Neuropathic Pain For Health Professionals

Today's post from journals.lww.com (see link below) written for Nursing magazine, is a comprehensive article about neuropathy, its causes and treatments for health professionals. It's often interesting to read about how professionals are taught to approach the disease. We can then better understand the reasons for their decisions on our behalf. It also can give us some insights that the doctors don't tell us, either because they don't have time, or because they consider the subject matter too complex for the patient to understand. Definitely worth a read on a day when you don't have to rush off to work. The reference links referred to by the numbers throughout the article can be followed in the original article (see link below).

Living with the nightmare of neuropathic pain
D'Arcy, Yvonne MS, CRNP, CNS Nursing 2014

PATIENTS LIVING WITH a neuropathic pain syndrome will tell you that this vicious pain can ruin quality of life and spoil dreams. Some neuropathic pain, such as that from diabetic neuropathy, has a gradual onset, but other types, such as complex regional pain syndrome (CRPS), can develop suddenly. Some patients with neuropathic pain who have difficulty getting a diagnosis can experience increased pain and anxiety from the uncertainty of their pain condition.

To get a better understanding of this pain, let's look at a patient who had an accident that resulted in a neuropathic pain syndrome that changed her life.
 
Meet the patient

Mrs. S, age 65, is a retired teacher who went to bed one night free from pain. During the night, she got up to use the bathroom without turning on the light and ran into a table leg quite hard, injuring her right foot. Because the pain was so severe, her husband drove her to the ED. There she rated her pain as an 8 on a pain intensity rating scale of 0 (no pain) to 10 (worst pain imaginable).

The healthcare provider (HCP) obtained an X-ray of her foot, which revealed no fractures. Believing that Mrs. S had only soft-tissue damage, the HCP prescribed an opioid-acetaminophen combination medication for moderate pain, and told her to elevate, ice, and rest her foot for several days.

Although Mrs. S very diligently rested her foot, used ice packs, and took her medications as needed, the pain didn't resolve. In fact, it increased and became constant. Over the next 6 weeks, Mrs. S was evaluated by many HCPs, but none could give her a concrete diagnosis. Her pain was 7/10 at best and none of the pain medications she'd been given significantly relieved it; instead, they just made her sleepy. Because she had trouble putting weight on her foot, she started to use crutches. Her foot often felt cold, so she tried to put a sock on for warmth, but she couldn't stand the pressure it put on her foot.

Her husband was concerned about her unrelieved pain, loss of function, and lack of sleep due to pain. At 3 months, Mrs. S was referred to the local pain management specialist, who diagnosed her with CRPS, a neuropathic pain syndrome where the injury is located in the peripheral nerves but can also include changes in the central nervous system.1 (See Focusing on CRPS.)

When Mrs. S asked about treatment, she was told the pain would most likely persist and that the best approach was to try medications designed to treat neuropathic pain to help reduce it. At this point, she broke into tears and told the specialist, “This can't be! I just retired after teaching for 30 years. I planned to travel the world and now I'm in constant pain. How could this have happened to me?”

What we know about neuropathic pain

Neuropathic pain is chronic pain caused by damage in the peripheral or central nervous system. It's been defined as pain that's the direct consequence of a lesion or disease affecting the somatosensory system.2 (See The language of pain.)

This distinct type of pain encompasses a wide variety of neuropathic pain conditions. Unlike acute pain, it has absolutely no protective function and doesn't require any nociceptive input; that is, it exists independent of a stimulus. In contrast, nociceptive pain results from damage to tissue that's nonneural, such as surgical tissue damage or a tissue injury. Nociceptive pain is caused by activation of thermoreceptors, chemoreceptors, and mechanoreceptors, depending on whether the pain is caused by burns or muscle or tendon damage.3

Clinically, a patient such as Mrs. S doesn't have to move or walk on her affected foot to have pain. This type of pain persists without any pressure or sensory input.

Sorting out neuropathic pain

Of the many different types of neuropathic pain, some are caused by chronic diseases such as diabetes or HIV infection. Others, such as postmastectomy pain syndrome, result from surgery or treatments such as chemotherapy. Overall, neuropathic pain is thought to affect 1,765,000 people in the United States, not including those with back pain neuropathy.4 (See Sorting out common neuropathic pain conditions.)

Neuropathic pain has many sources and causes. For example, the continued inflammatory process of osteoarthritis may create neuropathic pain. Fibromyalgia is now considered a disease caused by dysregulation of pain inhibition pathways and amplification of central pain.5
 
Pathophysiology: Getting to the root

Generation of neuropathic pain involves both the peripheral nervous system and the central nervous system, and both the ascending and descending neural pathways. It's maladaptive: Neuropathic pain promotes abnormal functioning of nerves in one or both systems leading to a difficult-to-treat chronic pain condition.6 As the nerves change function, a phenomenon called neural plasticity occurs. These changes are responsible for heightened pain sensitivity and unpredictable, sudden pain exacerbations.

If the source of the neuropathic pain is in the periphery, continued pain stimuli from the peripheral nerve injury create sensitization that over time creates abnormal neural activity along the afferent nerve pathways leading to the central nervous system.7 This sensitization causes the release of what's commonly called an “inflammatory soup” of pain-promoting substances such as cytokines, tumor necrosis factors, bradykinin, and substance P. This in turn leads to hypersensitivity of the nerves, allowing them to crosstalk with each other, release pain-facilitating substances, activate higher level pain-generating functions such as N-methyl-D-aspartate receptors, and fire faster.

Sodium channels on nerve fibers play a part in the creation of neuropathic pain. In normal neural functioning, nerve depolarization occurs when the stimulus reaches the activation point and the nerve is forced to fire. When neuropathic pain is created, more primary and secondary sodium channels are activated, allowing for an ectopic neural discharge.4

Pain that originates from the central nervous system is even more difficult to manage. Pain that's centrally controlled can be created by a continued barrage of pain stimuli to the peripheral neurons, causing central neurons to become hyperexcitable. This hyperexcitability has been transferred to the central nervous system through the synaptic junction between the two nervous systems. As a result of this central sensitivity, synaptic connectivity reorganizes, causing lower activation thresholds and increased responses to stimuli.8

Additionally, collateral neurons may sprout and create larger fields of effect with the ability to crosstalk with each other and recruit additional neurons for pain creation. This phenomenon, called wind-up, causes an increased response to painful stimuli.6 Meanwhile, the descending pathway inhibition potential used to block pain is adversely affected, letting more pain reach the patient.

This explains the pain that Mrs. S is continuing to have. Continual pain stimuli from the periphery have created central sensitization and the wind-up effect has been created related to neuronal plasticity. Because the pain had continued at high levels for so long, the central nervous system pain-facilitating process was activated, which will make her pain much harder to manage.
 
Signs and symptoms

When assessing neuropathic pain, the nurse must ask the patient to describe the pain. Aside from the numeric pain intensity scale, the descriptors the patient uses are the best means of identifying the pain. If the patient uses words such as burning, shooting, electric, painful numbness, or tingling, the pain has a neuropathic source. After a mastectomy, some patients complain of strange painful sensations or painful pruritus in the ipsilateral axilla or upper arm. This is also classified as neuropathic pain.

