Exercise Reverses Some Effects of Fatty Meals

 

Vitamin C and Blood Pressure

“A critical weekly review of important new research findings for health-conscious readers…”

 

By, Robert A. Wascher, MD, FACS

 
Last Updated:  01/11/2009

The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author.  Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.

 

EXERCISE REVERSES SOME EFFECTS OF FATTY MEALS

The cells lining the interior of our bodies’ blood vessels do more than just provide a smooth surface over which blood cells can glide without forming dangerous blood clots.  These vascular endothelial cells also regulate the tone and diameter of our blood vessels, including the critical vessels that supply blood to the heart, brain, kidneys, and other vital organs.  Complex biochemical feedback loops control the synthesis of nitric oxide, and other chemicals, from within the vascular endothelial cells, enabling blood vessels to dilate up when the organs that they serve require additional blood flow.  When this “demand-related” dilation of blood vessels is impaired, vital organs, including the heart, can become starved of life-sustaining oxygen due to reduced blood flow (also known as ischemia).  In addition to potential ischemia, other adverse physiological effects are also associated with inadequate blood vessel dilation, or vasodilation.  These adverse factors include an increase in vascular resistance that can strain the heart, an increased risk of potentially dangerous clots within blood vessels, and increased inflammatory activity that can accelerate atherosclerosis (narrowing of the arteries) and organ damage.

 

There are multiple known risk factors for decreased vascular endothelial cell function, including elevated cholesterol levels, high blood pressure, obesity, diabetes, smoking, atherosclerosis, and increasing age.  Interestingly, merely eating a fatty meal can rapidly induce vascular endothelial cell dysfunction, leading to a decrease in nitric oxide synthesis by these cells.  When this happens, arteries become stiff, and can no longer dilate up to provide increased blood flow when required.  When coronary arteries are already narrowed and diseased by atherosclerosis, a sudden loss of nitric oxide from endothelial cells can result in a critical lack of blood supply to the heart’s muscle, causing myocardial ischemia, as well as the formation of blood clots within severely narrowed coronary arteries.  This, in turn, can result in a complete obstruction of the coronary arteries, causing a heart attack (myocardial infarction).  Similar events can occur in the brain, causing a stroke.

 

It is known that vigorous exercise can improve vascular endothelial cell function, although the precise mechanisms at work are not entirely understood at this time.   However, just as regular and vigorous exercise helps to keep our bodies looking and feeling young, overall, so does exercise also appear to keep our blood vessels young, supple, and able to dilate up to provide increased blood flow when required.  Now, a newly published study in the Journal of the American College of Cardiology looks at the ability of exercise to prevent vascular endothelial dysfunction following a fatty meal.

 

In this study, 8 healthy adult males were fed high-fat meals.  All patient volunteers underwent vascular testing before and after consuming the high fat meals in order to assess the level of endothelial cell dysfunction in the artery that supplies the arm.  The experiment was varied such that each high-fat meal was preceded by either a 16 to 18 hour period of rest, a similar period of moderate-intensity exercise, or by a similar period of high-intensity exercise.  The ability of the brachial artery to dilate up under conditions requiring increased blood flow was then measured under each of these three experimental conditions.

 

Following consumption of a high-fat meal, the brachial arteries of the men who had rested before eating narrowed, on average, by about 10 percent from their pre-meal baseline diameter, confirming the onset of significant endothelial cell and arterial dysfunction.   The men who engaged in moderate-intensity exercise prior to their super-sized meals also experienced a 10 percent reduction in the diameter of their brachial arteries after consuming their high-fat meals, just like the men who rested before they ate.  However, even these moderate levels of exercise did restore some (but not all) of their arteries’ ability to dilate in response to increased blood flow requirements, whereas there was no return of this flow-mediated vasodilation in the arteries of the men who had rested prior to eating.  Among the men who engaged in vigorous, high-intensity exercise prior to chowing down, however, arterial dilation in response to increased blood flow was preserved even after a high-fat meal.  This protective effect of high-intensity exercise on vascular endothelial function following a high-fat meal occurred despite laboratory evidence of increased fat and cholesterol levels in the blood of these same men after eating.

