January Newsletter
In This Issue
Do I Need an Antibiotic?
Belly Fat and Sugary Drinks
Brush Your Teeth, It May Save Your Life
A New Model of Medical Care
Dr. Niedfeldt
Old-fashioned medicine with 21st Century convenience and technology
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  January/2016
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I hope this newsletter finds you and your family well. I'm getting this newsletter in just under the wire. I just got back from spending time with the US Snowboarding and US Freeskiing Teams at Mammoth, California. It was a great week with over 2 feet of snow which was not good for competitions but great for powder days!

 
Sun rise over the halfpipe


This time of year, it seems like everyone is getting a cold, has a cold, or is just getting over a cold. The first article this month, from the Annals of Internal Medicine, looks at guidelines for antibiotic use in respiratory tract infections. I know that sometimes patients may get upset that I am not prescribing antibiotics for their cold, bronchitis, sore throat or sinus congestion like their previous doctors may have. This article shows explains the reasons why it is best to usually let these infections run their course, because most are viral. 

  

Sugary drinks are commonly consumed by many people. While most people know they aren't good for them, this study shows an especially concerning issue with these drinks. Check out the second article for details and be sure to check out the link to see how much sugar is in your favorite drinks.  

 

I don't know about you, but my mother told me to be sure to brush by teeth twice a day. I guess she was onto something (besides better breath). The third article explores the link between poor oral hygiene and heart attacks (yes, bad teeth may give you a heart attack). 

 

Click on the links the the left to check out our web site...
Do I Need an Antibiotic?
Guidelines for prescription of antibiotics for respiratory tract infections
 
This time of year, there is a lot of sneezing, coughing and nose blowing going on wherever you go. When is a  common cold, not a common cold; when is it something more which could require antibiotics? 
   
Summary of findings:
  • Background: Acute respiratory tract infection (ARTI) is the most common reason for antibiotic prescription in adults. Antibiotics are often inappropriately prescribed for patients with ARTI. This article presents best practices for antibiotic use in healthy adults (those without chronic lung disease or immunocompromising conditions) presenting with ARTI.  
  • Methods: A narrative literature review of evidence about appropriate antibiotic use for ARTI in adults was conducted. The most recent clinical guidelines from professional societies were complemented by meta-analyses, systematic reviews, and randomized clinical trials. To identify evidence-based articles, the Cochrane Library, PubMed, MEDLINE, and EMBASE were searched through September 2015 using the following Medical Subject Headings terms: "acute bronchitis," "respiratory tract infection," "pharyngitis," "rhinosinusitis," and "the common cold."
  • High-Value Care Advice 1: Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected.
  • High-Value Care Advice 2: Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
  • High-Value Care Advice 3: Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening).
  • High-Value Care Advice 4: Clinicians should not prescribe antibiotics for patients with the common cold.

This review of the medical literature is a good starting point for a lot of conversations this time of year. You may get diagnosed with bronchitis, pharyngitis, respiratory tract infection or even sinusitis and correctly not get antibiotics. These conditions are the most common reasons for acute physician office visits and 41% of all antibiotic prescriptions are given for respiratory conditions. Antibiotic resistance is a by-product of overuse of antibiotics and is responsible for 2 million illnesses and 23,000 deaths annually. Direct costs of antibiotics is $6.5 billion annually. So you can see, this isn't a small deal. 

Acute bronchitis is inflammation of the large airways with cough lasting up to 6 weeks and is the leading cause of inappropriate antibiotic prescriptions. Over 90% of coughs are caused by a virus and won't respond to antibiotics. For this reason, unless there are findings to support bacterial pneumonia, antibiotics shouldn't be given. Symptomatic care is given which can include decongestants, cough suppressants, antihistamines, and expectorants. 

