We all know that vegetables are good for you. But are you aware that each veggie has something special to offer? “The recommendation is to eat a variety since they each individually shine in one area of vitamins or nutrients,” says Registered Dietitian Toby Smithson, a representative for the Academy of Nutrition and Dietetics. That said, some vegetables pack a bigger nutritional punch than others or provide an especially convenient way to get essential nutrients. Read on and see if your favorite vegetable made the list of most nutritious veggies.
Day: 05/08/2015
Palate Workout Turns Down Snoring
Daily oropharyngeal exercises yield results, but mechanism is unclear..
Daily oropharyngeal exercises reduced snoring levels compared with nasal dilator strips plus respiratory exercises, researchers reported.
Three months of oropharyngeal exercises reduced both the frequency and power of snoring, wrote Vanessa Ieto, PhD, of the Heart Institute at the University of Sao Paulo Medical School in Brazil, and colleagues in CHEST.
The randomized, controlled study looked at 39 adults with a primary complaint of snoring and a recent diagnosis of primary snoring or mild-to-moderate obstructive sleep apnea (OSA).
There are no standard treatments for snoring unless patients have severe sleep apnea, Geraldo Lorenzi-Filho, MD, PhD, a pulmonologist at the Heart Institute, told MedPage Today in an email. “Science had devoted little attention to treatments of snoring,” he said.
The principle of exercising while awake to influence muscle behavior while asleep is a good one, but the mechanism is neither known nor intuitive, Kingman Strohl, MD, a pulmonary/critical care and sleep medicine specialist at University Hospitals Case Medical Center in Cleveland, told MedPage Today.
Previous studies have shown that training the upper airways either by an exercise regimen or by playing the didgeridoo (a wind instrument) can reduce moderate OSA and snoring, the authors wrote.
“You can change how your muscles work if you are training muscles that open the airway more than you’re training muscles that close the airway, or you’re de-training muscles that close the airway while keeping muscles that open the airway more active,” Strohl said. “But these are speculation.”
More research is needed to define exactly which muscles are being activated during such exercises and which muscles are involved in snoring and sleep apnea, he added.
The exercises were developed by speech therapists in Brazil over the last 15 years, Lorenzi-Filho said. “[They] are directed to the muscles that are involved directly and indirectly with snoring and sleep apnea, and include the tongue and the palate.”
Exercises involved the tongue, soft palate, and hard palate. They included elevation of the soft palate and uvula for several seconds, pushing the tip of the tongue against the hard palate while sliding the tongue backward, sucking the tongue upward against the hard palate, and pushing the back of the tongue against the floor of the mouth.
Authors acknowledged the limitation that the exercises were derived from those targeting speech or swallowing activity rather than snoring itself.
Patients in the control group used nasal dilators while sleeping, performed nasal lavage with saline solution three times daily, and did deep breathing exercises through the nose.
Those in the therapy group did nasal lavage three times daily followed by 8 minutes of oropharyngeal exercises.
More than three-quarters of patients in both groups adhered to the exercises for 3 months (mean 85 ± 8%).
Adherence may also be a limitation in a real-world setting without regular coaching, Strohl said. “Unless there is an immediate response perceived by the individual, it’s hard to maintain,” he said.
Author Lorenzi-Filho agreed. “[The exercises] are not long, but most people do not have the determination to do it,” he said. “However, this is a little bit like doing exercises — it may be be difficult to start, but once you get used to it and see results, it is feasible.”
The study excluded patients with a body mass index ≥ 40 kg/m2, those who were smokers, had a history of alcohol abuse, lacked teeth, had severe nasal obstruction, had hypertrophic tonsils, had craniofacial malformation, used hypnotic medications regularly, or had severe comorbidities.
Before randomization, all patients underwent polysomnography and a snore recording to diagnose OSA and establish objective measurements for snoring.
Patients were primarily “middle aged and overweight patients who were disturbed by snoring, were on average not sleepy, and did not present severe OSA,” the authors wrote.
Outcomes were expressed as Snore Index (total number of snores/total sleep time) and Total Snore Index (sound intensity power generated by all snoring episodes/total sleep time).
Questionnaires were also completed by both the participants and the bed partner to evaluate snoring levels, daytime sleepiness, and quality of sleep.
Those in the therapy group had a reduction in snoring frequency by 36% and total power by 59%. There was also a decrease in the perception of snoring by the bed partner.
Patients in the therapy group had a “small but significant decrease” in neck circumference as well.