 

While I am certainly not suggesting that it is safe to gorge on high-fat foods as long as you exercise like a maniac before you eat, this clinical study nonetheless suggests that at least one adverse cardiovascular effect acutely associated with eating a fatty meal can be substantially prevented with exercise, but only when that exercise is performed before eating, and at a very high intensity level.  On the other hand, this research study cannot provide any reasonable assurance that all of the other adverse and life-threatening health effects of high-fat diets (including cancer) can be prevented by exercising before meals, even if you exercise like crazy!

 

VITAMIN C AND BLOOD PRESSURE

 

The past few years have not been very kind to antioxidant vitamins like Vitamin C, Vitamin E, and Vitamin A and its derivatives.  Large-scale, high-powered prospective clinical trials have recently dashed prior hopes that these vitamins can significantly reduce the risk of cancer or cardiovascular disease.  Despite intriguing results from earlier and much lower powered research studies, we simply have not been able to show that any of these potential health benefits are associated with antioxidant vitamin supplements in humans.  However, a new clinical research study in the Nutrition Journal suggests that there may still be some potential long-term cardiovascular health benefit from high Vitamin C levels in the blood.

 

High blood pressure is generally defined as a systolic blood pressure (the “top number”) greater than or equal to 140 mm Hg, or/and a diastolic blood pressure (the “bottom number”) greater than or equal to 90 mm Hg.  As we age, our blood pressure tends to gradually rise, and by the time we reach our 60s, the majority of us will have elevated blood pressure.  Hypertension is known as “the silent killer” for good reason, as it can cause gradual, asymptomatic, and irreversible damage to the body’s vital organs, including the heart, brain, and kidneys, if left untreated.

 

More than 240 African-American and Caucasian women participating in a large prospective study (the National Heart, Lung and Blood Institute Growth and Health Study) were evaluated in this smaller study.  All of these women were between 18 and 21 years of age when they enrolled in this large public health study.  During their 10th year of participation in this ongoing clinical study, blood levels of Vitamin C were measured in all of these women.  Blood pressure readings during the 9th and 10th years of participation were then analyzed as a function of Vitamin C levels in the blood of these 242 patient volunteers.  These patient volunteers were then divided into 4 groups, based upon the level of Vitamin C in their blood. 

 

The women in the group with the highest blood levels of Vitamin C had, on average, significantly lower systolic and diastolic blood pressure readings when compared to the women in the group with the lowest Vitamin C levels, even after adjusting for differences between the two groups of women in terms of other hypertension risk factors like race, obesity, dietary intake of fat and salt, and education levels.  The average systolic blood pressure among the women with the highest levels of Vitamin C in their blood was almost 5 mm Hg lower than the systolic blood pressure among the women with low Vitamin C levels.  Likewise, the average diastolic blood pressure reading among the women with highest Vitamin C levels was 6 mm Hg lower than what was observed among the women with very low Vitamin C levels in their blood. 

 

When blood pressure readings in the 10th year of this study were compared with the blood pressure results from the previous year, higher Vitamin C levels also appeared to be associated with a smaller annual increase in blood pressure when compared with very low Vitamin C levels. 

 

Thus, in this prospective clinical research study, high levels of Vitamin C in the blood appeared to be linked with, on average, lower blood pressure readings and with significantly less increase in blood pressure readings over a period of one year.

 

While the results of this cohort study are very intriguing there are, as always, a few caveats that must be mentioned.  First of all, this study did not link dietary Vitamin C intake with Vitamin C levels in the blood, so it is not possible to know, from this study, if a diet rich in vitamin C (which is rapidly excreted from the body following ingestion) resulted in the higher blood levels of this vitamin that were observed, or if there are other factors, including genetic factors, that determine a person’s average Vitamin C levels in the blood.  Similarly, if genetic factors are primarily responsible for the level of Vitamin C in the blood, these same genetic factors could also be affecting blood pressure independent of any direct action by Vitamin C.  Also, while this study of young women strongly suggests that high levels of Vitamin C in the blood may decrease the natural rise in blood pressure that occurs with aging, it cannot yet tell us if these favorable changes in blood pressure, presumably due to Vitamin C, will be sustained as these women grow older.  This study also cannot tell us whether or not, in the long run, the apparently favorable effects of Vitamin C on blood pressure will actually lead to any clinically significant improvements in health, either.