Using fiber wisps for sensation testing or alcohol to create a cool sensation and touching the painful areas can determine just how large an area is affected. Ask patients if they experience hyperalgesia, increased pain from a stimulus that's normally painful, such as a pinprick, or allodynia, a painful response to a stimulus that isn't normally painful, such as touch from clothes or bedsheets.6 Assess for other signs of neuropathic pain. Other common types of neuropathic pain include paresthesia, an abnormal sensation that isn't unpleasant, such as numbness or tingling, and dysesthesia, an unpleasant sensation such as painful pruritus or feeling as though bugs are crawling under the skin.6

In the acute phase, patients who are developing CRPS after an injury continue to report high-intensity pain despite escalating doses of opioids. As the condition develops, besides allodynia, patients report edema, skin discoloration due to changes in blood flow, temperature differences between the affected and nonaffected extremity, changes in hair and nail growth, weakness, and tremor.9

Mrs. S is having difficulty with severe pain and she can't put any pressure on her foot. She has allodynia, and she's started to use descriptors indicative of CRPS, such as painful coldness.
 
Treatment options

One of the best ways to manage neuropathic pain is to use a stepwise approach. To adequately assess and diagnose a patient with neuropathic pain, the HCP will need to perform a focused physical exam. If possible, the HCP will identify the source, make a diagnosis, and examine any contributing comorbidities such as diabetes. Remember that the patient may not understand that pain descriptors may be the key to adequate management.

Besides explaining the diagnosis to the patient and discussing treatment options, the HCP will set realistic achievable goals. Many patients with neuropathic pain have seen multiple HCPs with no success; receiving a diagnosis may end the uncertainty that these patients have experienced and give them some hope for reducing the pain. Although complementary techniques such as relaxation or yoga may be beneficial for adjunct pain relief, the mainstay is pharmacologic management.

Stepping up to medications

Using the stepwise approach to treatment includes using first-line medications with the highest level of evidence for success in controlling neuropathic pain. (See Lining upmedications for neuropathic pain.)

After patients begin drug therapy, nurses need to reassess the efficacy of the therapeutic regimen. If the first medication chosen doesn't provide pain relief or increase functionality, the HCP may try titrating the dose upward. If that doesn't provide adequate pain relief, the HCP may consider combining two first-line medications.

If careful drug choices in the first-line category don't provide adequate pain relief, trialing second-line options may be a way of optimizing pain relief. As always, adding nonpharmacologic therapies, such as yoga, pool therapy, or meditation, can help with pain relief and relaxation.

For Mrs. S, our patient with CRPS, using one or more first-line therapies should provide some level of pain relief. Her current medication is an opioid, which is a second-line option. Using first-line medications either alone or in conjunction with the opioid may optimize her pain relief, and a consultation with physical medicine and rehabilitation professionals to work on increasing functionality is highly recommended. Mrs. S may never be pain free—that isn't a reasonable goal for her—but she should be able to move to a higher level of physical activity and perhaps begin to take short trips to see some of the places she's been dreaming about.

New options on the horizon

Research evidence supports the use of some antiepileptic drugs for certain types of neuropathic pain such as painful diabetic neuropathy. However, lacosamide, an antiepileptic drug, was trialed for managing neuropathic pain and fibromyalgia but failed to show significant benefit. The FDA has declined to approve its use for neuropathic pain.10 Another therapy that produced better outcomes is topical application of high-dose capsaicin, 8% patch, which is thought to produce desensitization. It's indicated for a particularly difficult-to-treat neuropathic pain syndrome called postherpetic neuralgia. In six studies involving 2,073 patients, a small number of participants with postherpetic neuralgia and HIV neuropathy with high pain levels benefited.11 Pain relief lasted for up to 12 weeks. In studies, 11 or 12 patients had to be treated to get 1 positive outcome of reduced pain (this is known as numbers needed to treat and is considered high).11 However, some patients did benefit, and their pain was significantly reduced.

Although single medications used alone can positively affect neuropathic pain, combination therapy demonstrates superior pain relief. Some agents caused problematic sedation.12 Unfortunately, there weren't enough comparative or replication studies to identify particular combinations of drugs that had improved pain relief. In a meta-analysis with 386 patients, gabapentin plus an opioid was superior to gabapentin alone, according to a modest but clinically significant finding.12

One of the most exciting ideas for managing neuropathic pain is attempting to use molecular approaches. Chromaffin cells release a combination of pain-reducing neuroactive compounds, including catecholamines and opioid peptides.13 Encapsulating the cells and implanting them in the subarachnoid space has relieved pain in both animal and human studies.13

In these cell transplantation studies, encapsulated cells with permeable membranes turn into cellular pumps that create and dispense analgesic compounds.13 Future research targets include astrocyte cells that are genetically modified to secrete enkephalin and genetically engineered cells designed to secrete gamma-aminobutyric acid, a pain inhibitory substance.13 Patients thought to be good candidates for study include those with low back pain and knee pain; these can have neuropathic elements. Understanding the pathways and physiology of neuropathic pain transmission can help researchers look for ways to use these specialized cells to reduce pain right at the source of pain generation.

Other options for managing neuropathic pain include using autologous bone marrow-derived progenitor cells to repair damaged neurons in patients with diabetic peripheral neuropathy and gene transplants applied to peripheral nerves, injected into dorsal root ganglia, or introduced into the intrathecal space of the spine via lumbar puncture or injected directly into the brain.13 Gene transplants have been tested only in animals using the herpes simplex virus.13

Stem cell transplantation also provides promise for pain research. Mesenchymal stem cells can be harvested from bone marrow, are fairly stable, and can, once transplanted, migrate to injured tissue and have immunosuppressive characteristics.14 They can also differentiate into astrocytes and neurons and migrate to injured neuronal areas to mediate functional recovery.14 Although many of the finer points of the process are yet to be discovered, studies of mice have shown that the transplanted stem cells relocated themselves into key areas for neuropathic pain generation in the brain.14

Although many new management options are still being studied in animals, they hold promise for human use in the future. Researchers are attacking the pain process from many different directions and using the known pain pathophysiology to direct the therapy to targets that may yield good results.

In the foreseeable future, patients like Mrs. S won't be limited to medications or interventions for intractable pain syndromes such as spinal cord stimulators. Instead, they'll have options that include stem cell transplants for nerve repair or genetically engineered cells that will enhance the production of pain-reducing substances. Using these new techniques will help many patients leave the nightmare of neuropathic pain behind and fulfill their dreams.

Focusing on CRPS

CRPS, or complex regional pain syndrome, was formerly called causalgia or reflex sympathetic dystrophy.3 It's usually the result of a crush injury or repeated tissue trauma. Continuing pain or abnormal sensation is out of proportion to the event that initiated it. At some time, the patient experiences edema, skin blood flow changes, or abnormal sudomotor activity in the region of pain. No other condition is identified that could explain the pain or dysfunction.15

The International Association for the Study of Pain defines two types of CRPS:

CRPS I, which doesn't require the presence of a nerve lesion.
CRPS II, which includes the presence of a nerve lesion.
Although the true cause of CRPS hasn't been determined, the most accepted rationales include the following:
enhanced peripheral neurogenic inflammation
sympathetic nervous system dysfunction
structural reorganization in the central nervous system.

Source: Fechir M, Geber C, Birklein F. Evolving understandings about complex regional pain syndrome and its treatment. Curr Pain Headache Rep. 2008;12(3):186–191.


