In the Journals

Mai – June 2019

High-amylose wheat lowers the postprandial glycemic response to bread in healthy adults: A randomized controlled crossover trial.
The Journal of Nutrition

The moderating effect of childhood disadvantage on the associations between smoking and occupational exposure and lung function: A cross sectional analysis of the UK Household Longitudinal Study (UKHLS)
BMC Public Health

Dementia awareness and risk perception in middle-aged and older individuals: Baseline results of the MijnBreincoach survey on the association between lifestyle and brain health
BMC Public Health

Telomere length and frailty in older adults: A systematic review and meta-analysis
Ageing Research Reviews

A randomized placebo-controlled trial of omega-3 and sertraline in depressed patients with or at risk for coronary heart disease
The Journal of Clinical Psychiatry

Serum 25-hydroxyvitamin D levels and depression in older adults: A dose-response meta-analysis of prospective cohort studies
The American Journal of Geriatric Psychiatry

U-shaped association of vigorous physical activity with risk of metabolic syndrome in men with low lean mass, and no interaction of physical activity and serum 25-hydroxyvitamin D with metabolic syndrome risk
Internal Medicine Journal

Natural history of prediabetes in older adults from a population-based longitudinal study
Journal of Internal Medicine

β-blockers and risk of all-cause mortality in patients with chronic heart failure and atrial fibrillation: A meta-analysis
BMC Cardiovascular Disorders

Individualized decision aid for diverse women with lupus nephritis (IDEA-WON): A randomized controlled trial
PLoS Medicine

Your resting heart rate (RHR) – a fitness indicator

What does your resting heart rate (RHR) tell you?

The resting heart rate gives you a pretty good clue on how ‘fit’ you are. There is a direct link between a high RHR and increased risk of dying from cardiovascular events according to some research.

A study from 2015 found that a higher resting heart rate is associated with a higher risk of dying from a cardiovascular disease, even in people who do not present with the usual risk factors.

It was found that when comparing with a resting heart rate of 45 beats per minute (bpm), the rate for All-cause mortality risk increased linearly as resting heart rate went up. The most significant increase in mortality risk was however at a resting rate of 90 bpm or more.

Further analysis showed a mortality excess of 30-50% for every increase of 20 beats per minute at rest.

What is a reasonable resting heart rate?

A regular heart rate for adults ranges from 60 to 100 bpm at rest.

In general, a slower beating heart at rest is a sign of a more efficient heart function and a fitter cardiovascular condition. A marathon runner, for example, could have a heart rate as low as 40 beats a minute.

If your heart rate is continuously above 100 bpm, consult your doctor. He/she might want to do some tests to find the underlying cause.

How do I measure my resting heart rate?

Do it first thing in the morning, ideally before getting up. Find the pulse on the thumb-side of your wrist, and count how many times it beats within 60 seconds, this gives you the beats per minute figure. You can also check it by counting the pulse in your neck.

Several factors can influence heart rate:
  • Activity levels
  • Air temperature
  • Standing up /Lying down
  • Emotions
  • Body size/volume
  • Medication

How can I improve my resting heart rate?

First of all, start with regular aerobic exercise programs such as cycling, running, walking, swimming or hiking.

It has also been found that a good night sleep can help improve your heart rate. The healthy cardiovascular friendly diet can also contribute to a healthier heartbeat. Try and reduce stress, both physical and emotional and if you suffer from anxiety, try some relaxation therapies. Smoking as well as being overweight also increased your resting heart rate – you know what to do.

Why do we get cold sores?

Where do cold sores come from?

Although cold sores appear with your cold, they are not caused by the cold virus but an entirely different one, called Herpes Simplex Virus (HSV); to be more precise HSV-1. Many of us carry this virus, sometimes without even knowing and women are slightly more prone to this infection. Over 50 % of the population in the Western World are infected with HSV-1, in some regions of Europe even up to 80%.