 

Given the recent drumbeat of dismal news regarding the antioxidant vitamins and other related dietary supplements, this small study does offer some hope that Vitamin C might still be associated with potential health benefits beyond its primary role in the synthesis of collagen (a critical structural protein found throughout the body).  However, it will take many more years before we know whether or not Vitamin C supplementation can truly reduce the inexorable rise in blood pressure that occurs with aging, and if so, whether or not this effect has any clinically meaningful impact on health.    

Dr. Wascher is an oncologic surgeon, professor of surgery, widely published author, and the Director of Surgical Oncology for the Kaiser Permanente healthcare system in Orange County, California

rwascher@doctorwascher.net

 

Dr. Wascher’s Biography

Links to Other Health & Wellness Sites

http://doctorwascher.com

Copyright 2009.  

Robert A. Wascher, MD, FACS.  

All rights reserved.

 

 

Dr. Wascher’s Archives:

1-4-2009:  Secondhand Smoke & Heart Attack Risk; Poor Physical Fitness During Childhood & Heart Disease Risk During Adulthood

12-28-2008:  Stress & Your Risk of Heart Attack; Vitamin D & the Prevention of Colon & Rectal Polyps

12-21-2008:  Breast Cancer Incidence & Hormone Replacement Therapy; Circumcision & the Risk of HPV & HIV Infection

12-14-2008:  Vitamin E, Vitamin C and Selenium Do Not Prevent Cancer;  Postscript: A Possible Cure for Down’s Syndrome

12-7-2008:  Generic vs. Brand-Name Drugs, Stress & Breast Cancer Survival

11-30-2008:    A Possible Cure for Down’s Syndrome?; Smoking & Cognitive Decline; Calcium & Vitamin D & Breast Cancer Risk

11-23-2008:  Breast Cancer & Fish Oil; Lymphedema after Breast Cancer Treatment; Vasectomy & Prostate Cancer Risk

11-16-2008:  Vitamin E & Vitamin C: No Impact on Cardiovascular Disease Risk; Does Lack of Sleep Increase Stroke & Heart Attack Risk in Hypertensive Patients?

11-9-2008:  Statins Cut Heart Attack Risk Even with Normal Cholesterol Levels; Statins & PSA Level

11-2-2008:  Radiation Treatment of Prostate Cancer & Second Cancers; Sexual Content on TV & Teen Pregnancy Risk

10-26-2008:  Smoking & Quality of Life

10-19-2008:  Agent Orange & Prostate Cancer

10-12-2008:  Pomegranate Juice & Prostate Cancer

10-5-2008:  Central Obesity & Dementia; Diet, Vitamin D, Calcium, & Colon Cancer

9-28-2008:  Publication & Citation Bias in Favor of Industry-Funded Research?

9-21-2008:  Does Tylenol® (Acetaminophen) Cause Asthma?

9-14-208:   Arthroscopic Knee Surgery- No Better than Placebo?; A Healthy Lifestyle Prevents Stroke

8-23-2008:  Alcohol Abuse Before & After Military Deployment; Running & Age; Running & Your Testicles

8-12-2008:  Green Tea & Diabetes; Breastfeeding & Adult Cholesterol Levels; Fish Oil & Senile Macular Degeneration

8-3-2008:   Exercise & Weight Loss; Green Tea, Folic Acid & Breast Cancer Risk; Foreign Language Interpreters & ICU Patients

7-26-2008:  Viagra & Sexual Function in Women; Patient-Reported Adverse Hospital Events; Curcumin & Pancreatic Cancer

7-13-2008:  Erectile Dysfunction & Frequency of Sex; Muscle Strength & Mortality in Men; Cryoablation for Prostate Cancer

7-6-2008:  Sleep, Melatonin & Breast Cancer Risk; Mediterranean Diet & Cancer Risk; New Treatment for Varicose Veins

6-29-2008:  Bone Marrow Stem Cells & Liver Failure; Vitamin D & Colorectal Cancer Survival; Green Tea & Colorectal Cancer

6-22-2008:  Obesity, Lifestyle & Heart Disease; Effects of Lifestyle & Nutrition on Prostate Cancer; Ginkgo Biloba, Ulcerative Colitis & Colorectal Cancer

6-15-2008:  Preventable Deaths after Coronary Artery Bypass Graft (CABG) Surgery; Green Tea & Colorectal Cancer; Attention-Deficit/Hyperactivity Disorder (ADHD) & St. John’s Wort