The language of pain

Allodynia: painful response to a stimulus that isn't normally painful, such as touch from clothes or bed sheets.
Crosstalk: new communication, or neural sprouts, between nerves that don't normally synapse with one another.
Dysesthesia: an unpleasant sensation, such as painful pruritus or feeling as though bugs are crawling under the skin.
Hyperalgesia: increased pain from a stimulus that's normally painful.
Neural plasticity: continued noxious stimuli and inflammation causing an elevation of nociceptive input from the periphery to the central nervous system, which then creates an increased response at the cortical level to change its somatotopic organization for the painful site, inducing central sensitization.
Neuropathic pain: chronic pain caused by damage in the peripheral or central nervous system that's the direct consequence of a lesion or disease affecting the somatosensory system.
Nociceptive pain: pain that results from nonneural damage to tissue.
Paresthesia: an abnormal sensation that isn't unpleasant, such as numbness or tingling.
Wind-up: an increased response to painful stimuli. Add, on a new line as source format:

Source: Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–130.

Sorting out common neuropathic pain conditions

Peripheral syndromes and U.S. patients affected

Painful diabetic neuropathy; 600,000
Postherpetic neuralgia; 500,000
Cancer associated; 200,000
HIV associated; 100,000
Phantom limb pain; 50,000

Central syndromes and U.S. patients affected
 
Spinal cord injury; 120,000
CRPS I and II; 100,000
Poststroke; 30,000

Source: Irving GA. Contemporary assessment and management of neuropathic pain. Neurology. 2005;64(12 suppl 3):S21-S27.

http://journals.lww.com/nursing/Fulltext/2014/06000/Living_with_the_nightmare_of_neuropathic_pain.12.aspx

Is Your Health Insurance Company Playing Fair

Today's post from lindanee.wordpress.com (see link below) looks at the activities of the international insurance company UNUM when it comes to disability claims from people living with HIV. It is clear in this day and age of economic crisis that all companies who may be paying out on the basis of ill-health and inability to work are looking for every possible means of not doing exactly that. This frequently means that people with genuine illnesses preventing them from being able to work, come under suspicion that they are somehow trying to defraud the system. UNUM is by no means unique in aggressively disputing HIV disability claims but this article highlights them as a major player. Of course, we all know that certain people will try to take advantage of any system that may pay out when ill-health is concerned but the vast majority of people are genuinely trying to claim what is their entitlement and what they have paid premiums for. All anybody is asking for is a level playing field and it is incumbent on firms like UNUM to be aware of the genuine problems that living with HIV can bring and assess based on facts and not assumptions. Too many people are being given parameters that are impossile to fulfill and losing out on benefits because they are being unfairly judged.

Unum – Targeting HIV/AIDS Insureds On The Internet
April 2, 2013 by lindanee

Lindanee's Blog
By and For Those With Private Disability Claims
”Search and find the weakest of us, and therein lies our strength.” Linda Nee

Since its inception more than 10 years ago, DCS, Inc. has been an advocate and supporter of those diagnosed with HIV/AIDS who have applied or been denied benefits by private disability insurers. Insurance companies such as Unum have long treated HIV insureds as vulnerable cash cows. With today’s modern medical advance technology, AIDS is no longer a death sentence giving those with the disease normal lifespans, and of course in Unum’s view, work capacity.

The development of life-saving HIV “cocktails” does not take into account the long list of HIV-related symptoms and diagnoses which continue to rob insureds of their quality of life. Regardless of the success and invention of better drugs and treatments for HIV patients there are often physical side-effects from medications taken, and in combination with other immunosuppression diseases, HIV continues to rob a large percentage of those affected with HIV from the ability to work and sustain full active lives.

Those who suffer from HIV/AIDS often report continuing symptoms of severe fatigue, unrelenting diarrhea, peripheral neuropathy, dizziness, and cognitive deficits. My research seems to indicate individuals with T-Cell counts of 500 and above are capable of normal functioning depending on combinations of medications taken and the severity of side-effects.

Although it is possible for HIV patients to live normally, these same individuals would never be able to consistently sustain full-time work. Those with T-Cell counts under 500 are susceptible to life threatening bacterial infections and are medically recommended to stay away from social contact such as work environments. Severe, unpredictable fatigue and the necessity of finding bathroom facilities quickly would make it impossible for anyone affected by AIDS to sustain work of any kind.

Over the years Unum has had many project focus days targeting HIV/AIDS claims. A few years ago, I read several of Unum’s internal medical reports recommending return to work for HIV patients with T-Cell counts as low as 200. These same Unum insureds had also provided Unum with medical evidence of severe peripheral neuropathy, and cognitive dysfunction. One Unum HIV medical review criticized the insured because he was able to travel to his second home in Texas. Clearly, Unum periodically targets the “weakest of us” whether it is HIV, heart disease, chronic back pain, or even cancer.

Of course, the Internet information highway in combination with Unum’s “snoop moles”, fuels and arms Unum with data which for the most part is inaccurate and ill-serving. Unum’s current trend is to search the Internet for HIV/AIDS related non-profit organizations and find out who is submitting articles for publication. Potentially unreported income “red flags”go up, and Unum’s claims handler’s begin investigations looking for income never received, and occupations that are merely volunteer efforts to contribute on an “as able” basis.

Unum’s first inappropriate accusation to HIV individuals who voluntarily write articles for AIDS supportive publications, is “You’re working, and you are a writer.” What follows is a long list of accusatory questions such as, “How many articles have your written? How much money have you made in the last 5 years? “Submit all of your tax returns…” “Who is your employer?” Good grief, sometimes I wonder at the intelligence of people working for Unum these days.

The voluntary submission of articles for pro-HIV/AIDS publications is NOT the same as having demonstrated physical or mental stamina, or for that matter the ability to perform full-time work. In addition, articles published on the Internet are largely unpaid and therefore there is no income to report. Further, the authors certainly are not professional writers. A professional writer must “write” every day and meet deadlines on an ongoing basis. Those with HIV can’t do that, and Unum knows it.

There are no employers; no income to report; and certainly those diagnosed with HIV do not suddenly turn into professional, free-lance writers because they are able to voluntarily submit an article for publication every now and then. My experience with assisting HIV/AIDS insureds is that as a group they feel a moral responsibility to assist others affected by the disease. And, they have a right to do that, whether they have Unum disability claims or not.

Unum as a company has always targeted HIV claims on a periodic basis. Insureds and claimants are frequently stricken by fatigue, have very low stamina and certainly are not capable of engaging in conflicts with a major disability insurer. HIV insureds receive frequent phone calls from Unum reps along with harassing requests for updated information. There appears to be a definite visible Unum paranoia concerning HIV insureds and their ability to work.

Nevertheless, as an organization Unum Group remains the only disability insurer to my knowledge which outwardly manages HIV AIDS related claims with a clearly visible bias resulting in prejudicial decisions which are largely not supported by the medical community. After all, HIV patients with T-Cell counts of 200 cannot sustain full-time work, nor should they be denied disability benefits just because Unum says they can.

In the last 11 years DCS, Inc. has developed an expertise in managing HIV private disability claims, but our success is more than just expertise. As a disability consultant, I’ve learned that our strengths as human beings often come from the weakest among us. I would not be in the business I’m in if I didn’t think so.

Unum Group is wrong in its unconscionable targeting of HIV claims and as long as DCS, Inc. and NCDI are going-concerns we will continue to offer our services to those affected by HIV. Unum’s lack of any moral, ethical, or regulatory accountability for its actions continues to pinpoint the company as a modern insurance rainmaker for those suffering from HIV.

http://lindanee.wordpress.com/2013/04/02/unum-targeting-hivaids-insureds-on-the-internet/

POOR SPERM QUALITY LINKED TO HYPERTENSION OTHER HEALTH PROBLEMS

A study of men who were evaluated for the cause of their infertility finds previously unknown relationships between deficiencies in their semen and other, seemingly unrelated health problems.