Once infected, this virus is likely to stay with you the entire life. It tends to sleep in the nucleus of sensory nerve cells without causing any harm, now and then it may, however, wake up and trigger the typical blisters on the skin from where this nerve conducts sensation. This skin rash typically affects the lips and skin around mouth and nose. It is not entirely known what causes the virus to become active; fever can be a trigger hence the association to the cold and the name “fever blisters”; ultraviolet light is another cause, and both physical and emotional stress may also cause a reactivation. These blisters often start with a tingling and then become painful, they will crust over and heal without leaving a scar. They can last up to 10 days.

How did I get it in the first place?

Infection happens when you get in contact with the virus, and it can enter via breaks in your skin or mucosa. An intact skin does not let the virus though and acts as a perfect barrier. The virus itself can be found in saliva, the affected skin and even tears. Note that it is mostly transmitted from people with an activated HSV, but it can also be given to you by people who do not have any symptoms.
It is recommended that people who are experiencing a cold sore should ensure that their affected skin from touching other people or objects that could act as a mode of transfer and to refrain from exchanging saliva.

What about HSV-2

When we hear Herpes, we associated this word mostly with a sexually transmitted disease. Here HSV-2 comes into play. With the same mode of action like his upper body fellow, this virus affects the skin of the genital areas and is transmitted during sexual intercourse. Traditionally 80% of genital herpes is caused by HSV-2 and 20% by HSV-1. The incidence of HSV-1 infection in the genital area has recently increased. Especially in adolescents, this ratio has moved up to 30-40%, which is explained by increased oro-genital contact.

How to treat sold sores

Cream which contains the antiviral Acyclovir, especially if applied early in the development of cold sores, can help to reduce the duration. In other words, the pain period will be shorter, and the crusting over and healing process will happen faster. Other than that, lip balm against dry lips which often go hand in hand can give some relief.

HIV Preexposure Prophylaxis (PrEP)

Antiretroviral Medication as Prophylaxis


Preexposure Prophylaxis (PrEP) with antiretroviral drugs is a concept that is gaining increased recognition as a method of primary prevention for people with a risk of becoming infected with the Human Immunodeficiency Virus. We know what works best in the prevention of HIV but human nature, mainly when guided by their sexual drive, will not always follow the best advice – a fact that even the Catholic church must have realised by now.

Prophylaxis PreP

Recent clinical trials show promising results for the use of PrEP when delivered as part of a comprehensive set of prevention services for individuals at high risk for HIV acquisition. This approach works best when accompanied by regular monitoring of HIV status, side effects, adherence and risk behaviours.

It is biologically plausible that antiviral medication could affect the acquisition of HIV especially when the prophylactic drug has a long half-life, achieves a high concentration in monocytes, macrophages and genital secretions, has a high barrier to genetic resistance and is safe and inexpensive.

Tenofovir seems to tick all these boxes and is the most widely studied substance either in combination with Emtricitabine (Truvada) or on its own.
The danger of PrEP facilitating resistance and thus spreading a drug-resistant virus is a possibility, especially if this method becomes widespread.
A possibility exists that offering PrEP could encourage increased high-risk sexual activity. However, no evidence of increased high-risk sexual activity was demonstrated in the few observational studies that addressed this.
High-risk individuals include those who have a partner known to be HIV infected or who are sexually active within a high prevalence area. In the gay community, the use of PrEP is becoming a regular feature especially in men participating in anal intercourse.

Aspirin in colorectal cancer

The timeline of Acetylsalicylic Acid

Aspirin (Acetylsalicylic Acid), who started its life as an ordinary headache tablet turned out to be an effective blood thinner and established itself on the cardiology shelves of our pharmacies. If the outcome of recent studies is to be confirmed, Acetylsalicylic Acid will soon be prescribed by oncologists.

Encouraging outcomes

Evidence is accumulating that Aspirin has a beneficial effect in the prevention of colorectal cancer. Some hypothesis suggests that Aspirin might play a role in the T cell-mediated anti-tumour activity.