6-8-2008:  Vitamin D & Prostate Cancer Risk; Radiofrequency Ablation (RFA) of Kidney (Renal) Cancer; Antisense Telomerase & Cancer

6-2-2008:  Acute Coronary Syndrome- Do You Know the Symptoms?; Green Tea & Lung Cancer; Episiotomy & Subsequent Deliveries- An Unkind Cut

5-25-2008:  Early Childhood Screening Predicts Later Behavioral Problems; Psychiatric Disorders Among Parents of Autistic Children; Social & Psychiatric Profiles of Young Adults Born Prematurely

5-18-2008:  Can Statins Reverse Coronary Artery Disease?; Does Breast Ultrasound Improve Breast Cancer Detection?; Preventive Care Services at Veterans Administration (VA) Medical Centers

5-11-2008:  Smoking Cessation & Risk of Death; Childhood Traumas & Adult Suicide Risk; “White Coat Hypertension” & Risk of Cardiovascular Disease

5-4-2008:  Super-Size Me: Fast Food’s Effects on Your Liver; Exercise, Weight & Coronary Artery Disease; Contamination of Surgical Instruments in the Operating Room

4-27-2008:  Stents vs. Bypass Surgery for Coronary Artery Disease; The “DASH” Hypertension Diet & Cardiovascular Disease Prevention; Testosterone Therapy for Women with Decreased Sexual Desire & Function

4-20-2008:  BRCA Breast Cancer Mutations & MRI Scans; Bladder Cancer Prevention with Broccoli?; Diabetes: Risk of Death Due to Heart Attack & Stroke

4-13-2008:  Breast Cancer Recurrence & Hormone Replacement Therapy (HRT); Carotid Artery Disease: Surgery vs. Stents?; Statin Drugs & Cancer Prevention

4-6-2008:  Human Papilloma Virus (HPV), Pap Smear Results & Cervical Cancer; Human Papilloma Virus (HPV) Infection & Oral Cancer; Hormone Replacement Therapy (HRT) & the Risk of Gastroesophageal Reflux Disorder (GERD)

3-30-2008:  Abdominal Obesity & the Risk of Death in Women; Folic Acid Pretreatment & Heart Attacks; Pancreatic Cancer Regression after Injections of Bacteria

3-23-2008:  Age of Transfused Blood & Risk of Complications after Surgery; Obesity, Blood Pressure & Heart Size in Children

3-16-2008:  Benefits of a Full Drug Coverage Plan for Medicare Patients?; Parent-Teen Conversations about Sex; Soy (Genistein) & Prostate Cancer

3-9-2008:  Flat Colorectal Adenomas & Cancer; Health Risks after Stopping Hormone Replacement Therapy (HRT); Television, Children & Obesity 

3-2-2008:  Medication & Risk of Death After Heart Attack; Hormone Replacement Therapy (HRT) & Mammogram Results; Selenium: Cancer, Heart Disease & Death

2-23-2008:  Universal Healthcare Insurance Study; Glucosamine & Arthritis

2-17-2008:  Exceptional Longevity in Men; Testosterone & Risk of Prostate Cancer; Smoking & Pre-malignant Colorectal Polyps

2-10-2008:  Thrombus Aspiration from Coronary Arteries; Intensive Management of Diabetes & Death; Possible Cure for  Down’s Syndrome?

2-3-2008:  Vitamin D & Cardiovascular Health; Vitamin D & Breast Cancer; Green Tea & Colorectal Cancer

1-27-2008:  Colorectal Cancer, Esophageal Cancer & Pancreatic Cancer: Update from the 2008 American Society of Clinical Oncology’s Gastrointestinal Cancers Symposium

1-20-2008:  Testosterone Levels & Risk of Fractures in Elderly Men; Air Pollution & DNA Damage in Sperm; Statins & Trauma Survival in the Elderly

1-12-2008:  Statins, Diabetes & Stroke and Obesity; GERD & Esophageal Cancer

1-7-2008:  Testosterone Supplements in Elderly Men; Colorectal Cancer– Reasons for Poor Compliance with Screening Recommendations

12-31-2007:  Minority Women, Hormone Replacement Therapy & Breast Cancer; Does Health Insurance Improve Health?

