This week from Dr. Cerami and Utah Sports and Wellness

From: Journal of Craniovertebral Junction Spine, April-June 2016

Quick Summary:

These authors evaluated 39 subjects with leg length discrepancy and low back pain and 43 controls to quantify the occurrence of disc herniation between the two groups. Traditionally, surgery has been the primary approach in the treatment of discogenic low back pain. However, “the surgical treatment of ruptured lumbar intervertebral discs is sometimes discouraging to both the surgeon and the patient.” This study, for the first time, shows that disc herniation may actually occur as a result of the leg length inequality. “Leg length discrepancies “may lead to disorders in postural movement coordination. It may lead to significant changes in spinal posture and deterioration of postural stability.” “Human coronal balance may be one of the causes of operative failure after disc surgery. Assessment of pathologic coronal imbalance requires a clear understanding of normal coronal alignment.” “These authors suggest that the surgical treatment of lumbar disc herniation does not always lead to improved outcome because of “abnormal coronal balance.” “Correction of abnormal load transmission across the spine and degenerated disc may, therefore, be beneficial.”

Abstract:

Inequality in leg length may lead to to abnormal transmission of load across the endplates and degeneration lumbar spine and the disc space. There has been no study focusing on lumbar disc herniation (LDH) and leg length discrepancy. This subject was investigated in this study. Consecutive adult patients with leg length discrepancy and low back pain (LBP) admitted to our department were respectivelly studied. A total number of 39 subjects (31 women and eight men) with leg length discrepancy and LBP and 43 (25 females and 18 males) patients with LBP as a control group were tested. Occurrence of disc herniation is statistically different between patients with hip dysplasia and control groups (P < 0.05). The results of this study showed a statistically significant association between leg length discrepancy and occurrence of LDH. The changes of spine anatomy with leg length discrepancy in hip dysplastic patients are of importance in understanding the nature of LDH.

These authors also note:

• Low back pain has a lifetime prevalence of 85%.
• The primary cause of LBP is disc disease.
• “Inequality in leg length may lead to to abnormal transmission of load across the endplates [causing] degeneration of the lumbar spine and the disc space.”
• “One of the essential roles of the spine is to support mechanical loads in the upright position. Balance of the body essentially depends on how far the head is to the midline.”
• Spinal imbalance may be an important cause for failed back surgery cases.
• “Subtle anatomic abnormality in the pelvis is associated with altered mechanics in the lumbar spine.”
• Short extremity length and lumbar disc herniation were statistically coupled in this study. “Occurrence of disc herniation is statistically different between patients with short leg and controls.” “Our result showed statistically significant difference.”
• “Patients with chronic LBP have a minor balance defect. Inequality in leg length is important for the understanding of the pathophysiology of lumbar disc degeneration and herniation.”
• “Patients with intervertebral disc disease are characterized by asymmetrical leg loading.” “Leg length discrepancy may be another causative condition” in low back pain.
• “An asymmetrical loading pattern may deteriorate spine biomechanics.”
• “A coronal imbalance of the spine is usually noted in patients with leg length discrepancy.” “Abnormal patterns of load transmission may be accepted as a principal cause of degenerative changes in these cases.”
• “Our observations suggest that LBP may have etiologies related to abnormal load transmission due to coronal imbalance. It seems that a successful treatment may sometimes exist beyond good surgery. In these situations, abnormal coronal balance may be an important factor.”
• “The results of this study showed a statistically significant association between leg length discrepancy and occurrence of lumbar disc herniation.”

