Patient-reported triggers of paroxysmal atrial fibrillation can be avoided

A study published in the Journal of Heart Rhythm reported that the most common triggers of atrial fibrillation (AF) are avoidable behaviors like drinking alcohol, coffee consumption and exercise.  

Of 1295 participants with symptomatic AF, 957 (74%) reported triggers for episodes of AF. In comparison to participants without triggers and after multivariate adjustment, those reporting triggers had a 71% lower odds of congestive heart failure and a >2-fold greater odds of a family history of AF.  The most commonly reported triggers were alcohol (35%), caffeine (28%), exercise (23%), and lack of sleep (21%). Patients reported a median of 2 different triggers.  Female sex, Hispanic ethnicity, obstructive sleep apnea, and a family history of AF were each associated with a greater number of AF triggers. Vagal nerve mediated triggers tended to cluster together within individuals.

The authors concluded that the majority of patient-reported triggers are modifiable, thus potentially identifying accessible means to prevent and reduce AF episodes. 

Is one blood pressure measurement enough?

While In the U.S., 116 million adults have high blood pressure, it is estimated in the world nearly 1.5 billion adults will have hypertension in the decade ahead.

Ι analyzed 107 consecutive blood pressure (BP) measurements that were obtained between June 1 and November 20, 2019.  The BP measurements were obtained with an Omron BP-monitor; model BP786N, a device that obtains 3 consecutive measurements at one-minute intervals, which it also averages.   All four measurements were recorded.  

The average BP measurements were grouped in the following four categories; Normal readings were those systolic blood pressure was less than 120mmHg.  Elevated readings were those with systolic blood pressure between 120 and 129mmHg.  Hypertension-1 were those with systolic blood pressure between 130 and 139mmHg and hypertension-2 were those with systolic blood pressure over 140mmHg.   

In the normotensive category with readings under 120mmHg, in 12 of 59 readings or 20.3% the first of the 3 measurements were over 120mmHg.  In those patients treatment will be initiated incorrectly in the U.S.

In the elevated category with readings between 120 and 129mmHg 8 of the 20 measurements or 40%, were over 130mmHg which means treatment will be initiated incorrectly in Europe.

In the hypertension-1 category with readings between 130 and 139mmHg 2 of the 15 readings or 13% were below 130mmHg, which means treatment will not be initiated incorrectly in Europe.

In the hypertension-2 category with average measurements over140mmHg, 12 of 13 readings or 92.3% the first reading was over 140mmHg and 1 measurement was over 130mmHg, which means treatment would have been correctly initiated in 100% of the cases in both the U.S. and Europe.

We conclude both in the U.S. and Europe if the first measurement is over 140mmHg patients should be placed on hypertensive medications.  If the first measurement is less than 139mmHg then 3 measurements should be obtained and treatment or not should be initiated based on the average of 3 blood pressure measurements.   

Measles Outbreak 2019

From January 1 to November 7, 2019, the Center for Prevention and Disease Control (CDC) reported 1,261 cases of measles in 31 States in the USA.  

The World Health Organization (WHO) confirmed that measles is the world's largest and fastest-moving epidemic and that it has infected over 165,000 and has killed nearly 5,000 people 90% of who were children under the age of 5 in the Democratic Republic of Congo alone since the beginning of 2019.

Measles is a highly contagious disease that spreads through coughing and sneezing. Up to 90% of the people close to the infected person, who are not immune, will also become infected. 

UNICEF said it was urgently trying to vaccinate more children against measles and rushing life-saving medicines to health centers to help prevent deaths. WHO said that it was working with the government in Congo and other NGO groups in an effort to vaccinate 825,000 children. 

WHO says that the largest numbers have been reported in Congo Madagascar, Ukraine, Angola, Cameroon, Chad, Kazakhstan, Nigeria, Philippines, South Sudan, Sudan and in Thailand. 

Rates of crash fatalities involving kids on foot or cycling continue to decline in America

A study published in the journal of Injury Prevention found the rates of crash fatalities involving kids on bikes or foot continue to decline each year.   The authors reviewed police reported crash reports from 26 States between the years 2000 to 2014.  They calculated rates of pedestrian and bicycle crashes. 

School-age children accounted for nearly one in three pedestrians and one in two cyclists struck by motor vehicle from 2000 to 2014. Interestingly, the rates of these crashes declined 40% and 53%, respectively, over that time, even as adult rates rose. Average crash rates varied geographically from 24 to 100 pedestrians and 15 to 56 cyclists struck per 100 000 youth. 

Despite substantial progress, motor vehicle crashes remain a leading killer of US children.  Although there were recent increases in adult pedestrian crashes, younger pedestrians and bicyclists experienced ongoing declines in motor vehicle crashes through 2014 across the USA.