In a subgroup analysis of patients with moderate OSA, the Apnea-Hypopnea Index decreased significantly in the therapy group: 25.4 (22.1-28.7) versus 18.1 (15.4-24.1) events/hour, P=0.017).
FDA to Study Safety, Effectiveness of Healthcare Antiseptics
Healthcare antiseptic products used up to 100 times a day by clinicians must prove themselves to be safe and effective, especially over the long haul, to remain on the market under proposed regulations announced today by the US Food and Drug Administration (FDA).
The antiseptic products in question are found in hospitals, nursing homes, physician offices, clinics, and other outpatient settings. Their manufacturers would have to submit safety and efficacy data on 29 active ingredients, which include alcohol, iodine, phenol, and hexachlorophene.
The FDA is looking for information about, among other things, topical absorption, potential hormonal changes, possible bacterial resistance, and the effects, if any, on pregnant and breast-feeding healthcare workers.
The proposed regulations do not apply to consumer antiseptics such as antibacterial soaps and hand sanitizer rubs.
Today’s announcement could create cognitive dissonance for physicians, nurses, and other healthcare workers, who are urged to heed increasingly stringent infection control protocols. They include faithful use of hand washes and rubs, including those for surgeons, and preoperative skin preparations for patients, all of which come under the FDA proposal.
At a news conference today, an FDA official encouraged clinicians to stick to their infection-control habits and to continue using the antiseptic products with the 29 targeted ingredients. “We don’t believe they’re ineffective and unsafe,” said Theresa Michele, MD, director of the nonprescription drug department in the FDA’s Center for Drug Evaluation and Research.
However, confirmatory studies are needed in light of changing infection control procedures, more frequent use of antiseptic products, new technology that can detect low levels of antiseptics in the body, and new findings about their effects, Dr Michele said. “Emerging science suggests that for some ingredients, systemic exposure is higher than previously thought.”
She added that her agency “thought long and hard” about the possibility of clinicians perceiving a mixed message on antiseptics.
“I think for healthcare workers, these [products] are critical elements of infection control,” Dr Michele said. “The fact that healthcare workers are now using these much more than they used to emphasizes why we need to gather this additional data.”
The 29 antiseptic active ingredients in question currently fall into the FDA regulatory category of GRASE, or generally recognized as safe and effective. The proposed regulations released today would require manufacturers to submit safety and efficacy data in the next 12 months to re-earn this stamp of approval. Meanwhile, the FDA will accept public comments on the proposed regulations for 180 days, followed by a 60-day rebuttal period. The agency then will evaluate the comments as well as the data from manufacturers and publish a final set of regulations that determine the GRASE status for each ingredient. Those that make the cut will stay on the market.
Two healthcare organizations have already weighed in favorably on the proposed FDA regulations.
“Since all infection prevention and control guidelines are evidence-based, it is important to stay up-to-date on safety and effectiveness data to protect healthcare personnel and their patients,” the Society for Healthcare Epidemiology of America and the Association for Professionals in Infection Control and Epidemiology said in a joint news release. They also said they agreed with the FDA that clinicians should continue to use antiseptic products while more data are gathered.
‘First Clinical Evidence’ of Remyelination in MS
Researchers are reporting what they call “the first clinical study to show evidence of proof of biology for remyelination in multiple sclerosis [MS] with a drug therapy.”
The research team from Biogen report that patients with optic neuritis (often the first symptom of MS) who were given the monoclonal antibody BIIB033 had improved conduction of electrical impulses along the optic nerve between the retina and the brain.
Lead author Diego Cadavid, MD, Biogen Inc, Cambridge, Massachusetts, explained to Medscape Medical News that eyes normally transmit visual information to the brain in around 100 milliseconds. During an episode of optic neuritis, this may be delayed by 15 to 40 milliseconds. This delay is known as latency and is caused by loss of myelin in the optic nerve.
“Patients in this study who were given BIIB033 had an improvement of 40% in latency compared with placebo, and they were twice as likely to get back to normal times. This is giving us confidence that the drug is active and remyelination is occurring,” Dr Cadavid said.
“This is the first time that evidence has been seen in humans that we might be able to repair myelin with a drug treatment. This is very exciting,” he added.
Full results will be presented at next week’s American Association of Neurology (AAN) 67th Annual Meeting.
Commenting on the study for Medscape Medical News, Jeffrey Cohen, MD, Cleveland Clinic Foundation, Ohio, noted that acute optic neuritis has been proposed as an experimental model system to carry out preliminary studies of potential neuroprotective or repair promoting strategies.