A sore throat is also a common finding and often results in an antibiotic prescriptions. However, most sore throats are viral, especially if accompanied by cough, nasal congestion, pink eye, or hoarseness. People with sore throat, no cough, persistent fever, tender lymph nodes in the neck and white plaques on swollen tonsils should be tested for strep throat. If positive, then antibiotics can be given. Otherwise, the symptoms should be treated symptomatically with pain relievers such as Tylenol or ibuprofen, lozenges and salt water gargles.

Runny nose and or sinus congestion and pressure can be caused by a number of things such as viral infection, allergies or irritants. While most episodes resolve in a week, symptoms can last for 3-4 weeks. Almost 80% of visits for these symptoms result in antibiotic prescriptions and most are unnecessary. If you have symptoms for more than 10 days with at least 3 consecutive days of severe symptoms (fever over 102 F, foul nasal discharge, facial pain) or if you symptoms worsen after improving for more than 3 days, you may have a bacterial infection. If you have nasal discharge without fever and some sinus pressure or ear pressure, you very likely don't have a bacterial infection. In this case, supportive care such as analgesics for pain, decongestants, saline nasal spray, expectorants may be beneficial for symptom relief.

The common cold is the most common acute illness in the US. Symptoms can include sneezing, runny nose, sore throat, cough, low grade fever, headache and body aches. There are over 37 million office visits for colds every year. They are caused by multiple viruses which occur seasonally and are spread by direct hand contact, contact with a contaminated surface or from airborne droplets. Good hand washing is the best prevention. Treatment is symptomatic. Antibiotics don't speed recovery. 

Bottom line: The average adult gets 2-3 respiratory tract infections annually. Symptoms typically resolve in 1-2 weeks but can last for 6 weeks. Symptomatic treatment is recomomended to provide some relief. Antibiotics don't cure most of these infections or reduce time to symptom resolution and can cause significant adverse effects. They should be reserved for those with confirmed bacterial infections. 

Belly Fat and Sugary Drinks
Drinking sugar-sweetened drinks increases visceral fat
sugary soft drinks

At least one serving daily of a sugar-sweetened drink increased visceral (belly) fat by 27% over 6 years. Visceral fat can cause multiple other problems in the body. 

Summary of findings      
  • BACKGROUND:  Sugar-sweetened beverage (SSB) intake has been linked to abnormal abdominal adipose tissue. We examined the prospective association of habitual SSB intake and change in visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT).  
  • METHODS AND RESULTS: The quantity (volume, cm(3)) and quality (attenuation, Hounsfield Unit) of abdominal adipose tissue were measured using computed tomography in 1,003 participants (mean age 45.3 years, 45.0% women) at exam 1 and 2 in the Framingham's Third Generation cohort. The 2 exams were approximately 6 years apart. At baseline, SSB and diet soda intake were assessed using a valid food frequency questionnaire. Participants were categorized into 4 groups: none to <1 serving/month (non-consumers), 1 serving/month to <1 serving/week, 1 serving/week to 1 serving/day, and ≥1 serving/day (daily consumers) of either SSB or diet soda. After adjustment for multiple confounders including change in body weight, higher SSB intake was associated with greater change in VAT volume (P-trend<0.001). VAT volume increased by 658 cm(3) (95%CI: 602-713), 649 cm(3) (95%CI: 582-716), 707 cm(3) (95%CI: 657-757), and 852 cm(3) (95%CI: 760-943) from non-consumers to daily consumers. Higher SSB intake was also associated with greater decline of VAT attenuation (P-trend=0.007); however, the association became non-significant after additional adjustment for VAT volume change. In contrast, diet soda consumption was not associated with change in abdominal adipose tissue.  
  • CONCLUSIONS: Regular SSB intake was associated with adverse change in both VAT quality and quantity, whereas we observed no such association for diet soda.

