Hopkins PodBlog

Is body checking absolutely fundamental to ice hockey? No doubt ice hockey fans would roar a resounding yes! but a study in this week's JAMA illustrates just how dangerous body checking is for neophyte hockey players in Canada.

Turns out Canada has some fascinating social experiments percolating, and this is one of them: in the province Alberta, body checking is allowed among PeeWee hockey players. Those are players 11-12 years old. In Quebec province, this practice is forbidden. Researchers crunched data from the top 60% of divisions of play for the 2007-2008 ice hockey season for both leagues, representing close to 2200 players.

The data show that when Alberta players were compared with Quebecoise, the former were at a three fold higher risk for concussion, severe injury, and severe concussion. There was no difference in rates of injury for the two study groups experienced during practice, when presumably, players aren't body checking each other with a view to a kill.

Risk factors for more frequent injury included smaller body size and hours of play, while severe concussion was associated with position played and the player's attitude toward the practice of body checking. Clearly the take home conclusion is that if we want to reduce injuries, some of them severe, to young hockey players body checking should not be allowed. It's unclear to me why body checking is necessary at all at any level of play, but I guess hockey fans are a bloodthirsty lot, and as Rick quips in the podcast, "I went to a boxing match and a hockey game broke out," perhaps it is expected.

This study is published at a time when concussions experienced while playing sports are receiving a lot of media attention. A week ago I attended an NFL/Johns Hopkins conference on 'mild traumatic brain injury,' or concussion, sponsored by the NFL. The central question is what is the risk of repeated injury on the subsequent development of dementia or other health problems later in life? Other questions identified during the conference included ways to assess severity of injury, appropriate recuperation periods before returning to play, and others. A dearth of evidence is apparent, as is the need for considerable research to convincingly answer these questions. But here's one thought that occurs to me: professional football players choose to play football, but PeeWee hockey players are not in a position to assess evidence and make informed decisions, and therefore protective measures must be undertaken by coaches and parents. If we're worried about the deleterious health impact of head injury in adults, what are the consequences in children?

Other topics this week include a new use for an old drug: allopurinol and angina in the Lancet, nonsteroidal antiinflammatory drugs and cardiovascular risk in Circulation, Cardiovascular Quality Outcomes, and abuse of prescription medications in US teenagers from the CDC. Check out our YouTube, and until next week, y'all live well.

As I opine in this week's podcast, it seems curious to me that so many of our body parts are treated separately, as though feet, backs, and teeth were distinct entities. Indeed, I've often thought it would be great to simply drop my teeth off at the dentist and come back later to retrieve them but the fact is, they're attached to my jaw, and therefore to me and the rest of my body. Further evidence of their inextricable link emerges in a study in BMJ: Toothbrushing, inflammation, and risk of cardiovascular disease.

This study took a look at how often folks brushed their teeth (almost 12,000 of them! That's people, not teeth) and how that correlated with cardiovascular events, such as heart attacks or strokes, over an average follow up period of 8 years. Three levels of tooth hygiene were possible: less than once per day, once a day, or twice a day. Sure enough, there was a dose response. Those who brushed their teeth least were at the greatest risk of a cardiovascular event, with about a 70% greater chance of experiencing a heart attack or stroke compared with those who brushed twice a day. Seems compelling to Rick and me that twice a day interaction with a toothbrush is a good idea.

The study also measured blood levels of C-reactive protein, one marker of inflammation, and fibrinogen, a blood component related to clotting, in almost 5000 participants. Once again, higher levels of both of these blood markers were associated with less frequent tooth brushing.

Things not assessed in the study I would like to see would be flossing in addition to brushing, since presumably more of the bugs that reside in our mouths and may cause low grade inflammation are removed when we floss, and perhaps use of mouthwash and its potential impact. The inescapable conclusion, though, is that our oral health does impact general health. And as Rick points out, not only will our bodies be grateful for vigilant oral hygiene, so will those around us.