12-23-2007:  Is Coffee Safe After a Heart Attack?; Impact of Divorce on the Environment; Hypertension & the Risk of Dementia; Emotional Vitality & the Risk of Heart Disease

12-16-2007:   Honey vs. Dextromethorphan vs. No Treatment for Kids with Night-Time Cough, Acupuncture & Hot Flashes in Women with Breast Cancer, Physical Activity & the Risk of Death, Mediterranean Diet & Mortality 

12-11-2007:  Bias in Medical Research; Carbon Nanotubes & Radiofrequency: A New Weapon Against Cancer?; Childhood Obesity & Risk of Adult Heart Disease

12-2-2007:  Obesity & Risk of Cancer; Testosterone Level & Risk of Death; Drug Company Funding of Research & Results; Smoking & the Risk of Colon & Rectal Cancer 

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ACUTE CORONARY SYNDROME- DO YOU KNOW THE SYMPTOMS?

The acute coronary syndrome (ACS) describes patients who are experiencing symptoms of inadequate blood flow to the heart (myocardial ischemia), or who are experiencing an actual heart attack (myocardial infarction).  Patients who are experiencing ACS should see a qualified emergency room or cardiology physician immediately, as there is abundant research evidence showing that the early diagnosis and treatment of ACS leads to improved survival, and improved heart function in survivors.

Most of us know the classic g and symptoms of ACS, including the acute onset of crushing chest pain, which sometimes radiates to the left arm or the left jaw.  However, for many patients with heart disease, ACS can present without these classic “textbook” symptoms.  These atypical ACS symptoms can include any of the following: isolated pain (i.e., without chest pain) in the right or left arm, upper back, neck, jaw or upper abdomen (the latter is often perceived as “indigestion”); shortness of breath; the new onset of weakness or extreme fatigue; fainting or the feeling that one is about to faint; nausea or vomiting; and palpitations or other abnormal heart rhythms (patients with diabetes and elderly patients are more likely to experience these atypical signs and symptoms, rather than the classic signs and symptoms associated with ACS).

Certainly, it is understandable that many lay people who have no personal history of coronary artery disease might not be aware of the atypical signs and symptoms of ACS, but one would think that patients with a known history of myocardial ischemia or prior myocardial infarction would have a pretty fair idea regarding both the typical and atypical signs and symptoms of ACS.  However, a clinical study, just published in the journal Archives of Internal Medicine, suggests that almost half of patients with a history of ischemic heart disease were ill-informed about the signs and symptoms of ACS.

This multi-institutional study was conducted by researchers at the University of California (the San Francisco and Los Angeles campuses), the University of Pennsylvania, the University of Washington, the University of Kentucky, the University of Nevada (Reno), and other institutions in the United States and Australia.  In this clinical study, 3,522 patients with a history of either heart attack or a prior medical intervention for coronary artery disease participated in a survey designed to assess their knowledge about the symptoms of ACS, as well as the appropriate steps that should be taken by patients experiencing the symptoms of ACS.  The average age of these patients was 67, and 68% of these study volunteers were men.

The researchers defined a score of less than 70% on the survey as being representative of a low level of knowledge.  The average score among all of these adults with a history of significant coronary artery disease was only 71%.  Moreover, the scores of 46% of the participating patients, or nearly half of the patients, fell within the “low knowledge” range!  When the researchers analyzed factors that were associated with higher knowledge scores on the survey, they found that the following factors were statistically significant predictors of adequate or excellent knowledge about the symptoms of ACS:  female gender, younger age, higher levels of education, previous participation in a cardiac rehabilitation program, and receiving care by a cardiologist rather than an internist or general practitioner.  A prior history of heart attack or coronary artery bypass surgery (ABG) was not associated with a higher level of knowledge as tested by the survey, however. 

The results of this clinical study are rather provocative, and suggest that more needs to be done to educate patients at high risk of experiencing ACS, including those who have already experienced episodes of ACS in the past.  When ACS occurs, delays in diagnosis and treatment can truly become a matter of life-and-death.  If you believe that you are experiencing the symptoms of ACS, then please do not ignore them.  Instead, you should seek appropriate medical assistance, and without delay!