The visceral fat found around our internal organs is different than subcutaneous fat which is found around our body under the skin. Visceral fat is a metabolically active organ. Increased amounts of it lead to systemic inflammation, diabetes, heart disease, fatty liver, decreased testosterone and increased estrogen levels, and it stimulates growth of prostate and breast tissue which may increase cancer risk. It's just bad stuff. Drinking soda and other sweetened drinks was shown to lead to a significantly higher level of this harmful fat. The good news is it can be treated. Reduce caloric consumption (especially by reducing sugar intake), and push sugar into the cells by exercising. Here is a chart from Harvard with the sugar contents of a number of common drinks. I think you will be surprised. Remember to watch those lattes!

Brush Your Teeth, It May Save Your Life
Periodontitis increases risk of first Heart Attack
   
Inflammation has been implicated in the risk of heart attacks. Inflammation can be brought on by smoking, visceral fat, oxidative LDL, high insulin levels and even stress. It can also be increased by some infections such as chronic bronchitis, urinary tract infections, skin ulcers and periodontal disease.This study, from the journal Circulation, shows that poor oral health may increase your risk of having a heart attack.   

Summary of findings:   
  • BACKGROUND:  The relationship between periodontitis (PD) and cardiovascular disease (CVD) is debated. PD is common in patients with CVD. It has been postulated that PD could be causally related to the risk for CVD, a hypothesis tested in PAROKRANK.  
  • METHODS AND RESULTS: 805 patients (age <75 years) with a first MI and 805 age (mean 62±8), gender (male 81%) and area matched controls without MI underwent standardized dental examination including panoramic x-ray. The periodontal status was defined as healthy (≥80% remaining bone) or as mild-moderate (79-66%) or severe PD (<66%). Great efforts were made to collect information on possibly related confounders (≈100 variables). Statistical comparisons included Student's pair-wise t-test and Mc Nemar's test in 2x2 contingency tables. Contingency tables exceeding 2x2 with ranked alternatives were tested by Wilcoxon signed rank test. Odds Ratios (95% CI) were calculated by conditional logistic regression. PD was more common (43%) in patients than in controls (33%; p<0.001). There was an increased risk for MI among those with PD (OR = 1.49; 95% CI 1.21-1.83), which remained significant (OR =1.28; 95% CI 1.03-1.60) after adjusting for variables that differed between patients and controls (smoking habits, diabetes, years of education and marital status).  
  • CONCLUSIONS: In this large case-control study of PD, verified by radiographic bone loss and with a careful consideration of potential confounders, the risk of a first MI was significantly increased in patients with PD even after adjustment for confounding factors. These findings strengthen the possibility of an independent relationship between PD and MI. 
This study of 805 patients in Sweden who had their first heart attack and compared them to a control group.The investigators classified periodontal status into three categories: healthy, mild to moderate, or severe periodontal disease. They found that the individuals who had a first MI more often had periodontal disease. Bacterial products from the mouth can stimulate inflammation. This study supports the idea that poor oral health can be a risk factor for heart disease. So now we all have another reason to brush and floss regularly. It's good for our hearts! 
 
Thank you for taking the time to read through this newsletter. I hope you have found this information useful as we work together to optimize your health. 

 

Antibiotics are one of the great advances in medicine over the past 50+ years. They have saved countless lives. However, we are now in an era of antibiotic-resistant diseases caused by overuse of these life-saving medications. The common cold is one of the most common reasons for a doctor visit and one of the most common reasons for antibiotics being used. This needs to change. While I don't have a magic bullet for the common cold, there are some things than can help with the symptoms besides antibiotics until your body is able to kick the virus. 

 

Sugary drinks will increase levels of visceral fat. This metabolically active organ is responsible for increased inflammation in the body which can lead to many health issues. Try substituting lemon water or even a small squirt of MIO instead of you sugary drink. Your belly will thank you!

 

While I think we all know that brushing our teeth helps keep people from avoiding us, but now we have another very important reason to brush. It's good for our hearts.

 

As always, if you have questions about anything in this newsletter or have topics you would like me to address, please feel free to contact me by email, phone, or just stop by! 


To Your Good Health,
Mark Niedfeldt, M.D.