A study of more than 9,000 men with fertility problems has revealed a correlation between the number of different defects in a man's semen and the likelihood that the man has other health problems.

The study, conducted by investigators at the Stanford University School of Medicine, also links poor semen quality to a higher chance of having various specific health conditions, such as hypertension, and more generally to skin and endocrine disorders.

The findings, published online Dec. 10 in Fertility and Sterility, may spur more-comprehensive approaches to treating male infertility. They also point to the wisdom of performing complete physical examinations of men experiencing reproductive difficulties.

"About 15 percent of all couples have fertility issues, and in half of those cases the male partner has semen deficiencies," said the study's lead author, Michael Eisenberg, MD, assistant professor of urology and director of male reproductive medicine and surgery at Stanford. "We should be paying more attention to these millions of men. Infertility is a warning: Problems with reproduction may mean problems with overall health."

A study Eisenberg co-authored a few years ago showed that infertile men had higher rates of overall mortality, as well as mortality linked to heart problems, in the years following an infertility evaluation. "But here, we're already spotting signs of trouble in young men in their 30s," he said.

Analyzing medical records

In the new study, Eisenberg and his colleagues analyzed the medical records of 9,387 men, mostly between 30 and 50 years old, who had been evaluated at Stanford Hospital & Clinics (now Stanford Health Care) between 1994 and 2011 to determine the cause of their infertility. The men had routinely provided semen samples, which the researchers assessed for characteristics including volume, concentration and motility. In about half of all the male infertility cases, the problem was abnormal semen; in the rest, the fault lay elsewhere. So, using the database, the investigators were able to compare the overall health status of men who had semen defects to that of the men who didn't.

With a median age of 38, this was a fairly young group of men. However, 44 percent of all the men had some additional health problem besides the fertility problem that brought them to the clinic. In particular, the investigators found a substantial link between poor semen quality and specific diseases of the circulatory system, notably hypertension, vascular disease and heart disease. "To the best of my knowledge, there's never been a study showing this association before," said Eisenberg. "There are a lot of men who have hypertension, so understanding that correlation is of huge interest to us."

In addition, as the number of different kinds of defects in a man's semen rose, so did his likelihood of having a skin disease or endocrine disorder. When looking at the severity of all health problems, the scientists observed a statistically significant connection between the number of different ways in which a man's semen was deficient and the likelihood of his having a substantial health problem.

Health, semen quality 'strongly correlated'

The study wasn't designed to determine precisely how connections between semen deficiencies and seemingly unrelated disorders, such as cardiovascular or endocrine disease, come about. But, Eisenberg noted, some 15 percent of all genes in the human genome are connected fairly directly to reproduction, and most of these genes also have diverse functions in other bodily systems. He also noted that it may not be a disease itself, but the treatment for the disease, that's actually responsible for reproductive malfunction. He said he is exploring this possibility now.

As we treat men's infertility, we should also assess their overall health.

"A man's health is strongly correlated with his semen quality," he said. "Given the high incidence of infertility, we need to take a broader view. As we treat men's infertility, we should also assess their overall health. That visit to a fertility clinic represents a big opportunity to improve their treatment for other conditions, which we now suspect could actually help resolve the infertility they came in for in the first place."

The senior author of the study is Mark Cullen, MD, professor of medicine at Stanford. Other Stanford co-authors are professor of reproductive endocrinology and fertility Barry Behr, PhD; former professor of obstetrics and gynecology Renee Reijo Pera, PhD; and statistical programmer Shufeng Li.

How Alpha Lipoic Acid Can Restore Nerve Health

Today's post from prohealth.com (see link below) is another article examining the benefits of the anti-oxidant and co-enzyme, alpha lipoic acid to the nervous system and especially to the protective lining of nerves - mitochondria. There are other articles on this blog about lipoic acid to be found by checking the alphabetical list to the right of the blog. Many people living with neuropathy have benefited by supplementing with alpha lipoic acid and Acetyl L-carnitine but it has to be stressed that for some, it makes no difference whatsoever. Whether you believe all the claims or not, it's certainly worth talking over with your doctor or neurologist, as a possible non-drug option in your treatment regime. In order to follow all the reference links via the numbers, you will need to visit the original page.
  

Lipoic Acid Reverses Mitochondrial Decay
By Michael Anderson • www.ProHealth.com • October 28, 2014

It is estimated that 85% of the oxygen contained in every breath you take is consumed by the mitochondria within each cell of your body.1

The decay of these energy-producing powerhouses in turn lies at the core of most age-related pathologies.

In experimental models examining the mitochondrial theory of aging, it has been shown that cells microinjected with mitochondria isolated from old animals degenerate far more rapidly than those microinjected with mitochondria from young animals.2

The good news is that when supplied with a nutrient regimen that includes lipoic acid, a profound regeneration is observed in similar animal models,3 including improved metabolic function and a marked decline in oxidative stress.

In this article, the recent data on lipoic acid’s multimodal power to combat a host of age-related diseases is detailed. You will learn how it may help prevent cardiovascular disease, obesity, diabetes, neurodegenerative disorders, and cancer. You will also learn of drug company efforts to produce high-cost, synthetic forms of lipoic acid to capitalize on its unique health-promoting properties at your expense.

Mitochondrial Decay and Aging

The mitochondrial theory of aging has long held a prominent place in scientists’ understanding of the processes that impact aging. First proposed by Denman Harman in 1972, this theory posits that accumulated DNA damage to mitochondria, the cells’ energy generators, leads to increased free radical stress and decreased cellular energy production.4 In the past 30 years, a wealth of evidence supporting the mitochondrial theory of aging has led prominent researchers such as Bruce Ames to consider it a major contributor to aging.5

Experimental models support this theory and demonstrate the importance of youthful mitochondria function in maintaining cellular health. For example, cells microinjected with mitochondria from aged animals display greater cellular degeneration, compared with cells microinjected with mitochondria from youthful animals.2 The mitochondrial theory of aging has analyzed the components of young and old cells. Youthful organisms contain abundant numbers of smaller, bioenergetically efficient mitochondria, while older organisms contain larger, inefficient mitochondria that decrease energy supply in the cells.6,7

Delaying mitochondrial aging through the use of nutrients such as lipoic acid and acetyl-L-carnitine has been proposed as a top-line strategy for preventing aging-related diseases.8

How Lipoic Acid Combats Cellular Degeneration

Lipoic acid is a vital “co-factor” for enzymatic reactions within the mitochondria, helping to optimize energy conversion.9,10 It possesses unique properties that specifically slow mitochondrial aging by preventing release of mutagenic oxidants.11 Recent research further reveals lipoic acid’s ability to alleviate mitochondrial dysfunction in aging cells (thus improving mitochondrial function).12,13

Researchers have further discovered that lipoic acid enhances the effects of insulin, benefitting glucose metabolism and lowering blood sugar levels.10

This in turn mitigates the pathologic cross-linking of glucose and protein that result in advanced glycation end products (AGEs).14

These advanced glycation end products have been shown to accelerate the onset of cardiovascular disease, brain degeneration, ocular disorders, and cancer.14-17

Lipoic acid also suppresses production of inflammatory cell-signaling molecules, while increasing production of molecules involved in vascular tone, such as endothelial nitric oxide synthase (eNOS).18,19

Owing to its pronounced power to combat mitochondrial aging, behemoth pharmaceutical companies are now attempting to manipulate its molecular structure and render it patentable.20 Such drugs include more complex molecules in which lipoic acid is “conjugated,” or chemically joined, to form hybrid compounds with additional biological characteristics.