This week from Dr. Cerami and Utah Sports and Wellness

From: Journal of the American Medical Association Internal Medicine, January 2017

Quick Summary:

In the November 15, 2016 issue of the JAMA, the latest US Preventive Services Task Force recommendation statement on statins for prevention of cardiovascular disease in adults was published. The authors point out methodological flaws in the Task Force’s analysis of the evidence for taking statins for primary prevention of cardiovascular disease, as well as shortcomings, bias, errors, etc., that “inflate” the benefits of statin drugs. This editorial is a careful analysis and essentially a rebuttal to the recommendation of the Task Force. The evidence report summarized data from 19 trials including a total of 71 344 patients and concluded that statin therapy was associated with reduced risk of all-cause and cardiovascular mortality and cardiovascular disease (CVD) events. Thus, the task force recommended “initiating use of low- to moderate-dose statins in adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors and a calculated 10-year CVD event risk of 10% or greater (B recommendation)” or “7.5% to 10% (C recommendation).” Although the task force did their usual careful job of reviewing the evidence, the evidence for treating asymptomatic persons with statins does not appear to merit a grade B (high certainty that the net benefit is moderate) or even a grade C (moderate certainty that the net benefit is small) recommendation. With statins, persons at low risk of heart disease have little chance of benefit and are more likely to have net harm. Using current data, “of 100 people who take a statin for 5 years, only 2 of 100 will avoid a myocardial infarction, and 98 of the 100 will not experience any benefit.” While there will be no mortality benefit for any of the 100 people taking the medicine every day for 5 years. 5 to 20 of the 100 will experience muscle aches, weakness, fatigue, cognitive dysfunction, and increased risk of diabetes. The task force evidence report estimated that to prevent 1 death from any cause over a 5 year period, 244 patients would need to take a statin daily. Given the serious concerns about the harms of the reliance on statins for primary prevention, it is in the interest of public health and the medical community to refocus efforts on promoting a heart healthy diet, regular physical activity and not smoking.

These authors also note:

• Sadly, “exacerbating the potential bias, all of the trials included in the task force evidence report were industry-sponsored except 1 trial.”
• “Industry-sponsored studies have been shown to report greater benefit and lesser adverse effects than non-commercially sponsored trials of the same drugs.”
• With statins, persons at low risk of heart disease have little chance of benefit and are more likely to have a net harm.
• Amazingly, many of the trials used by the Task Force did not ask about commonly reported statin effects, such as muscle pains and weakness.
• Using creatine kinase levels to diagnose myopathy in statin-consuming patients “leads to a significant underestimate of muscle problems” because “most muscle problems do not involve an increase in creatine kinase levels.”
• Studies estimate that about 20% of statin users have muscle problems.
• With statins, the actual trial data are held by the Cholesterol Treatment Trialists’ Collaboration on behalf of the drug industry sponsor and have “not been made available to other researchers, despite multiple requests over many years.”
• “Although reported rates of adverse events in clinical trials are low, this does not reflect the experience of clinicians who see patients who are taking statins.”
• An NPR reporter with a calculated 2.9% risk of heart disease over 10 years was prescribed a statin, and she reported that “going for a walk was like slogging through mud” until “I ditched the statin. The weakness evaporated. I could run again.”
• Studies show an association between the use of statins and cognitive dysfunction, and most studies show an increased risk of diabetes with statin use.
• In 2012, the US Food and Drug Administration issued safety label changes for statin drug labels, including:
  • The potential for cognitive side effects such as memory loss, confusion, etc.
  • Increased blood sugar
  • Increased glycosylated hemoglobin (HbA1c) levels
• The rate of statin use for primary heart disease prevention among those older than 79 years increased from 8.8% in 2000 to 34.1% in 2012.
• “There are unintended consequences of the widespread statin use in healthy persons.”
• “People taking statins are more likely to become obese and more sedentary over time than non-statin users, likely because these people mistakenly think they do not need to eat a healthy diet and exercise as they can just take a pill to give them the same benefit.”
• “Although the estimates of the benefits of statins for primary prevention used by the task force may be inflated, even if these estimates are accurate, this is still a relatively weak intervention.”
• At best, the benefits from taking statins as primary prevention is “relatively
  small.”
• “The global market for statins has been estimated to be a staggering $20 billion annually;” this market would boom if statins were used routinely for primary heart disease prevention.
• “It is incumbent on clinicians to be sure that before recommending that a patient take a daily pill [statins] that has multiple adverse effects, there is evidence that the medication will lead to a better quality of life, longer life, or both. Such evidence is lacking for statins in primary prevention.”
• “Given the serious concerns about the harms of the reliance on statins for primary prevention, it is in the interest of public health and the medical community to refocus efforts on promoting a heart-healthy diet, regular physical activity, and not smoking.”

