Coffee--what's the scoop?

A slipped disc: do surgery

CRP test better than cholesterol test

CYP46 gene marker linked with Alzheimers disease

Celiac's disease frequency examined in this US study

more sensitive people tend to feel anxious with a single cup of coffee per day, others can tolerate many cups. When a patient complains about panic attacks or insomnia the physician will likely inquire about how much coffee the person drinks.

A Slipped Disc: Do Surgery

In the Dec.31, 2002 edition of the Medical Post a report of the recent North American Spine Society's annual meeting in Montreal was entitled: "Aggressive approach to slipped discs needed". A ground breaking study from England was presented that will change the attitude of many physicians about "slipped discs".

Discs in the lower back do not really "slip". The disc can bulge, protrude or herniate. In the center of the disc is a more liquid part (nucleus pulposus), which can leak out when the fibrotic shell of the disc tears.

This occurs commonly with aging and also with obesity. Dr. Keith Greenfield from the University of Bristol presented data together with the Walton Neurosurgery Centre in Liverpool showing that the borderline cases ("bulging discs")that previously were treated without surgery do much better when early surgery is done (discectomy). This is a shift for many European countries and Commonwealth countries including Canada. In the US back surgeons always had a higher surgical rate as MRI scans have been used much earlier as the standard and the hidden minor disc protrusions and bulging discs are visualized earlier. Dr. Greenfield's study involves 88 patients who belong into the group of patients who are borderline cases between those who definitely need surgery because of a sciatic nerve compression and those who do not need surgery (normal MRI scan). Clinically the "slipped disc" group (with disc bulges) has moderate back pain and some pain that radiates into the leg. They have moderate disabilities with problems of walking, sitting, travelling and standing. The investigators treated half of the patients with microdiscectomy and the other half with conservative treatment (physiotherapy etc.). One year after the surgery a large percentage of them had returned to work and are feeling fine. The control group is quite the opposite: a large percentage of them has slipped into total disability that makes it impossible for them to return to work. Many have entered into chronic pain syndromes that might keep them disabled for a long time. The study is ongoing and the group will report about the two year follow-up point in Vancouver/B.C./Canada in May 2003 at a conference of the International Society for the Study of the Lumbar Spine. For now it seems that microdiscectomy is the treatment of choice in the bordrline cases of disc bulges and mild disc protrusions.

Comments: The rate of back surgery in the US has been 10 times that in England. Perhaps it is time that back surgery is being standardized and MRI scans are done routinely in every more significant back case to find out what's going on earlier in the course of back pain. The direction medicine is going is that back pain that persists for more than 1 month likely should be MRI scanned. In case of a positive finding (bulge, protrusion or disc herniation), this study suggests that doing a microdiscectomy would be the new standard of therapy. Early mobilisation is the other key, which sports medicine physicians have been aware of and used for the last decade. If it's good for athletes, it is likely good for the public at large.

Other link: Low back pain.

CRP Test Better Than Cholesterol Test

At the 75th Annual Scientific sessions of the American Heart Association in Chicago several presentations centered around the use of the C-reactive protein test to evaluate risks for heart attacks, strokes and the risk of restenosing after doing a cardiac procedure to reopen stenosed coronary arteries.

I have previously reported about the use of the C-reactive protein (CRP) test in a review regarding Dr. Paul Ridker's study in the New England Journal of Medicine. This study is ongoing and is known under the name "Women's Health Study". He followed a large group of women and found that an increase of the CRP was closely associated with heart attacks. Other investigators found now that an increase of CRP is closely linked with obesity, with the metabolic syndrome (also known under "insulin resistance") and hormone replacement therapy. There appears to be a pivotal shift among cardiologists in that it is now clear that inflammation seems to be at the center of the process of hardening of the arteries, not just in a few cases. Here is a summary about some of the features of CRP:

There will be a lot of information coming out in the next few years. Two major trials have been started where patients with a normal cholesterol, but an abnormally high CRP, will be followed along.