Other topics this week include treatment of one partner who is HIV positive and preventing infection in the other partner in the Lancet, timeliness of treatment for heart attack in JAMA, and group medical appointments in Annals of Internal Medicine. If you haven't looked at our YouTube we'd be so happy if you did! and until next week, y'all live well.

I'm a big fan of the tried and true when it comes to medications and procedures. After tens of thousands or even better, hundreds of thousands of people have run the gauntlet, I too, am much more willing to give things a try. Call me a coward, but I get a big lift from following the crowd in this regard. So if I had type 2 diabetes I would be okay with taking metformin (after trying weight loss and dietary changes, of course). But now a study in the current issue of the British Medical Journal raises a red flag about metformin use: it may cause vitamin B12 deficiency.

In this long term study of several hundred people who were given metformin or placebo three times a day for an average of 4.3 years, those who received metformin saw a reduction in their levels of vitamin B12 of about 19%. People taking metformin also experienced an increase in homocysteine levels, a marker of cardiovascular disease risk, assumed to be caused by the decrease in vitamin B12.

Yowl! So what's a responsible person with diabetes to do? Uncontrolled diabetes is a major risk factor for cardiovascular disease, and now one of the most trusted agents for managing the condition may also precipitate increased risk? And when the other drugs used to manage type 2 diabetes are considered, things look bleak indeed.

Steady, now. Although the effects of vitamin B12 deficiency at the low end may include fatigue, poor memory and depression and at the high end, irreversible damage to the brain and other parts of the nervous system, the authors of this study suggest that simply measuring blood levels of the vitamin is a simple and prudent step. Those who are found to be deficient can first try consuming foods rich in B12: meats, fish, and milk and milk products among them. If these don't correct the problem supplements may be the answer. But there's no compelling reason to avoid metformin use as long as there's awareness of this possibility. And that's good news.

Other topics in this week's podcast include drowning prevention in Pediatrics, the dangers of multifocal eyeglasses in the elderly in BMJ, and sugar sweetened beverages and blood pressure in Circulation. Watch our YouTube, and until next week, y'all live well.

Maternal depression is a common condition following childbirth, and its negative consequences for all concerned have been studied extensively. Now it turns out that dads, too, suffer a high rate of depression following the birth of a child, a study in the current issue of JAMA reports.

Depression in both parents can develop prior to the birth of the child, but this study reports it most often happens afterward, when the baby is three to six months old. Makes a lot of sense to me! I remember those days without regret that they are over. I would add, especially after the birth of my first child, that it was so much more life-altering than I had any idea about. Add to that sleep deprivation, worry about parenting skills or their lack, mountains of laundry, frequent pediatrician visits, and it's no wonder depression ensues. And my children were healthy and my deliveries uncomplicated. How much worse for those who don't have such good fortune.

I write, of course, from the maternal perspective, but this study shows that about 10% of the men who participated in reviewed studies, since this was a meta-analysis, experienced depression. Frequently it was correlated with the development of depression in the partner, and this too makes sense. One of the concerning aspects of the study is the fact that depression on the part of the father, just like that in mothers, may also contribute to negative outcomes for the child.

So what can we do about this depression? One clear answer is to screen for it, especially among partners of women who develop depression during this period. The findings suggest that families should be treated as a unit and screened as such. The big question is how should such depression be treated? The answer is beyond the scope of this study but certainly suggests a direction for future research. In the meantime it may provide comfort to men who experience depression following the birth of their child that it's not an aberration and it's okay to seek help.

Other topics in this week's podcast include depression following traumatic brain injury in the same issue of JAMA, an individual's risk for developing resistant infections with antibiotic use in BMJ, sildenafil or Viagra in a lung condition called pulmonary fibrosis in NEJM, and pesticide residues and risk of ADHD in children in Pediatrics. Please check out our YouTube and until next week, y'all live well.

Proton pump inhibitors are a very popular form of antacid medication usually abbreviated PPIs. They're available in both prescription and over the counter (OTC) strengths, and the latest issue of Archives of Internal Medicine states their prescription-only sales total almost $14 billion per year. Only the manufacturers know what the OTC sales are worth, but what's emerging in this issue of Archives is a rather concerning picture of the multitude of side effects related to use of PPIs.