This would allow drug manufacturers to make absurd claims of superior benefit for their artificial, synthetic lipoic acid products. The result would be needless additional cost for what is already a proven multi-modal nutrient.

Lipoic acid in the biologically active “R” form (see below) is readily available without a prescription and affordable.

Use the “Right” form of Lipoic Acid

Lipoic acid comes in two “mirror image” forms labeled “R” and “S.” Only the R form is produced and used by life processes. Inexpensive chemical manufacturing produces equal quantities of R and S lipoic acid, often labeled “R/S Lipoic Acid” or simply “alpha lipoic acid” (ALA).

Newer precision techniques allow production of a pure R-lipoic acid, which has a much higher potency. A dose of pure R-lipoic acid provides twice the active ingredient as a typical R/S-alpha lipoic acid supplement, simply because the whole dose consists of the active “R” molecule. Look for the “R” label to assure you are getting the most potent form of this valuable nutrient.21,22

Cardiovascular Defense

Lipoic acid’s powerful antioxidant, anti-inflammatory, and lipid-lowering capabilities make it an ideal, multi-targeted nutrient for reducing cardiovascular risk.23,24 Lipoic acid helps protect the endothelium, the delicate, one-cell-thick lining of blood vessels. Additionally, lipoic acid improves blood vessels’ ability to relax, helping to lower blood pressure, improve blood flow, and reduce risk for cardiovascular events such as heart attack and stroke.25-28 Better blood flow in legs can also mean reduced pain with prolonged walking or other exercise.29

Cardiac surgeons are now beginning to recommend lipoic acid, along with other antioxidants such as CoQ10, prior to surgery in order to protect delicate blood vessels during surgery. Improved physical and mental quality of life in such patients has been reported to last for more than a month after the surgery.30

You can use lipoic acid to help lower your risk for cardiovascular disease long before you need cardiac surgery, though. Lipoic acid lowers total cholesterol and low-density lipoprotein (LDL) levels and reduces the size and number of atherosclerotic plaques, the dangerous points of arterial narrowing that produce heart attacks and strokes.23,24,28,31 In addition, lipoic acid may also lower levels of certain cellular toxins that contribute to cardiovascular diseases, especially those related to diabetes.32,33

Even people with pre-existing heart disease can benefit from lipoic acid. Cardiac stents, intended to improve blood flow following a heart attack, can become blocked by formation of unwanted new tissue, an effect that is prevented by lipoic acid supplementation.34 And, lipoic acid prevents death of heart cells exposed to high blood sugar levels, a contributor to diabetic heart disease.35

Targeting Obesity

Lipoic acid has beneficial effects on the forces that cause us to gain weight and store excess fat. It works on brain areas to reduce appetite, food intake, and body weight.36-39 Lipoic acid also stimulates increased energy expenditure, burning excess calories by activating cellular energy signaling complexes.13,36

Overweight and obese people lose their normal sensitivity to insulin, resulting in ever-higher levels of blood sugar and advanced glycation end product–induced tissue damage. Lipoic acid improves insulin sensitivity and stimulates sugar uptake from the blood to help normalize sugar levels.40-43 In the liver, lipoic acid decreases fat production and accumulation, helping to prevent development of dangerous non-alcoholic fatty liver disease (NAFLD).44,45

Lipoic acid has been successfully used in patients taking medications that stimulate weight gain, such as antipsychotic drugs.46 Even in people who are only overweight (not yet obese), lipoic acid reduced body weight by 8% while shrinking waist size by more than 2 inches.47 In patients who are already obese, there was a 9% loss of weight and a decrease in waist size of more than 3 inches.47

What You Need to Know: Lipoic Acid Reverses Mitochondrial Aging

Cells with mitochondria isolated from old animals degenerate far more rapidly than those with mitochondria from young animals.
When supplied with a nutrient regimen that includes lipoic acid, a profound regenerative effect is observed.
Experimental models show that lipoic acid optimizes function of the mitochondria in aging cells and reverses cell aging.
Recent data reveal that lipoic acid specifically targets factors that contribute to mitochondrial aging, dysfunction, and cell death.
Lipoic acid can help to prevent cardiovascular disease, obesity, insulin resistance, and diabetic complications.
Lipoic acid protects against nerve and brain cell damage induced by aging and trauma.
New evidence suggests that lipoic acid may also have important cancer-preventive effects, even against some of the most difficult-to-treat malignancies.

An Anti-Diabetic

Lipoic acid has an important role in managing diabetes, particularly the massive oxidative and inflammatory changes the disease produces.48,49 The benefits of lipoic acid include promoting insulin sensitivity and glucose uptake.50-52 Diabetics are at increased risk for the kinds of cardiovascular problems that lipoic acid can prevent, including accumulation of cellular toxins.32,53 By protecting against endothelial damage, lipoic acid reduces the threat of diabetic vascular and kidney complications.26,54

Lipoic acid is proving to be especially effective at preventing the painful and debilitating condition known as diabetic neuropathy, an almost inevitable complication in people with poor blood sugar control.55 Diabetic neuropathy begins with pain, burning, and/or stabbing sensations in the extremities.56 In more advanced stages of this condition, the pain disappears as severe damage is done to microscopic blood vessels. Ultimately the loss of nerve function can lead to open sores, infections, and even amputations. Despite considerable knowledge about how diabetic neuropathy arises, no drug treatment has yet proved effective in preventing or reversing the condition.56

Lipoic acid’s powerful antioxidant actions limit damage to the lining and blood supply of nerves, helping to reduce both symptoms and nerve dysfunction.57 Clinical studies have uniformly demonstrated improvements in pain, numbness, and stinging, while also improving nerve conduction velocity, a measure of how efficiently nerves transmit electrical impulses.58-61 Studies have shown that lipoic acid produces significant improvements when administered for 3 weeks, and longer studies have shown sustained effects.62,63 Lipoic acid also has beneficial effects on circulation in patients with diabetic neuropathy, improving blood flow and the amount of blood reserve available during high demand.64

It’s essential to start early with optimal levels of lipoic acid to prevent diabetic neuropathy. People with good blood sugar control and younger patients do better, as do women, and thinner patients in general.58 While doses of up to 1,800 mg/day are well-tolerated, 600 mg/day of alpha-lipoic acid seems to produce the best results in those with diabetes.59 This translates into a 300 mg dose of R-lipoic acid to obtain the same biological activity.21,22

Protection from Brain Cell Degeneration

Lipoic acid protects brain tissue from the long-term effects of advanced glycation end products and the resulting inflammation and oxidative damage, conditions that lead to neurodegenerative diseases like Alzheimer’s disease.9,65,66 A hallmark of Alzheimer’s disease is the formation of an abnormal protein called amyloid-beta, the result of chronic inflammation and a producer of increased oxidative stress. Lipoic acid reduces amyloid-beta-induced inflammation and improves brain cells’ production of the chemical signaling molecules called neurotransmitters.67,68 Mitochondrial function is significantly impaired in the brains of Alzheimer’s and Parkinson’s disease patients and lipoic acid decreases mitochondrial oxidant stress in those cells.69,70

These effects work together with other nutrients like acetyl-L-carnitine, docosahexaenoic acid (DHA), phosphatidylserine (PS), and glyceryl-phosphoryl-choline (GPC) to improve cognitive performance.71 Research has shown that lipoic acid prevents cell death in the brain regions most affected in Parkinson’s disease.72 These findings are both good news and important reminders of the need to incorporate lipoic acid early, before symptoms progress in these chronic, debilitating diseases. Lipoic acid may also have an important role in preventing the immune over-response that causes multiple sclerosis, another chronic, progressive brain disease.73-81