“In this study, the monoclonal antibody demonstrated improved conduction in the optic nerve measured by visual evoked potentials (ie, potential repair) but no improvement in optical coherence tomography parameters which measure neuronal damage in the retina,” Dr Cohen said.
He added that he thought the results were “promising” and he was looking forward to hearing more details. “Also, future studies will be needed to determine whether these results can be extrapolated to chronic lesions and/or progressive MS.”
Dr Cadavid explained that the monoclonal antibody used in this study is targeted to the LINGO-1 protein expressed only in the central nervous system in axons of neurons and oligodendrocyte progenitor cells (OPCs) which produce myelin.
“The theory is that in MS, myelin is not produced as these OPCs are not differentiating properly. Scientists at Biogen identified the LINGO-1 protein as having a key role inhibiting the differentiation of OPCs. The monoclonal antibody targets the LINGO-1 protein so allows the cells to differentiate better and produce myelin again,” he said.
Laboratory and animal studies have shown enhancement of myelination with this agent, and a phase 1 safety study has also been completed, Dr Cadavid reported.
The current study — known as RENEW — is a phase 2 study looking at whether the drug facilitates new myelin production. “And the results suggest that it does,” he added.
RENEW involved 82 patients with a first unilateral acute optic neuritis episode. “This is often the first symptom of MS so this is as early as you can ever identify anyone with MS,” Dr Cadavid said.
They completed treatment with high-dose steroids and were then randomly assigned to 100 mg/kg BIIB033 intravenously or placebo once every 4 weeks (six doses total).
Remyelination was evaluated by recovery of optic nerve conduction latency using full-field visual evoked potential compared with the unaffected fellow eye at baseline.
In the intention-to-treat analysis, latency recovery improved by 3.48 milliseconds (P = .33) at 24 weeks and 6.06 milliseconds (P = .07) at 32 weeks with BIIB033.
In the per protocol analysis these values became significant, with latency recovery improving by 7.55 milliseconds at 24 weeks (P = .05) and 9.13 milliseconds (P = .01) at 32 weeks.
In addition, 53% of BIIB033 recipients got back to normal scores compared with 26% of placebo recipients. However, the drug did not affect amplitude (the strength of the information transmitted).
Neuroprotection was studied by measuring the thickness of the retinal nerve fiber layer and ganglion cell layer by using spectral-domain optical coherence tomography and the change in low-contrast letter acuity. No differences in these endpoints were seen.
Treatment-related serious adverse events were two cases of infusion-related hypersensitivity reactions and one asymptomatic transient elevation in liver aminotransferase levels.
“These results should encourage more groups to move into the space of reparative neurological therapies,” Dr Cadavid suggested.
A second phase 2 study — SYNERGY — is now examining the use of BIIB033 in patients with definite MS of different severities. “This will tell us which population this drug may help the most,” Dr Cadavid commented.
Adult Sinusitis Guidelines Updated
The American Academy of Otolaryngology–Head and Neck Surgery Foundation has presented an updated clinical practice guideline on adult sinusitis, with a greater focus on patient education and patient preference, published April 1 in Otolaryngology–Head and Neck Surgery.
In the United States, sinusitis affects approximately 1 in 8 adults, with more than 30 million diagnoses and $11 billion in direct costs per year. More than 1 in 5 antibiotics prescribed in adults are for sinusitis.
“More than ever before, there is a prominent role for shared decision-making between patients and clinicians when managing adult sinusitis — especially in deciding whether to use antibiotics for acute bacterial sinusitis or to instead try ‘watchful waiting’ to see if a patient can fight the infection on his or her own,” guidelines chair Richard M. Rosenfeld, MD, MPH, said in a news release.
The update recommends watchful waiting for initial management of all patients with uncomplicated acute bacterial rhinosinusitis, regardless of severity, and not just for those with “mild” illness, as in the 2007 guideline.
“Intuitively clinicians often feel that sicker patients benefit more from antibiotics, but our recommendation is that watchful waiting or antibiotics are both appropriate,” Dr Rosenfeld said. “This empowers patients and clinicians to use antibiotic judiciously, reserving antibiotics for cases that get worse or don’t improve over time.”
Another area benefitting from shared decision making is choice of symptomatic treatment, including analgesics, topical intranasal steroids, and nasal saline irrigation. The update includes a new algorithm to clarify decision-making and action statement relationships.