This week from Dr. Cerami and Utah Sports and Wellness

From: Stroke, April 2017

Quick Summary:

Sugar and artificially-sweetened beverage intake have been linked to cardiometabolic risk factors, which increase the risk of cerebrovascular disease and dementia. This study examined whether sugar or artificially sweetened beverage consumption was associated with the prospective risks of incident stroke or dementia. The authors looked at three combinations: intake of total sugary beverages (soft drinks, fruit juice), intake of sugar sweetened soft drinks (high sugar carbonated) and intake of artificially sweetened soft drinks (sugar free carbonated). They found that greater recent consumption of artificially sweetened soft drinks was associated with an increased risk of stroke, with the strongest associations observed for ischemic stroke.  While higher cumulative intake of artificially sweetened soft drinks was also associated with an increased risk of ischemic stroke.

Abstract:

We studied 2888 participants aged >45 years for incident stroke (mean age 62 [SD, 9] years; 45% men) and 1484 participants aged >60 years for incident dementia (mean age 69 [SD, 6] years; 46% men). Beverage intake was quantified using a food-frequency questionnaire at cohort examinations 5 (1991-1995), 6 (1995-1998), and 7 (1998-2001). We quantified recent consumption at examination 7 and cumulative consumption by averaging across examinations. Surveillance for incident events commenced at examination 7 and continued for 10 years. We observed 97 cases of incident stroke (82 ischemic) and 81 cases of incident dementia (63 consistent with Alzheimer’s disease). After adjustments for age, sex, education (for analysis of dementia), caloric intake, diet quality, physical activity, and smoking, higher recent and higher cumulative intake of artificially sweetened soft drinks were associated with an increased risk of ischemic stroke, all-cause dementia, and Alzheimer’s disease dementia. When comparing daily cumulative intake to 0 per week (reference), the hazard ratios were 2.96 (95% confidence interval, 1.26-6.97) for ischemic stroke and 2.89 (95% confidence interval, 1.18-7.07) for Alzheimer’s disease. Sugar-sweetened beverages were not associated with stroke or dementia. Artificially sweetened soft drink consumption was associated with a higher risk of stroke and dementia.

These authors also note:

• “Sugar- and artificially-sweetened beverage intake have been linked to cardiometabolic risk factors, which increase the risk of cerebrovascular disease and dementia.”
• Artificially sweetened beverages are typically sweetened with non-nutritive sweeteners, such as saccharin, acesulfame, aspartame, neotame, or sucralose.
• “When comparing daily cumulative intake [of artificial sweeteners] to 0 per week (reference), the hazard ratios were 2.96 for ischemic stroke and 2.89 for Alzheimer’s disease.” [This means that drinking intake of artificially sweetened soft drinks essentially tripled the risk of suffering both ischemic stroke and Alzheimer’s]. [The upper end of the risk range was an approximate 700% increased risk].
• “When examining cumulative beverage consumption, daily intake of artificially sweetened soft drink was associated with an increased risk of both all-cause dementia and AD dementia.”
• “To our knowledge, our study is the first to report an association between daily intake of artificially sweetened soft drink and an increased risk of both all cause dementia and dementia because of Alzheimer’s disease.”
• Diabetes is an important risk factor for both stroke and dementia; importantly, both sugar intake (including sweetened drinks) intake and artificially sweetened drinks intake increase the risk of diabetes. “Diabetes mellitus status was identified as a potential mediator of the association between artificially sweetened beverage intake and the risk of both incident all-cause dementia and AD dementia.”
• Artificial sweeteners cause glucose intolerance by altering gut microbiota and are associated with dysbiosis and glucose intolerance.
• “After adjustments for age, sex, education (for analysis of dementia), caloric intake, diet quality, physical activity, and smoking, higher recent and higher cumulative intake of artificially sweetened soft drinks were associated with an increased risk of ischemic stroke, all-cause dementia, and Alzheimer’s disease dementia.”
•  “Sugar-sweetened beverages were not associated with stroke or dementia.”