By increasing antioxidant capacity, scavenging free radicals, reducing lipid peroxidation, and enhancing energy utilization, lipoic acid may also minimize the damage produced by brain trauma.82 Lipoic acid has shown benefit in preventing trauma-related injuries to the brain, spinal cord, and even peripheral nerves, all of which are vulnerable following a major accident.83-85

Anti-Cancer Mechanisms

Cancer scientists are growing increasingly interested in lipoic acid because cancer cells offer many targets for its anti-inflammatory attributes.86 These attributes allow lipoic acid to intervene at multiple points in the chain of carcinogenesis.86,87 In experimental studies, lipoic acid shows promise against cancers of the blood (leukemia), lung, breast, and liver.88-93 Preliminary research indicates that lipoic acid acts to halt the cell reproductive cycle of cancer cells, slowing or stopping tumor growth.88,89 Lipoic acid may also help induce apoptosis, the programmed cell death that is the body’s natural control mechanism for weeding out nascent cancers.88-93 Lipoic acid also protects against chemical-induced DNA damage that can lead to cancerous transformation.94 Lipoic acid may help prevent metastatic cancer spread by reducing activity of enzymes that tumors use to invade tissues.93 Finally, in those unfortunate enough to require chemotherapy to treat an existing cancer, lipoic acid can afford powerful protection against some of the side effects, such as diarrhea, intestinal cramping, and ulcers, thanks to its antioxidant capabilities.87

Lipoic Acid: Research Update

An abundance of recently published studies reveals a wide range of new findings about lipoic acid:

Weight loss support. Overweight or obese individuals who received 1,800 mg of alpha lipoic acid daily for 20 weeks lost more weight compared with subjects who did not receive lipoic acid.95 This translates into 900 mg of the biologically active R-lipoic acid.

Migraine prevention. Individuals with frequent or poorly controlled migraine attacks who consumed lipoic acid each day displayed a trend toward fewer migraines.96 These findings build on earlier research suggesting a role for lipoic acid in migraine prevention.97

Improving endothelial function. Impaired glucose tolerance contributes to endothelial function, an underlying cause of cardiovascular disease. When lipoic acid was administered to individuals with newly diagnosed impaired fasting glucose, endothelial function improved, as did a marker of oxidative stress.98

Benefits for polycystic ovary syndrome. Polycystic ovary syndrome (PC OS) is characterized by hormone imbalances, irregular or absent menstrual periods, and blood sugar and lipid abnormalities. Lean, non-diabetic women with PC OS who consumed 600 mg of alpha lipoic acid daily demonstrated improved insulin sensitivity, decreased triglycerides, and beneficial changes in low-density lipoprotein (LDL), and some experienced more regular menstrual periods.99

Relieving back pain. Individuals undergoing rehabilitation therapy for back pain caused by disc compression of nerves who consumed 600 mg of alpha lipoic acid and 360 mg of gamma-linolenic acid (GLA) daily experienced greater improvements in nerve pain, compared with patients undergoing rehabilitation alone.100

Preventing steroid-induced osteonecrosis. Corticosteroids such as prednisone threaten bone health and increase fracture risk by impairing blood flow to bone.101

 In an animal model, lipoic acid helped prevent steroid-induced osteonecrosis (bone death that increases fracture risk), possibly by reducing oxidative stress and/or by improving endothelial function.102

Decreasing leptin levels. Elevated levels of the fat-secreted hormone leptin are involved in the development of metabolic syndrome and diabetes. Lipoic acid administration to animals decreased circulating leptin and leptin expression in fat tissue.103 

Summary

Cells with mitochondria isolated from old animals degenerate far more rapidly than those with mitochondria from young animals, revealing the importance of healthy mitochondria to delay the aging process. When supplied with a nutrient regimen that includes lipoic acid, a profound regenerative effect is observed, including improved metabolic function and significant declines in oxidative stress.

Recent data reveal that lipoic acid specifically targets factors that contribute to mitochondrial aging, dysfunction, and cell death. Lipoic acid can prevent and even mitigate cardiovascular diseases, obesity, insulin resistance, and complications of diabetes. Lipoic acid protects against nerve and brain cell damage induced by aging and trauma.

New evidence suggests that lipoic acid may also have important cancer-preventive effects, even against some of the most difficult-to-treat malignancies.

http://www.prohealth.com/library/showarticle.cfm?libid=19361

LIQUID DETERGENTS PODS POSE RISK TO CHILDRENS EYE HEALTH

Liquid laundry and dishwasher detergent pods are an emerging source of chemical exposure in children. When squeezed or bitten into, these pods can burst and send detergent into the mouth, nose, and eyes. A new report published in the current issue of the Journal of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) cautions that these products should be kept away from children because the bursting detergent pods can cause significant corneal injury.

Detergent pods may offer a simpler way to do laundry, but they represent a source of potential danger when in the hands of a young child. Available in the European market for over a decade and first introduced to the American market in 2010, liquid detergent pods are brightly colored, which makes them attractive to young children who mistake them for toys.

Michael E. Gray, MD, and Constance E. West, MD, from the Abrahamson Pediatric Eye Institute at Cincinnati Children’s Hospital Medical Center, began tracking ocular injuries from detergent pods after noticing an increase in patients over the course of several months beginning in 2012. Ten children, all under 4 years of age, were treated for eye injuries stemming from burst detergent pods. Over the same time frame, 21 other children were seen in the emergency room for injuries caused by ingestion of the detergent contained in the pods.

For the children with eye injuries, two cases involved the child biting down on the pod, seven cases resulted from children squeezing the pod in their hands, and in the last case, the cause was unknown. All ten children with eye injuries presented with significantly bloodshot eyes, although no limbal ischemia or clinically significant conjunctival chemosis was found. Corneal abrasions were found in all of the cases, with defect sizes ranging from 3 mm in diameter to a nearly complete corneal epithelial defect. In addition, three children also had mild periorbital edema or erythema ipsilateral to the corneal abrasion.

During ophthalmologic examination, the ocular surface pH was measured and found to be neutral in all cases, but as study co-author Dr. Gray, Pediatric Ophthalmologist and Assistant Professor, Division of Pediatric Ophthalmology at Cincinnati Children’s and UC Department of Ophthalmology, points out, the pH levels among different brands can vary. “Alkaline injury should also be suspected in association with the ocular cases. However, reported pH from Material Safety Data Sheets (MSDS) of different brands of pods is variable. The pH of some brand name pods is close to neutral (6.8 – 7.6), whereas other brands are considerably alkaline (8.0 – 11.0).”

The report also explains that because these pods are designed to be concentrated, they often contain higher levels of surfactants than traditional detergent, making them more likely to cause injury when they are ingested or when the chemicals enter the eye.

In the study, all affected subjects were treated with irrigation and topical antibiotic ointment. The recovery period for the children averaged just under four days, and none of the patients experienced additional complications or relapse.

While makers of these detergent pods have made changes to packaging to try to keep children out, not all brands adhere to the same safety standards. “Manufacturers have taken steps to prevent such injuries, such as warning labels and container lid safety features,” states Dr. West, Pediatric Ophthalmologist and Associate Professor, Cincinnati Children’s and UC Department of Ophthalmology. “These safety features are not always present, however, particularly with off-brand or generic laundry pods that might be sold at discount stores.”