Many Vaping-related lung injuries tied to illegal marijuana products

According to a report released by the Centers for Disease Control and Prevention(CDC) many people with vaping-related lung injuries used illegal marijuana products. Health officials in Wisconsin and Illinois, where the first cases were reported conducted in-depth interviews with 86 patients who said they used a wide range of e-cigarette products, and found that the vast majority reported using illicit products containing THC, the psychoactive component of marijuana. The health officials also named several specific products tied to cases of vaping-related injuries, including “Dank Vapes,” “Moon Rocks,” “Off White,” and “TKO”.  The CDC warned people to stop using e-cigarettes, especially those with THC.

In a letter published in the NEJM pathologists at the Mayo Clinic who examined lung tissue specimens from 17 patients sent to them from around the country said that some vaping-related lung injuries resemble chemical burns.   The Mayo clinic physicians also cast doubt on the notion that vitamin E oil or other thickeners were the cause of the vaping-related lung injuries.

As of today there have been 1,080 cases of vaping-related lung illness, including 18 deaths, according to the CDC.

Statins may be beneficial for people after 75

A retrospective study published in the European Heart Journal reports  that people who continue taking statins even after they turn 75 reap benefits. 

A total of 120 173 subjects were followed for an average of 2.4 years.  17 204 (14.3%) discontinued statins and 5396 (4.5%) were admitted for a cardiovascular event. The adjusted hazard ratios for statin discontinuation were 1.33   for any cardiovascular event, 1.46 for coronary event, 1.26 for cerebrovascular event, and 1.02 for other vascular events.

The authors concluded that statin discontinuation was associated with a 33% increased risk of admission for cardiovascular events in 75-year-old primary prevention patients.

Over seven percent of cancers are attributable to obesity

According to a study published in JAMA Oncology more than seven percent of cancer cases in the United States are attributable to excess body weight (EBW). 

This nationwide study of US adults found that the proportion of cancers attributable to obesity ranges from 3.9% to 6.0% among men and from 7.1% to 11.4% among women, with the highest proportions found in several Southern and Μidwestern states, Alaska, and the District of Columbia.

Each year, an estimated 37 670 cancer cases in men (4.7%) of all cancers excluding non-melanoma skin cancers and 74 690 cancer cases in women (9.6%) 30 years or older in the United States were attributable to EBW.

The researchers concluded that the number of cancers attributable to obesity varies among states, but EBW accounts for at least 1 in 17 of all incident cancers in each state.

Measles Cases in 2019

The Centers for Disease Control and Prevention (CDC) reported that from January 1 to June 13, 2019, 1044 cases of measles have been confirmed in the United States. This is the greatest number of cases reported in the U.S. since 1992 when 963 cases were reported for the entire year.

The outbreak has escalated since 82 people in 2018 and more that 40 people in 2019 brought measles to the U.S. from other countries, most frequently Israel, Philippines and Ukraine.

CDC Director Robert Redfield stated that measles is a highly contagious and sometimes deadly disease and for the way to end this outbreak is for children and adults to get vaccinated.

Measles was declared eliminated in 2000 from the list of endemic infectious diseases in the United States but if the current outbreak continues the U.S. could loose that status and the disease would be considered again endemic in the country for the first time in a generation. 

Thirty minutes of daily activity increases lifespan

A paper published by Diaz et al in the American Journal of Epidemiology found that replacing just 30 minutes of sitting with any kind of movement, every day, could help people to live longer.

The study involved nearly 7,999 American adults, aged 45 and older. Participants wore physical activity monitors (accelerometers) for at least four days as part of research conducted between 2009 and 2013. The study authors then tracked deaths among the participants until 2017.

The study found that half an hour of light activity – like walking, when a person would usually be sitting – corresponded to an estimated 17% lower risk of early death.

The study also found that half an hour of moderate or vigorous exercise corresponded to about a 35% lower mortality risk.

The authors concluded that physical activity of any intensity help in decreasing mortality risks incurred by sedentary lifestyle.

Weight Training in the Elderly

The New York Times  (3/20, Reynolds) reports, “Weight training by older people may build not only strength and muscle mass but also motivation and confidence, potentially spurring them to continue exercising,” researchers concluded. The study revealed that individuals “who discovered that they enjoyed and felt capable of completing a weight-training session subsequently joined a new gym and showed up for workouts.” The findings were published in the Scandinavian Journal of Medicine & Science in Sports.

A study published in the Journal of the American Medical Association indicates that nearly 40 percent of American adults were obese with body mass index (BMI) of over 30 in 2015 and 2016. During the same period data indicate that 7.7 percent of American adults were severely obese with BMI over 40.