 

GREEN TEA & LUNG CANCER

Lung cancer remains the most common cause of cancer-associated death in the United States more than 40 years after the link between smoking and lung cancer was first publicly disclosed by the US Surgeon General.  In 2008, the American Cancer Society estimates that approximately 215,000 new cases of lung cancer will be diagnosed (almost evenly split between men and women), and about 166,000 Americans will die of this highly lethal cancer.  The greatest tragedy surrounding this greatest of cancer killers is that more than 95% of lung cancer cases could be preventing simply by eliminating smoking.  When I hear people complain that the war on cancer has not delivered dramatic reductions in the incidence of most cancers, I immediately think about lung cancer.  In 2008, and there will be an estimated 566,000 deaths due to cancer in the United States, and more than 166,000 of these deaths, or 29% of all cancer deaths, will be due to a cancer that is almost completely preventable (i.e., simply by leading a reasonably healthy lifestyle)….  For these reasons, and because the available treatments for most cases of lung cancer are rarely successful in eradicating all traces of cancer, I rarely include reviews of lung cancer research clinical studies in this column.  However, an intriguing research paper, just published in the journal Carcinogenesis, looks at the effects of an extract of green tea upon lung cancers induced in laboratory mice.  This study was conducted by researchers from the University of Cincinnati, the University of Minnesota, and Washington University.

In this laboratory study, a decaffeinated extract of green tea leaves was added to the diet of mice after they were injected with a mutagenic chemical known to cause lung cancer in mice. A control group of additional mice received injections of the cancer-causing chemical, but did not receive the green tea extract in their diet.  While green tea extract supplementation did not appear to reduce the overall number of lung cancer tumors that developed in the mice, it did appear to significantly reduce the maximum size of the lung tumors when compared to the tumors that developed in the control group of mice.  Using both MRI scans of the lung tumors and microscopic evaluation of lung tumors after the mice were euthanized, the researchers confirmed that the mice that had received green tea extract supplementation had significantly smaller tumors than the untreated control group mice.

While green tea extract did not appear to prevent the development of lung cancer in mice treated with a chemical (benzo[a]pyrene, which is also present in cigarette smoke) known to induce this type of cancer in laboratory mice, dietary green tea did appear to reduce the progression of the resulting lung tumors.  As with all animal-based research studies, however, extrapolating the effects of various treatments on laboratory animals to humans requires a big leap of faith.  In some cases, humans do respond in similar ways as has been observed in laboratory animals.  In many other cases, what appears to work in mice turns out not to work (at least to any clinically significant degree) in people.  However, this research article joins hundreds of others that suggest a modest-to-moderate anti-tumor effect associated with green tea polyphenols for at least some types of cancer.  Currently, there are 25 registered clinical research trials underway in the United States that are looking at the effects of green tea supplements on the development and progression of various types of cancer, including lung cancer.  Hopefully, at least some of these trials will confirm a beneficial effect of green tea supplementation in humans, as has previously been observed in cell cultures and animal studies.  Meanwhile, please do your part in the war against cancer.  If you don’t currently smoke, then please don’t start.  If you already smoke, then please quit, now.

EPISIOTOMY & SUBSEQUENT DELIVERIES- AN UNKIND CUT

Increasingly, obstetricians, and their patients, are questioning the traditional wisdom about routinely performing episiotomies in the delivery room.  An episiotomy involves making an incision on the edge of the vaginal wall and perineum as the baby’s head descends within the vaginal birth canal.  In theory, the episiotomy is a “controlled” laceration of the highly sensitive perineal tissues between the vagina and rectum, and was originally thought to reduce the incidence of deep tears of these tissues, including the sphincter muscles of the anus and rectum.  (After the baby is born, the episiotomy is then repaired by the obstetrician with sutures.)  However, in recent years, the beneficial effects of episiotomy, if any, have increasingly been called into question.  In fact, recent clinical research studies have confirmed what many new mothers, their husbands, and even many obstetricians, have long suspected, and that is that episiotomies often appear to cause the very same injuries and long-term complications that they are intended to prevent.  These complications can leave women incontinent, and with chronic perineal pain that often interferes with their ability to comfortably have intercourse for months, and sometimes for years.  Ask any new mother (or her husband) who has delivered children both with and without an episiotomy which delivery left her with the greatest amount of perineal pain, and for the longest amount of time…. 