As convenient as detergent pods may be, families with young children need to take safety precautions. As Dr. Gray concludes, “This consecutive case series highlights the risk of ocular injuries from laundry detergent pods in the United States. Parents or caregivers must be aware of the potential for ocular injury from these pods and prevent access to these chemicals by young children.”

HUNTING DOWN HIDDEN DANGERS AND HEALTH BENEFITS OF URBAN FRUITS

Forgotten trees from long lost orchards and 20th-century city landscaping are being rediscovered in urban areas, and their fruits are proving not only largely free of urban pollutants, but more nutritious than their retail counterparts.

Scientists at Wellesley College have joined forces with the League of Urban Canners (LUrC), based in Cambridge/Somerville and greater Boston area, to collect and eventually analyze 166 samples of apples, peaches, cherries and other urban fruits and herbs, collected from remnants of historical farms, urban parkland, and residential properties. The efforts grew out of concern for a LUrC member who was found to have high levels of lead in their blood. Members of LUrC wanted to make sure that the urban fruits they were harvesting and processing were not harboring toxic metals.

"This is a story with a good ending: not much lead in these urban harvested fruit," said Wellesley geosciences and environmental studies professor Dan Brabander, who has previously studied lead exposure risk in urban gardens and in areas impacted by historical mining activities.

The LUrC study investigated the concentrations of lead in urban fruits when they were peeled and unpeeled as well as washed and unwashed. That was intended to distinguish whether the fruits were taking up lead internally or being contaminated by dry deposition from the air or from soil dust.

"We found there was no difference between these variables," said Ciaran Gallagher, an undergraduate researcher majoring in Environmental Chemistry at Wellesley College, who will be presenting the research on Monday, Nov. 2 at the annual meeting of the Geological Society of America in Baltimore. Gallagher will be co-presenting with geoscience undergraduates Hannah Oettgen and Disha Okhai.

The researchers also looked at arsenic in the fruits, because in older orchards farmers commonly used lead arsenate as a pesticide. "So we are keeping an eye on places where this pesticide might have been historically applied." To date the researchers have not found evidence of use in the LUrC samples.

For the lead analysis, fourteen urban and eight commercial fruit samples were dried in a fruit dehydrator to mimic methods used by LUrC members in their home kitchens, and analyzed for trace elements. Gallagher and her colleagues found that the lead concentrations in urban apples ranged from 0.5 to 1.2 ug/g (dry weight basis). They then looked at the estimated consumption of the fruit to model how much lead the urban fruit eaters were being exposed to. The resulting finding suggest that eating urban fruit is not a significant source of lead exposure, when compared to the EPA regulated benchmark for lead in drinking water.

In addition to lead and arsenic, they also looked into the nutritional value of urban fruit. They compared micronutrient levels with those in commercially grown fruits and found that calcium concentrations in urban apples and peaches are more than 2.5 times those in their commercial counterparts. Concentrations of calcium and iron were higher in urban fruits for every fruit type tested, and manganese, zinc, magnesium, and potassium concentrations were higher in certain urban fruit types. On average, urban fruit contains a wider range of micronutrients than its commercial counterparts.

"When they grow in a commercial setting the soils can become quite impoverished," Brabander explained. "In the urban setting where the trees sampled tend to be older perhaps they are able to shuttle micronutrients from a wider and more diverse range of horizons." Planned future soil coring work into urban soils will try to figure out the mechanism of nutrient transfer in this unique setting.

"That's not to say that all urban produce is safe to eat, however, because local conditions vary and antique fruit trees are found in some very unexpected -- and sometimes very polluted places, like along major roadways," said Brabander.

"By working with the Wellesley researchers the LUrC members are able to get a much broader, clearer look at the health benefits and any potential health threats from urban fruit than they ever could have if they had randomly spot checked fruits," said Brabander.

"The citizen-science component to both study initiation and sampling is so central to how this project has been conceived and executed to date," said Gallagher. "Simply stated, without the League of Urban Canners, this project would not have been possible."

Brabander concludes, "The intersection of urban geohealth and citizen science is an emerging research paradigm for prioritizing projects that have immediate implications for designing best practices that promote a wide expression of safe and sustainable urban agriculture."

DIARY IS GOOD FOR YOUR METABOLIC HEALTH

Dairy is considered part of a healthy diet and dietary guidelines recommend the daily consumption of 2-4 portions of milk-based products such as milk, yogurt, cheese, cream and butter

It's well known that dairy products contain calcium and minerals good for bones, but new research has shown that dairy consumption may also have beneficial effects on metabolic health and can reduce risk of metabolic diseases such as obesity and type 2 diabetes.

Curious about these impacts, researchers from CHU de Québec Research Center and Laval University studied the dairy-eating habits of healthy French-Canadians' and monitored how dairy consumption may have an effect on their overall metabolic health. They published their findings today in the journalApplied Physiology, Nutrition, and Metabolism.

The aim of this study was to determine associations between dairy intake and specific metabolic risk factors, including anthropometric status, plasma glucose, plasma lipid profile, inflammatory markers and blood pressure, in a healthy population.

A total of 254 participants from the greater Quebec City metropolitan area were recruited; 233 participants (105 men and 128 women) met all the eligibility criteria for the study ‒ meaning subjects had healthy metabolic profiles.

The study showed that the average individual consumed 2.5 ± 1.4 portions of dairy per day. However, nearly 45% of the population in this study did not meet Canada's Food Guide recommendations of at least 2 portions of dairy products a day. These findings are supported by recent Canadian surveys that highlighted an under consumption of dairy products by Canadians.

Data suggest that trans-palmitoleic acid found in plasma may be potentially used as a biomarker to evaluate dairy consumption. Trans-palmitoleic acid, is naturally present in milk, cheese, yogurt, butter, and meat fat but cannot be synthetized by the body. This fatty acid has been recently shown to have health-promoting effects. In this study, that trans-palmitoleic acid level was related to lower blood pressure in men and women, and to lower body weight in men.

Dairy intake is associated with lower blood glucose and blood pressure in the population studied, though no causal relationships can be made due to the cross-sectional design. This study adds to a growing body of literature demonstrating a lack of detrimental health effects with higher dairy intake.

Dr. Iwona Rudkowska, a research scientist at the Endocrinology and Nephrology Department, at the CHU de Québec Research Center and assistant professor at Laval University , says "additional well-designed intervention studies are needed to ascertain the effects of increased dairy consumption on metabolic health in healthy and in metabolically deteriorated populations."

NATURAL LIGHT IN OFFICE BOOSTS HEALTH

Office workers with more light exposure at the office had longer sleep duration, better sleep quality, more physical activity and better quality of life compared to office workers with less light exposure in the workplace, reports a new study from Northwestern Medicine and the University of Illinois at Urbana-Champaign.

The study highlights the importance of exposure to natural light to employee health and the priority architectural designs of office environments should place on natural daylight exposure for workers, the study authors said.

Employees with windows in the workplace received 173 percent more white light exposure during work hours and slept an average of 46 minutes more per night than employees who did not have the natural light exposure in the workplace. There also was a trend for workers in offices with windows to have more physical activity than those without windows.

Workers without windows reported poorer scores than their counterparts on quality of life measures related to physical problems and vitality, as well as poorer outcomes on measures of overall sleep quality and sleep disturbances.

The study was reported in the Journal of Clinical Sleep Medicine in June.