The authors analyzed data from 27 449 adults and 16875 youths. Age-standardized prevalence of obesity among adults increased from 33.7% in 2007-2008 to 39.6%. Prevalence of obesity increased in adult men and women aged 20 to 59 years. There was no significant linear trend among adults 60 years and older. Age-standardized prevalence of severe obesity in adults increased from 5.7% in 2007-2008 to 7.7%.  Among youth, obesity prevalence was 16.8% in 2007-2008 and 18.5% in 2015-2016.

In conclusion over the periods between 2007-2008 and 2015-2016, there was a sharp increasein obesity among American adultsfrom a decade earlier.  Severe obesity prevalence persisted among American adults, whereas there were no overall significant trends among youth. 

Syphilis Cases Increased Among Pregnant Women in the U.S.

A study published in Obstetrics and Gynecology found the rate of primary and secondary syphilis among women increased, and the rate of congenital syphilis increased too.

During 2012–2016, the number of syphilis cases among pregnant women increased 61%, from 1,561 to 2,508 among all women aged 15–45 years, and in all U.S. regions.  The most commonly reported risk behaviors were a history of a sexually transmitted disease (43%) and more than one sex partner in the past year (30%).  Over the same period the rate of congenital syphilis increased 87 percent.  Approximately 40 percent of newborns with syphilis are stillborn and those infected if left untreated develop serious complications such as jaundice, blindness and deafness.  Treatment of pregnant women with penicillin is 98% effective in preventing congenital syphilis.

The authors concluded that efforts to reduce syphilis among pregnant women should involve screening all pregnant women for syphilis at the first prenatal visit and rescreening high-risk women during the third trimester and at delivery. 

Percutaneous Occlusion of Patent Ductus Arteriosus

The Food and Drug Administration (FDA) approved Amplatzer Piccolo Occluder, a self-expanding wire mesh device to be used in the closure of patent ductus arteriosus (PDA) an abnormal communication between aorta and pulmonary artery in premature infants.

Each year about 60,000 infants are born prematurely in the United States -- including nearly 12,000 with a PDA large enough that may cause symptoms.  These patients may not respond to medical management, and due to their small size, may be at high-risk for corrective surgery.

The device is threaded into the PDA using a catheter that is advanced through the femoral vein or artery in the groin, with a minimally invasive procedure thus demanding surgery for these premature babies that weight as little as two pounds is avoided.

The FDA approved the occluder based on the ADO II trial that evaluated the occluder on 50 patients with a PDA who were older than three days. The safety and efficacy of the device was further supported by additional experience involving 150 more patients. The device builds on more than 20 years of clinical experience with the Amplatzer™ Duct Occluder II a product, already approved for use in the U.S., Europe and countries around the world to treat PDA in larger size pediatric patients and also validated in 6,896 very preterm infants, less than 31 weeks of gestation, in the EPICE cohort study.

Cigarette smoking in all-time low among U.S. adults

According to a report from the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration and the National Cancer Institute cigarette smoking has reached the lowest level ever recorded among U.S. adults. 

Only 14 percent of adults – around 34 million people – smoked within the past 30 days. That is down from 15.5 percent in 2016.  It is remarkable that adult smoking rates have declined by 67 percent since 1965.  

The report also showed about 10 percent of young adults aged 18 to 24 years smoked cigarettes in 2017, down from 13 percent in 2016.

 This new all-time low in cigarette smoking among U.S. adults is a tremendous public health accomplishment.

Caesarean section births nearly doubled since 2000

A study published in The Lancet by Boerma et al found that the rates of caesarean section (CS) births nearly doubled between 2000 and 2015 – from 12 to 21 percent worldwide.

The paper was based on data from 169 countries that includes 98% of the world's births.  The authors estimated that 29·7 million or 21% births occurred with CS in 2015, which was almost double the number of births by CS in 2000 16 million or 12·% births. C-section use in 2015 was up to ten times more frequent in the Latin America and Caribbean region, where it was used in 44% of births, than in the west and central Africa region, where it was used in 4% of births. 

C-section births varied from 0·6% in South Sudan to 58% in the Dominican Republic. Markedly high CS use was used even among low obstetric risk births, especially among more educated women in Brazil and China; and CS use was 1·6 times more frequent in private than in public facilities.

The researchers report that CS is unavailable to women in poor countries while often over-used in richer ones. The authors found that in 15 countries in North America, Western Europe and Latin America and the Caribbean more than 40 percent of all babies born are delivered by C-section. 

C-section use in excess of the 10-15% which is considered optimal is concerning because the procedure is associated with sort-term and long-term effects without offering any significant maternal benefits.

Rates of unvaccinated children have quadrupled since 2001

The Centers for Disease Control and Prevention (CDC) reports that a small but increasing number of children in the United States are not getting some or all of their recommended vaccinations with 1.3 percent of children born in 2015 having not received any vaccinations, up from 0.3 percent in 2001. 

Though the number remains small it is something that CDC is concerned about.  CDC data show children in rural areas and those without insurance had significantly higher rates of not being vaccinated.  The CDC estimates that 100,000 young children have not had a vaccination against any of the 14 diseases for which vaccines are recommended. 