If, as it is becoming apparent, episiotomies do not prevent perineal and anal sphincter complications during most routine deliveries, then what might the effects of episiotomies be during subsequent births?  A new research paper in the journal Obstetrics & Gynecology provides some answers to this question.  The researchers reviewed the medical records of more than 6,000 women who underwent at least two consecutive vaginal deliveries at the University of Pittsburgh.  They found that 48% of these women underwent episiotomy with their first delivery.  The researchers then compared the incidence of complications among these women who had received episiotomies with the remaining 52% of women who did not undergo episiotomy during their first delivery.  The results were both striking and concerning.

Among the women who had previously received an episiotomy, 51% experienced moderately severe perineal lacerations during their subsequent second vaginal delivery, while only 27% of the mothers who had not undergone a previously episiotomy suffered similar perineal lacerations.  Severe lacerations that involved the anal sphincter muscle (and which can lead to painful bowel movements and incontinence) occurred in almost 5% of the women who had previously undergone an episiotomy versus just under 2% of the women who had not received a previous episiotomy. 

In summary, this retrospective clinical study adds to a growing body of research suggesting that episiotomy almost certainly does more harm than good, at least for relatively routine deliveries.  In fact, the very birth-associated complications that episiotomy is supposed to prevent are actually more common in women who have been subjected to this procedure than in those who have not received an episiotomy.  While there may still be an occasional indication for episiotomy if the vaginal canal cannot safely accommodate and deliver a large or malpositioned baby, in the vast majority of cases of otherwise normal and spontaneous vaginal delivery, there appears to be no clinically valid reason, any longer, for episiotomy. 

If you are pregnant, it might be wise to raise this issue with your obstetrician, as many obstetricians who continue to routinely perform episiotomy consider the procedure to be an integral part of their obstetric care, and some obstetric physicians may, therefore, plan to perform this generally unnecessary, and potentially harmful, surgical procedure without first discussing it in detail with their patients. 

Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center:

http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html

Send your feedback to Dr. Wascher at:  rwascher@doctorwascher.net

http://www.doctorwascher.com

Copyright 2008.  Robert A. Wascher, MD, FACS.  

All rights reserved.

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 AGE OF TRANSFUSED BLOOD & COMPLICATIONS AFTER SURGERY 

Everyday, thousands of people undergoing surgery will require transfusions with lifesaving blood stored in hospital blood banks.  Because of the very small risk of passing infections along to patients with blood transfusions, and because some studies have suggested that blood transfusions might depress immune function, doctors try to reserve blood transfusions only for those patients at greatest risk of complications, including death, from severe anemia.  However, it has long been known that blood, which can be thought of as a living liquid human tissue, deteriorates while being stored, even under refrigerated conditions.  Although fresh blood can be stored for up to 42 days under optimal conditions, the levels of natural substances in red blood cells necessary for proper function begin to decline within few hours after collection from a donor.  At the same time, the living cells within the donated blood continue to churn out metabolic waste substances that can have an adverse effect on very sick patients receiving large volume blood transfusions. 

Because individual hospitals can never precisely predict how many blood transfusions will be required from one day to the next, blood banks need to keep a small surplus of blood products on hands at all times.  Since these products are highly perishable, and can only be stored for a limited time before being discarded, most blood banks release their older stocks of blood for transfusion first, much as your neighborhood grocery store places the oldest containers of milk at the front of the shelf.  Older blood, in addition to containing higher levels of potentially toxic metabolites, simply does not take up and unload life-sustaining oxygen as efficiently and as quickly as fresh blood does.  Additionally, the red blood cells contained in older bags of blood are more fragile, and are more easily ruptured (also referred to as hemolysis), further reducing the available number of blood cells available following transfusion (the breakdown products of ruptured red blood cells can also be toxic to the liver and kidneys in patients with abnormal liver and kidney function).  A new research study, just published in the New England Journal of Medicine, has cast further, important, light on this topic. 

In this study, nearly 3,000 patients undergoing open-heart surgery were evaluated after being transfused with almost 9,000 units of blood that had been stored for 14 days or less.  The complications and death rates for this group of patients were then compared to a similar group of almost 11,000 open-heart surgery patients who had received “older” blood, which had been collected and stored for more than 14 days.  On average, blood given to the first group of patients was about 11 days old, while the blood transfused into the second group of patients was, on average, about 20 days old (the latter is still well within current blood storage and transfusion guidelines).  

