out the article through the UTSW Library:

http://jama.jamanetwork.com.foyer.swmed.edu/article.aspx?articleid=1911306