Although 70 percent of the children have been vaccinated the new estimate of 1.3 percent of the children born in 2015 were completely unvaccinated is very concerning because young children are especially vulnerable to complications from vaccine-preventable diseases, some of which can be fatal.

Screening for Cervical Cancer

The U.S. Preventive Services Task Force issued new guidelines that were published in JAMA regarding cervical cancer screening, suggesting that women can get a test that looks for the human papilloma virus.

The task force recommends that screening should begin for women age 21-29 with a Pap test every three years, which they may continue from age 30 to 65, or they can get screened every five years with a test that looks for the high-risk types of HPV that cause cervical cancer or get both tests every five years.

The USPSTF guidelines say that women over 30 can safely wait five years between cervical cancer screenings thus reducing false alarms that lead to invasive follow-up tests and unnecessary treatment.

The new guidelines “are based on a now-solid body of evidence showing that almost all cases of cervical cancer are caused by the human papilloma virus.

Sleeping more than eight hours increases risk of death from heart disease and/or stroke.

In a study by Kwok et al published in the Journal of the American Heart Associationthe researchers found that sleeping more than eight hours a night may increase the risk of death from heart disease or stroke, while sleeping fewer than seven hours did not affect one’s likelihood of death.

The authors searched MEDLINE and EMBASE databases and identified seventy‐four studies that included 3,340,684 participants.  In those studies 242,240 deaths were reported among 2,564,029 participants. Self‐reported duration of sleep of more than 8 hours was associated with a moderate increased risk of all‐cause mortality, with risk ratio, 1.14 (1.05–1.25) for 9 hours, risk ratio, 1.30 (1.19–1.42) for 10 hours, and risk ratio, 1.47 (1.33–1.64) for 11 hours. No significant difference was identified for periods of self‐reported sleep of less than 7 hours, whereas similar patterns were observed for stroke and cardiovascular disease mortality. Subjective poor sleep quality was associated with coronary heart disease (risk ratio, 1.44; 95% confidence interval, 1.09–1.90), but no difference in mortality and other outcomes.

The authors concluded that divergence from the recommended 7 to 8 hours of sleep is associated with a higher risk of mortality and cardiovascular events. 

Moderate alcohol consumption increases the risk of cardiovascular events and death.

A study by Wood et al published in Lancet suggests that the risks of drinking vis-à-vis cardiovascular events and death are significant.

The authors analyzed data from 599 912 current drinkers without previous cardiovascular disease.  They characterized dose–response associations per 100 gram per week of alcohol across 83 prospective studies, adjusting for age, sex, smoking, and diabetes.

They recorded 40 310 deaths and 39 018 incident cardiovascular disease events among the 599 912 drinkers in high-income countries that were included in their study. For all-cause mortality, they recorded a positive and curvilinear association with the level of alcohol consumption, with the minimum mortality risk at or below 100 g per week. Alcohol consumption was roughly linearly associated with a higher risk of stroke, coronary disease excluding myocardial infarction, fatal hypertensive disease and fatal aortic aneurysm. By contrast, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction. In comparison to those who reported drinking >0–≤100 g per week, those who reported drinking >100–≤200 g per week, >200–≤350 g per week, or >350 g per week had lower life expectancy at age 40 years of approximately 6 months, 1–2 years, or 4–5 years, respectively.

The threshold for lowest risk of all-cause mortality was about 100 gram per week or one drink per day. The study concludes that there are no overall health benefits from moderate drinking which according to current guidelines is 196g per week or two drinks per day.  

An egg a day reduces cardiovascular and stroke risk

Qin et al in a study publish by British Medical Journal examined survey data from individuals that were followed for nine years and found that compared to people who never ate eggs, individuals who ate an average of 0.76 eggs per day were at less risk to develop cardiovascular diseases (CVD) and less likely to die from ischemic heart disease (IHD), major coronary events, hemorrhagic and ischemic strokes.

Among 461 213 participants free of prior cancer, CVD and diabetes, a total of 83 977 CVD incident cases and 9985 CVD deaths were documented, as well as 5103 major coronary events (MCE).

 Among the participants 13.1% reported daily consumption (usual amount 0.76 egg/day) and 9.1% reported never or very rare consumption (usual amount 0.29 egg/day). Compared with non-consumers, daily egg consumption was associated with 11 percent lower risk of developing CVD disease and cut the risk of stroke by 26 percent while also decreasing the risk of dying from CVD conditions to 18 percent compared to non-consumers.  Daily consumers also had a 28% lower risk of hemorrhagic stroke death compared to non-consumers.

The researchers concluded that a moderate level of egg consumption (up to <1 egg/day) was significantly associated with lower risk of CVD and largely independent of other risk factors.