When comparing the clinical outcomes for these two otherwise matched groups of patients, the researchers found that the incidence of serious complications and risk of death were significantly higher among the patients receiving the “older” blood.  Specifically, more patients receiving “older” blood remained on a mechanical ventilator for 3 or more days than did the patients receiving “newer” blood (9.7% vs. 5.6%, respectively), and these patients were also more likely to suffer severe infections than the patients who received “newer” blood (4.0% vs. 2.8%, respectively).  Similarly, the risk of kidney failure, which is associated with a high risk of death in critically ill patients, was also significantly higher in patients receiving “older” blood (2.7% vs. 1.6% in patients receiving “newer” blood, respectively).  Finally, and most importantly, the likelihood of death within 1 year of surgery was also significantly higher among the patients receiving “older” blood than was observed in the patients transfused with “newer” blood (11.0% vs. 7.4%, respectively).  

This study is a real eye-opener, because it suggests that significant increases in the risk of serious complications and death may be associated with transfusions of even relatively fresh blood, at least in patients undergoing major cardiac surgery.  Whether or not the same degree of adverse effects occur in patients undergoing other types of major surgery was not addressed by this study, although the mechanisms of transfusion-associated illnesses and death are generally thought to be similar irrespective of the type of surgery, and are likely more related to the number and severity of co-existing illness within individual patients.   

The findings of this study should generate further review of the current collection and storage guidelines for blood products, although the typically tight supply of lifesaving blood products at most hospitals means that a significant change in the allowable duration of blood product storage is not likely to change much at all.  At the same time, I expect that hospital blood banks will probably begin taking a closer look at which patients receive transfusions with “older” blood versus “newer” blood.  A prudent approach, based upon the results of this study, would be to develop an algorithm whereby the sickest patients would automatically receive blood that has been stored for less than 14 days, while less seriously ill patients requiring blood transfusions would receive the “older” blood products. 

OBESITY, BLOOD PRESSURE, AND HEART SIZE IN CHILDREN

As most of us know, the incidence of obesity among both adults and children in the developed world has been skyrocketing.  Obesity has long been known to be associated with a variety of life-shortening conditions, including high blood pressure, coronary artery disease, congestive heart failure, diabetes, stroke, liver disease and arthritis, among other ailments. 

Chronic high blood pressure (hypertension), by itself, can lead to irreversible damage to the heart, brain, kidneys, retinas and other vital organs.  In the case of the heart, a chronically elevated blood pressure causes the heart to have to work harder, resulting in progressive thickening of the heart’s main pumping chamber, the left ventricle.  Over time, the enlarged and increasingly stiff left ventricle can begin to fail, resulting in the development of congestive heart failure (CHF).  Historically, CHF has been viewed as a disease of the elderly, often occurring after decades of poorly controlled hypertension, or after heart attacks have further damaged the left ventricle.  However, the rising incidence of obesity among children has raised concerns that we may be on the cusp of an epidemic of early-onset obesity-related hypertension and coronary artery disease among young adults.  A timely new research study in the Journal of Pediatrics confirms that such an epidemic may be just around the corner.

In this small study, 44 obese and 22 non-obese children (average age was 8 years) were evaluated for blood pressure and left ventricular size.  Not surprisingly, average blood pressure readings were significantly higher in the obese children.  In fact, 48% of the obese children had documented episodes of hypertension during their daily activities.  Similarly, the obese kids were found to already have enlarged left ventricles, as measured by echocardiography. 

This study reveals the unpleasant truth that pre-pubertal obese children are at markedly increased risk of developing hypertension and left ventricular enlargement (hypertrophy), and should raise alarm bells for any parent with an overweight or obese child.  The presence of confirmed high blood pressure and left ventricular hypertrophy in these kids, and at an average age of only 8 years, almost certainly means that these children will face an extraordinarily high future risk of hypertension-related ailments, and early death, unless they are able to shed their excess weight. 

 Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center

http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html 

Send your feedback to Dr. Wascher at rwascher@doctorwascher.net
 

http://www.doctorwascher.com

Copyright 2008.  Robert A. Wascher, MD, FACS.  

All rights reserved.

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