A multidisciplinary panel of experts in otolaryngology–head and neck surgery, infectious disease, family medicine, allergy and immunology, advanced practice nursing, and a consumer advocate updated this clinical guideline based on current evidence.
Additional changes from the 2007 guideline to the 2015 update include:
The addition of additional information regarding the role of analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of acute bacterial sinusitis.
Changed recommendation for the preferred agent when antibiotics are prescribed. The 2007 guideline called for amoxicillin alone, whereas the 2015 update recommends amoxicillin with or without clavulanate.
Inclusion of several recommendations for management of chronic rhinosinusitis, which was not addressed in the 2007 guideline. These include addition of asthma and of polyps as chronic conditions modifying chronic rhinosinusitis management, a recommendation for use of topical intranasal therapy (saline irrigations or corticosteroids), and a recommendation against using topical or systemic antifungal agents.
“The update group made strong recommendations that clinicians (1) should distinguish presumed [acute bacterial rhinosinusitis] from acute rhinosinusitis…caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of [chronic rhinosinusitis] with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography,” the authors write.
Probiotic Nose Drops May Protect Against Meningitis
Probiotic nose drops reduced the likelihood of students being colonized with the bacteria that cause meningitis, according to a study published online March 25 in Clinical Infectious Diseases.
The nose drops contained Neisseria lactamica, a non-disease-causing relative of the bacterium that causes meningitis, Neisseria meningitidis. Epidemiological studies had previously shown that people who carry N lactamica in their nose and throat are both less likely to be colonized with N meningitidis and less likely to contract meningitis than people who do not, possibly because colonization with one species prevents colonization with the other.
“Neisseria lactamica may therefore be a potential ‘bacterial medicine’ to suppress meningococcal outbreaks,” write Alice M. Deasy, MBBS, from the Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals Foundation Trust, and colleagues. They note that the effect on N meningitidis colonization was stronger and happened more quickly than the effect seen in previous studies from meningococcal vaccine.
The study involved 310 students from two universities in Sheffield, United Kingdom. Each received either an inoculation of 104 colony-forming units of N lactamica or a sham inoculation. The investigators took samples of the students’ oropharyngeal bacteria at 2, 4, 8, 16, and 26 weeks after inoculation.
At baseline, a similar fraction of each group already carried N meningitidis: 24.2% of the treatment group and 22.4% of control patients. (Only a handful of participants in each group [1.9%; 95% confidence interval, 0.4% – 3.5%] carried N lactamica at baseline.) After inoculation, some, but not all, participants in the treatment group became colonized with N lactamica: 33.6% (95% confidence interval, 25.9% – 41.9%) 2 weeks after inoculation, rising to 41.0% (95% confidence interval, 33.0% – 49.3%) by 26 weeks.
Conversely, the proportion of students colonized with N meningitidis dropped after inoculation, going from 24.2% to 6.7% after 4 weeks, and then partially rebounding to 14.5% at 26 weeks. Colonization in the control group was not reduced.
The loss of N meningitidis was greater in the students who were colonized with N lactamica (P = .013), suggesting N lactamica competes with and displaces N meningitidis. These participants were also less likely to acquire new colonization with N meningitidis (P = .011). Of those who were colonized, 13.3% acquired N meningitidis within the 26-week study period compared with 29.2% of control patients and 28% of those who received the inoculation but were not colonized by the probiotic strain.
At the end of the study, all participants received another dose of N lactamica and were tested 2 weeks later. Those who had been in the treatment group were still able to be colonized by N lactamica, and those who had been in the control group showed a similar reduction in N meningitidis carriage as the treatment group had shown at the beginning of the study.
On the basis of these and previous results, including the ability of the treatment group to be recolonized with N lactamica, the investigators write that the protective effect is probably not a result of cross-protective antibodies; rather, “[t]he mechanism is either microbial competition within the nasopharynx, or innate immune responses that operate only in individuals actively carrying the commensal.”
Physician Salaries, Job Satisfaction Detailed in New Survey
Although compensation is still a sore issue for many physicians, according to Medscape’s 2015 Physician Compensation Report, most saw modest to significant gains.
The top three earners in this year’s report are orthopedists ($421,000), cardiologists ($376,000), and gastroenterologists ($370,000). Likewise, in 2011 — the first year Medscape conducted this survey — orthopedists topped the list, followed by radiologists and anesthesiologists.
The average compensation for a primary care physician (PCP) in 2014 was $195,000 and for a specialist it was $284,000.