Turns out that women in the Women's Health Study who took PPIs had an increased risk of fractures of the spine and lower arm. Patients who took PPIs and were hospitalized had a much heightened risk of becoming infected with that increasingly frightening pathogen, Clostridium difficile. C. difficile, for those in the know, causes diarrhea, often bloody, and can be very challenging to eradicate. And those on PPIs are also more likely to develop both hospital- and community-acquired pneumonia. Yikes! How then can we account for the popularity of PPIs?

Many people are placed on PPIs (and probably shouldn't be) when they're hospitalized and when they're discharged they simply stay on the medication. About a quarter of US adults report dyspepsia, medicalese for upset stomach or indigestion, and these drugs are very effective at treating it. Physicians accustomed to providing relief may prescribe PPIs. But the author of an editorial states that between 53 and 69% of prescriptions for PPIs are NOT indicated.

So, hmmmm. Seems we have a very effective medication for a common complaint that's costing our healthcare system a lot of money and that looked to be innocuous but now isn't. Clearly, PPI use needs to be scrutinized very carefully. What are the alternatives?

First of all, prevention, as always, is worth a pound of PPIs. Don't eat large meals late at night and then go to bed. Curtail consumption of wine, coffee and perhaps chocolate before retiring. Sleep with your head elevated. Lose weight if you need to.

So you overeat and go to bed. Then what? Start with the little guns first. Garden variety calcium-based antacids can be very effective, and then perhaps reach for the class of antacids known as H2 blockers, which although still associated with side effects don't seem to be quite as deleterious as PPIs.

Other topics in this week's podcast include the benefits of consuming nuts in Archives, the real incidence of food allergies in JAMA, and the effect of fibrates on cardiovascular risk in this week's Lancet. Until next week, y'all live well.

Before launching into this week's blog on celiac disease, Rick and I would like to invite you to view our YouTube. And now, on to the topic at hand:

Lots of people complain of gastrointestinal symptoms. In point of fact, this week's meta-analysis on diagnosing celiac disease in JAMA states that between 35 and 40 individuals out of every 1000 who visit their primary care doctor do so because of abdominal discomfort, bloating, diarrhea, or other chronic symptoms, and these can adversely impact quality of life.

Among the plethora of conditions that can cause chronic abdominal distress is celiac disease, with an estimated prevalence (medspeak for how many people have this in the population at large) of 0.5%-1.0%. That's a lot of people. And what exactly is celiac disease?

Celiac disease can be defined as a sensitivity to gluten, a protein found in wheat, barley and rye, that largely affects the small bowel or intestine. This sensitivity gives rise to nonspecific symptoms such as diarrhea and bloating, but can have long term consequences, including fertility problems, osteoporosis, and cancer. The best news about celiac disease is it can be managed very well by avoiding foods that contain gluten. Few conditions respond so well to such simple intervention.

Since both cause and cure are well known, diagnosing celiac disease properly is pivotal. This analysis makes the case that abdominal symptoms alone are not sufficient to diagnose the condition, and that two blood tests, used sequentially, may be the way to start. IgA antitissue transglutaminase antibodies and IgA antiendomysial antibodies are two types of antibodies found circulating in the blood in the majority of folks with celiac disease, and both tests are widely available. Those who test positive for the first can then be tested for the second, but as Rick points out in the podcast, the definitive test is a biopsy of the lining of the small bowel. I would be sorely tempted if I tested positive for both tests, however, to try eliminating gluten from my diet and see what happened rather than undergo biopsy.

Other topics this week include the benefits of early follow up in avoiding rehospitalization in people with congestive heart failure in JAMA, a new type of stent for the heart in NEJM, and the risk of Alzheimer's disease in spouses who provide care for their affected spouse in the Journal of the American Geriatrics Society. Until next week, y'all live well. And please watch the YouTube!