While some public health organisations have started to give out recommendations to use this drug as preventative measures, there is still no consensus on how to involve this drug in a context with colorectal cancer.

Questions that need to be addressed:

  • Should it be used as a primary or secondary prevention?
  • Which age group should be targeted?
  • Which risk group will benefit the most?

About 5% of patients with colorectal cancer have a rare genotype that does not respond to Acetylsalicylic Acid, in fact, these patients have an increased risk of developing CRC when using Aspirin. Should each patient be checked for this rare genotype before a recommendation can be made?

What will the future bring?

I believe that the near future and further studies will provide some answers soon. In the meantime, I remain in awe of that little headache pill and how new benefits of Aspirin are still being discovered today. The notion of Aspirin as a wonder drug is becoming more than an advertising slogan.

Ketamine to treat depression

There is a new light shining into the corner of treatment-resistant depression: in the form of a drug called Ketamine. This substance, not new to the medical world, is thought to have a rapid effect in clinical depression and could become a life-saver for people with severe suicidal depression.

The drug has hallucinogenic and pain relieving properties and is well known to anaesthetists for its use during the general anaesthetic. Commonly known as “horse tranquillizer”, due to its use in veterinary medicine, it is also a Saturday night drug for clubbers who appreciate the ‘out of body experience’ in its recreational use. Ketamine act on a receptor in the brain called NMDA. The exact mechanism of action related to major depressive disorder is not known yet. Although the effect of Ketamine kicks in much faster than conventional antidepressants, which take up to 3 weeks to show a mood enhancement, initial doses fade quickly and a regular treatment plan is needed to gain a long-term effect.

A substance called Esketamine, in the form of a nasal spray is currently going through phase III clinical trials and, if all goes well, could soon become a reality and a possible alternative to last resort Electroconvulsive therapy (ECT). Provided that side effects and long-term risks are causing any concerns, we could at long last be able to have an effective first aid treatment for major depression that acts safely and quickly.

China to accelerate drug approval

According to recent news China is reporting that it intends to accelerate the approval process for new medication by accepting the data from international clinical trials. This is obviously great news for many patients in need of new generation drugs such as immunotherapy.

By adopting this more open approach, the world’s second-largest drug market is providing exciting news to the international Pharma industry. In the long run, however, this move will reassure the steady drive of many R&D departments around the world and be a springboard for China to become a serious player in the development of new medication.

No Benefits of low-dose Oxygen during Acute Stroke

To give or not to give Oxygen

In case of an emergency and if in any doubt, give the patient oxygen. This first aid manoeuvre is also part of a knee-jerk when attending to an acute cerebrovascular accident. To protect brain tissue from hypoxia with continuous oxygen during the acute phase of a cerebrovascular accident seems to be a good idea. That was the motivation behind the SOS study in the UK, an extensive randomised control study conducted in acute stroke units all over the country for ten years. Most doctors who worked on an acute stroke unit over the last 10 years probably remember this study which managed to recruit over 8000 patients.

The Outcomes of the SOS study

The results are out and show that there is no benefit in giving every stroke patient routine low dose Oxygen (2 to 3 L/min), either continuously or at night time, in the first few days after the event.

A similar outcome was recently seen in a large US study, where benefits of routine oxygen administration in patients with an acute myocardial infarct failed to materialise.

Providing that oxygen saturations are continuously monitored, less routine Oxygen during an acute event can only be a good thing. For the simple reason that it will alert healthcare workers of an occurring acute hypoxia more quickly and could provide life-saving time for diagnosis and treatment thereof.

Winter is coming – the flu too

When again the earth’s northern axis is tilting away from the sun and the days are getting shorter, we know that winter is not far. With the cold season come runny noses, coughs and sneezes and the flu.

What is flu?

Flu is a communicable disease caused by the Influenza virus that spreads via direct contact and airborne droplets. The virus has two main subtypes, A and B. Type A causes more severe symptoms and is responsible for pandemics. B is less virulent, it just lingering around, mainly towards the end of winter.