"There is increasing evidence that exposure to light, during the day, particularly in the morning, is beneficial to your health via its effects on mood, alertness and metabolism," said senior study author Phyllis Zee, M.D., a Northwestern Medicine neurologist and sleep specialist. "Workers are a group at risk because they are typically indoors often without access to natural or even artificial bright light for the entire day. The study results confirm that light during the natural daylight hours has powerful effects on health."

Zee is the Benjamin and Virginia T. Boshes Professor of Neurology at Northwestern University Feinberg School of Medicine and director of the Sleep Disorders Center at Northwestern Memorial Hospital.

"Architects need to be aware of the importance of natural light not only in terms of their potential energy savings but also in terms of affecting occupants' health," said co-lead author Mohamed Boubekri, an associate professor of architecture at the University of Illinois at Urbana-Champaign.

A simple design solution to augment daylight penetration in office buildings would be to make sure the workstations are within 20 to 25 feet of the peripheral walls containing the windows, noted Boubekri. "Daylight from side windows almost vanishes after 20 to 25 feet from the windows," he said.

The study group included 49 day-shift office workers; 27 in windowless workplaces and 22 in workplaces with windows. Health-related quality of life and sleep quality were measured with a self-reported form and sleep quality was evaluated with the Pittsburgh Sleep Quality Index (PSQI). Light exposure, activity and sleep were measured by actigraphy in a representative subset of 21 participants; 10 in windowless workplaces and 11 in workplaces with windows.

Actigraphy is a single device worn on the wrist that gives measures of light exposure as well as activity and sleep. This is an ambulatory physiological data logger that records motion and light illuminance. The motion was used to determine activity levels during waking time and to calculate sleep time. The light luminance was used for measures of light exposure during the workday period.

"Light is the most important synchronizing agent for the brain and body," said Ivy Cheung, co-lead author and Ph.D. candidate in neuroscience in Zee's lab at Northwestern. "Proper synchronization of your internal biological rhythms with the earth's daily rotation has been shown to be essential for health."

Also, people who get more light during the day may sleep better at night, which can also help improve health, Zee noted.

Mental Health Problems From Opioids

Today's post from the ever-reliable pain-topics.org (see link below) discusses some of the potential effects of long term (and recreational) opioid use. Now many people living with neuropathy have no choice; they have to take opioids long term, to help control the pain but it is always worth knowing what they might do to you. The article looks at recent studies and assesses their accuracy. If you're concerned, discuss the issues with your prescribing doctor - he or she should be carefully monitoring you anyway, to reduce the risk of addiction and the question underlying this is whether long term opioid use actually makes us misusers (however unintentionally).

 

Pain, Depression, Anxiety in Rx-Opioid Misusers

Posted bySB. Leavitt, MA, PhD Wednesday, November 21, 2012
 Nonmedical prescription opioid use has become a substantial public health concern in North America and most other countries. Limited epidemiological data suggest an association between such Rx-opioid misuse and mental health or pain symptoms in different populations, although these correlations have not been systematically assessed, which was the purpose of a new study.

A team of Canadian researchers conducted a thorough systematic search, review, and meta-analysis to examine mental health problem symptoms and pain in general population samples reporting nonmedical Rx-opioid use [Fischer et al. 2012]. Overall, 9 qualifying epidemiological studies were identified and included in the review; 5 contributed data on the prevalence of mental health issues and 4 had data on the prevalence of pain in the target population. Most studies (8) were based on populations in the United States and the other one was centered in Ontario, Canada.

Writing in the November 2012 edition of the Journal of Pain, the researchers report that the pooled prevalence of any mental health symptoms in general population samples reporting nonmedical Rx-opioid use was 32% (95% confidence interval [CI], 24–40). Specifically, the pooled prevalence of depression was 17% (95% CI, 14–19) and the prevalence of anxiety was 16% (95% CI, 1–30). The pooled prevalence of pain in the population of interest was found to be 48% (95% CI, 37–59).

The researchers conclude that their study found evidence for disproportionately high prevalence levels of mental health problems (anxiety and depression) and pain among nonmedical Rx-opioid users in the general population. While causality cannot be established by such data, these comorbidities may influence Rx-opioid misuse and should be considered in preventive and treatment interventions.

COMMENTARY: Curiously, Fischer and colleagues do not even mention in their report the prevalence of nonmedical Rx-opioid use found in the 9 epidemiological studies they examined. However, they do include raw data in a table of study characteristics and extrapolating from those data we calculated the prevalence of Rx-opioid misuse as ranging from 1.8% to 12% (mean 5.6%; 95% CI, 3-8.2).

Judging whether 5.6% on average is an extraordinarily high and intolerable prevalence of Rx-opioid misuse requires further consideration of all factors that might be contributing to or account for the alleged aberrant behaviors. However, the wide prevalence range alone suggests that either the measurement of Rx-opioid misuse across studies was inconsistent or the populations examined were significantly different from each other.

The researchers defined “nonmedical use” or “misuse” as the use of Rx-opioids without being medically sanctioned, which may include, but is not limited to, the consumption of these medications for purposes other than prescribed, or taking nonprescribed, diverted, or illicitly obtained Rx-opioids. However, considering the high prevalence of pain, one must question how much of the putative “nonmedical use” actually was for medical purposes (pain relief), which raises questions about access to healthcare and/or the undertreatment of pain via legitimate healthcare channels.

Prevalence levels of anxiety and depression also were considered to be quite high by the researchers, but it is not known if these factors influenced Rx-opioid misuse, if they resulted from such misbehavior, or if they were largely related to unrelieved pain. These are important concerns worthy of further investigation.

Most, but not all, of the included epidemiological studies were of significant size; however, since all of them were focused in North America (primarily the U.S.), the results cannot be generalized to other populations. It is somewhat surprising that these issues have not been investigated by large-scale epidemiological surveys in the general populations of other countries.

There were some critical limitations of this review and meta-analysis by Fischer et al. that are noteworthy and question its validity. Concepts of systematic reviews and meta-analyses were discussed in a recent UPDATE here, and here are some of the concerns in the present study:
There was a significantly high degree of heterogeneity across all of the studies included in meta-analyses, even though differences between many of the studies were small and their confidence intervals were very narrow. For the 4 major analyses — any mental health symptoms, depression, anxiety, and pain — I² values (suggesting the amount of heterogeneity) were 97.3%, 94.8%, 99.8%, and 95.5%, respectively.

Also, there were extremely few studies for each of the 4 meta-analyses regarding factors of interest: 3 studies for any mental health symptoms, 2 each for depression and anxiety, and 4 for pain.

Appropriately, the researchers used random-effects modeling in the pooling of data; however, with so few studies they could not do any sensitivity analyses to determine sources of bias and reliability of results.

In sum, there were so many fundamental differences between studies — eg, population composition, definitions, assessment measures, etc. — influencing heterogeneity, and so few studies for each analysis, that it is questionable whether conducting meta-analyses of the data was appropriate. Perhaps, there have been other studies on these issues that were undiscovered by the researchers’ systematic review, although it did seem to be quite thorough. In any case, there is clearly a need for additional and more consistent research before reliable and valid conclusions can be reached on this subject of factors associated with nonmedical Rx-opioid use.

REFERENCE: Fischer B, Lusted A, Roerecke M, et al. The Prevalence of Mental Health and Pain Symptoms in General Population Samples Reporting Nonmedical Use of Prescription Opioids: A Systematic Review and Meta-Analysis. J Pain. 2012(Nov);13(11):1029-1044 [abstract here].

http://updates.pain-topics.org/2012/11/pain-depression-anxiety-in-rx-opioid.html