The three lowest earners for patient care were pediatricians ($189,000), family physicians ($195,000), and endocrinologists and internists (both at $196,000), according to the report. The bottom earners in 2011were also pediatricians, followed by primary care physicians, and endocrinologists.
More than 19,500 physicians in 26 specialties responded to this year’s survey between December 30, 2014, and March 11, 2015, reporting their compensation, number of hours worked, and career satisfaction.
Career, Compensation Satisfaction
About half of PCPs (47%) and half of specialists (50%) are happy with their compensation. PCPs feel about the same as they did in the 2011 Medscape Compensation Report, but specialists feel slightly less fairly compensated than in 2011, when 52% of them were satisfied.
Although only 48% of family physicians and 45% of internists feel they are fairly compensated, ophthalmologists (40%), allergists, and general surgeons (both 41%) are the least happy.
Dermatologists (61%) and emergency medicine physicians and pathologists (both 60%) are the most satisfied with their compensation. Compensation increased by 12% for emergency medicine physicians and pathologists in the past year.
According to the new report, the physicians with the highest career satisfaction are dermatologists (63%), followed by pathologists and psychiatrists (both 57%). The physicians with the least career satisfaction are internists (47%) and then nephrologists and general surgeons (48% and 49%, respectively).
In the 2011 Medscape Compensation Report, most physicians (69%) reported they would choose medicine as a career again, and 61% would choose their same specialty. In the newest report, 64% would still select medicine, but only 45% would stick with the same specialty.
Nonpatient Care Activities
Orthopedists also make the most compensation from nonpatient-care activities ($29,000), including expert witness duties, product sales, and speaking engagements. Next in line are urologists, plastic surgeons, and dermatologists (all three $26,000).
Radiologists ($6000), make the least in this category, followed by pediatricians ($7000), and anesthesiologists ($8000). Physicians, especially PCPs, who are at the lower end of patient-work compensation, also tend to get less in nonpatient-care compensation.
Rheumatologists, Urologists See Decrease, Others Increase
Compared with last year’s report, this year’s compensation for rheumatologists decreased the most, by 4%, followed by urologists, whose income decreased by 1%.
Compensation increased for all other physicians, with the greatest among infectious disease physicians (22%), followed by primarily hospital-based physicians: pulmonologists (15%) and emergency medicine physicians and pathologists (both at 12%).
Notably, compensation for family physicians increased by 10%.
Compensation Varies by Geographic Region
The wide variation in cost of living in certain geographic areas of the United States is problematic for the Centers for Medicare & Medicaid Services because of the need to balance the higher cost of living in some areas with the difficulty in attracting physicians to underserved areas with lower living costs.
Several government policies geared toward improving physician access in rural regions have resulted in higher incomes in several poorer regions, with the three top-earning states listed as North Dakota and Alaska ($330,000 each), and Wyoming ($312,000).
Overall, the highest salaries in this year’s survey were reported in the Northwest ($281,000) and South Central ($271,000) regions of the United States, and the lowest earnings were in the Northeast ($253,000) and the Mid-Atlantic ($254,000).
In 2011, the Medscape Compensation Report noted that the highest earners were in the West and North Central areas of the United States and the lowest earners were in the Southwest and Northeast.
This year’s report shows the lowest-paying regions were the District of Columbia ($186,000), Rhode Island ($217,000), and Maryland ($237,000) — all which are on the East Coast, where nonphysician incomes are generally higher than in other parts of the country. New Mexico and Utah were the only non-Eastern states in the bottom 10 for compensation.
Employment vs Self-Employment
In this year’s survey, most (63%) physicians are employed and make significantly less than the 32% of their colleagues who are in private practice. According to a major physician recruiter, 11% of physicians were employed by hospitals in 2004, and this rose to 64% in 2014.
PCPs who are employed make $189,000, and self-employed PCPs report annual earnings of $212,000. These figures are far less than average compensations for employed ($258,000) or self-employed ($329,000) specialists.
Women Earn Less, Work Fewer Hours
Women still earn less per year ($215,000) than their male counterparts ($284,000), according to the report, although the overall difference between women and men has decreased slightly since 2011, going from 28% in 2011 to 24% this year.
Some of this discrepancy may be explained by the fact that women often work shorter hours and fewer weeks than men. Almost a quarter (24%) of female physicians who completed the survey work part-time compared with 13% of men.
The data show that even women who are employed full-time work fewer hours per week and see fewer patients than their male counterparts. Greater flexibility and shorter hours may help improve female physician satisfaction and fend off burnout.
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