Unlike a cold, flu symptoms come on quickly including fever and aching muscles. It knocks the toughest out; too unwell to continue any regular activities, you need to rest in bed. Particularly in the frail and elderly, it can cause severe illness or even death.

Flu Virus

Flu symptoms include:

• sudden fever
• dry cough
• a sore throat, runny or blocked nose
• headache
• tiredness & weakness
• chills
• aching muscles, limbs or joints
• diarrhoea or abdominal pain
• nausea and vomiting
• difficulty sleeping
• loss of appetite

The flu vaccine

Every year, before the flu season, healthcare providers offer vaccination against this illness, primarily for people who are most at risk. The vaccine consists of protection against a mix of viruses from both subtypes. Scientists at the WHO figure out each year what the likely pathological strains will look like and release a recommendation for a vaccine for the Northern and Southern Hemisphere. Thie vaccine for the flu 2017/2018 in Europe and the US will be the same as the one used in Australia.

The vaccine is undoubtedly the best measure to protect from the flu. Even if it does not match the current virus entirely, it can provide partial protection.

Prediction for 2017/2018

The flu season typically starts in the southern hemisphere, while we are busy sunbathing, it finds the first casualties in Australia and then moves slowly northbound to reach us in November/December. It is more often than not the same strain of the virus.
This year Australia has suffered a severe flu epidemic caused by Influenza A(H3N2), infecting 2.5 times more people than the previous year and with double the fatalities.

In our flu season, we see the same features as the southern hemisphere, which would lead us to expect a higher than average epidemic in Europe and the USA. Unpredictability, however, is typical for viral outbreaks. But if Australia’s large number of flu cases is a reflection on the efficiency of this year’s flu vaccine, our hospitals better brace themselves and get some winter wards ready.
How to prevent the flu?

When you got the flu

If you get the flu and you’re an active, healthy adult you are going to feel too unwell for up to seven days, and you are unable to continue your usual activities; there is usually no need to visit a general practitioner.

Consider visiting your doctor if:

• aged 65 years or over
• during pregnancy
• long-term medical condition
• weakened immune system
• unusual symptoms like chest pain, shortness of breath or start coughing up blood

also if symptoms do not improve after a week or if they are getting worse


Keep up to date with the current flu situation:



Influenza virus

Pembrolizumab – immunotherapy for gastric cancer

After encouraging results in treating melanoma, lung and kidney, immunotherapy enters the realm of gastric malignancies.

The FDA has approved Pembrolizumab, (Keytruda) by Merk, for use as a third-line treatment for locally advanced or metastatic adenocarcinoma of the stomach and gastro-oesophageal junction that express programmed death receptor-ligand 1 (PD-L1).

Immunotherapy tries to elicit the mechanisms how cancer cells can hide from the immune system. It aims to help our immune system in recognising a tumour and facilitating the natural immune response that is believed to be more efficient than any drug could ever be.

What is PD-L1

PD-L1 is a molecule that can be found on cancer cells, it binds with PD-1, a receptor present on T cells and therefore plays a role in immune regulation. When the two molecules bind they transmit an inhibitory signal that reduces the proliferation of T cells or even causes their death; in other words, PD-L1 tells the immune system not to bother attacking it.

How does Pembrolizumab work?

The concept of PD-L1 inhibitors is to block this molecule and thus prevent it from binding to the T cells. In other words, blocking the inhibitory effect in order achieve activation of the immune response.

The results so far

Taking into account that this is treating a third-line gastric cancer, the figures for 6- and 12-month duration of response are not mind blowing but show some promising features. Larger numbers will help to get a clearer picture in the future.

Immunotherapy in solid tumours is always going to be harder to achieve, especially in the advanced stages. It will be interesting to see what results can be reached when using PD-L1 inhibitors in combination with other treatments and also how it will fare as an early treatment.