The JUPITER trial will look at the effect of treating these patients with rosuvastatin (brand name: Crestor). About 15,000 patients will be enrolled in this trial and followed for about 4 years. The Canadian 4R trial (Risk Reduction with Ramipril in patients with high CRP) uses ramipril (brand name: Altace) for 12 weeks to see whether it reduces CRP levels. Much more research is needed, but the doctors already know enough about CRP to state that it is a major player when it comes to hardening of arteries. They also know that LDL cholesterol is not outdated, as both LDL cholesterol and CRP play important roles in this process.

Based on a cardiology update in the Medical Post, Dec. 31, 2002, page 17 to 19.

Other links to related topics:

Heart disease:
http://www.nethealthbook.com/cardiovasculardisease_heartdisease.html

Two things will lead to a normal weight (as you likely have heard before):

Proper nutrition...

http://www.nethealthbook.com/nutrition.html

...and proper exercise (fitness):

http://www.nethealthbook.com/fitness.html

CYP46 Gene Marker Linked With Alzheimers Disease

Dr. Andreas Papassotiropoulos and his group from the University of Zurich in Switzerland have published an interesting paper in the January issue of archives of Neurology (Arch Neurol 2003;60:29-35). These researchers found when they compared a certain genetic area of 201 patients with Alzheimer's disease with that of 248 control subjects, that there were important differences in the socalled CYP46 genotype.

A modified form of this genetic region (CYP46*TT genotype) was much more common in the late onset Alzheimers patients than in normal controls. When this test was found to be positive in a patient, this was associated with a 2.16-fold risk of Alzheimers. However, if another known genetic Alzheimers marker (apolipoprotein E epsilon-4) was present also at the same time, the risk of that person having Alzheimers was 9.6-fold when compared to normal controls. With another group of patients who had died from Alzheimers disease, autopsies were done and the brain tissues and cerebrospinal fluids was examined. It was found that the brain tissues and cerebrospinal fluids were loaded with beta-amyloid, which is the glue-like substance typical for Alzheimers.

The Swiss authors concluded from their study that CYP46 is a novel susceptibility gene, which allows to test for Alzheimer's disease. From other studies it was known that the CYP46 gene encodes the cholesterol 24-hydroxylase, an enzyme that breaks down cholesterol in the brain. It was also known that the beta-amyloid is a by-product of this changed cholesterol metabolism in brains of Alzheimers patients. There are now new possibilities of prevention, if perhaps changes in diet would prevent the accumulation of cholesterol in the brain. Also, medications could be developed that help reducing the cholesterol load of Alzheimers brains to prevent the devastating memory loss.

Related link regarding Alzheimers and dementias: http://www.nethealthbook.com/neurologicaldiseases_alzheimersandothers.html#alzheimertable

Celiac Disease Frequency Examined In This US Study

There has not been a large study in the US looking at the natural frequency of Celiac disease (CD) in the population. Celiac disease is an inborn hypersensitivity to gluten, to be more precise, a hypersensitivity to the sub-fraction of gluten, called "gliadin".

Dr. Alessio Fasano, from the University of Maryland in Baltimore, and colleagues have examined a total of 13,145 subjects in their study to look for specific antibodies in the blood and by doing as many bowel biopsies to see how many cases of CD would be found. There were 4 groups of patients that could be identified: 4,508 first-degree relatives of CD proven patients; 1,275 second-degree relatives; 3,236 symptomatic patients who either had gastrointestinal (GI) symptoms or who had a disorder associated with CD; 4,126 patients not considered at risk and who could serve as a control group. Here is the result of the study in tabular form.

The blood tests that were performed were the anti-endomysial antibodies (EMA). In all positive tests two more specific CD blood tests were done as well.

The results in the table showed that the first degree relatives of CD patients are at a higher risk of developing he disease, even if they have no bowel symptoms (they may be incubating the disease before they even get CD). Second degree relative had about half the risk from first degree relatives. A surprisingly high number of patients with gastrointestinal symptoms do have CD (1 in 56 patients). The normal control group finding of 1 CD patient among 133 people was very similar to the European studies that had been published in the past.

Details about CD under this link:

http://www.nethealthbook.com/celiacdisease.html