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While they can be scary, most thyroid nodules are benign

By David Dunaief, M.D.

Dr. David Dunaief

Thyroid nodules are diagnosed, often incidentally, on radiologic exams, such as CT scans of the chest, MRI scans, PET scans and ultrasounds of the carotid arteries in the neck, rather than because of symptoms (1). More than 50 percent of people have thyroid nodules detectable by high-resolution ultrasound (2). Fortunately, most are benign. A small percent are malignant. Depending on the study, this can range from 1.1 to 6.5 percent of nodules (3, 4). 

There is a conundrum of what to do with a thyroid nodule. It depends on the size. If it is over one centimeter, usually it is biopsied by fine needle aspiration (FNA) (5). While most are asymptomatic, if there are symptoms, these might include difficulty swallowing, difficulty breathing, hoarseness, pain in the lower portion of the neck and a goiter (6).

FNA biopsy is becoming more common. In a study evaluating several databases, there was a greater than 100 percent increase in thyroid FNAs performed over a five-year period from 2006 to 2011 (7). This resulted in a 31 percent increase in thyroidectomies, surgeries to remove the thyroid partially or completely.

However, the number of thyroid cancers diagnosed with the surgery did not rise in this same period. Thyroid nodules in this study were least likely to be cancerous when the initial diagnosis was by incidental radiologic exam (8).

Evaluating indeterminate FNA results

As much as 25 percent of FNA biopsies are indeterminate. We are going to look at two techniques to differentiate between benign and malignant thyroid nodules when FNA results are equivocal: a PET scan and a molecular genetics test.

A meta-analysis of six studies of PET scan results showed that it was least effective in resolving an unclear FNA biopsy. The PET scan was able to rule out patients who did not have malignancies, but it did not do a good job of identifying those who did have cancer (9).

On the other hand, a molecular-based test was able to potentially determine whether an indeterminate thyroid nodule by FNA was malignant or benign (10).

Unlike in the PET scan study above, the researchers were able to not only rule out the majority of malignancies but also to rule them in. It was not perfect, but the percent of negative predictive value (ruled out) was 94 percent, and the positive predictive value (ruled in) was 74 percent. The combination test improved the predictive results of previous molecular tests by 65 to 69 percent. This is important to help decide whether or not the patient needs surgery to remove at least part of the thyroid.

Significance of calcification

Microcalcifications in the nodule can be detected on ultrasound. The significance of this may be that patients with microcalcifications are more likely to have malignant thyroid nodules than those without them, according to a small prospective study involving 170 patients (11). This does not mean necessarily that a patient has malignancy with calcifications, but there is a higher risk.

Considering a “wait and follow-up” approach

As I mentioned above, most thyroid nodules are benign. The results of one study go even further, showing that most asymptomatic benign nodules do not progress in size significantly after five years (12). The factors that did contribute to growth of about 11 percent of the nodules were age (<45 years old had more growth than >60 years old), multiple nodules, greater nodule volume at baseline and being male.

The authors’ suggestion is that, after the follow-up scan, the next ultrasound scan might be five years later instead of three years. However, they did discover thyroid cancer in 0.3 percent after five years.

Thyroid function’s role

In considering risk factors, it’s important to note that those who had normal thyroid stimulating hormone (TSH) were less likely to have a malignant thyroid nodule than those who had high TSH, implying hypothyroidism. There was an almost 30 percent prevalence of cancer in the nodule if the TSH was greater than >5.5 mU/L (13).

Fortunately, most nodules are benign and asymptomatic, but the number of cancerous nodules found is growing. Why the mortality rate remains the same year over year for decades may have to do with the slow rate at which most thyroid cancers progress, especially of the two most common forms, follicular and papillary.

References: 

(1) uptodate.com. (2) AACE 2013 Abstract 1048. (3) Thyroid. 2005;15(7):708. (4) European Thyroid Journal. 2022 Jun 29;11(4) online. (5) AACE 2013 Abstract 1048. (6) thyroid.org. (7) AAES 2013 Annual Meeting. Abstract 36. (8) AACE 2013 Abstract 1048. (9) Cancer. 2011;117(20):4582-4594. (10) J Clin Endocrinol Metab. Online May 12, 2015. (11) Head Neck. 2008 Sep;30(9):1206-1210. (12) JAMA. 2015;313(9):926-935. (13) J Clin Endocrinol Metab. 2006;91(11):4295.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

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Mild headaches and fatigue are common consequences

By David Dunaief, M.D.

Dr. David Dunaief

During the summer, we talk a lot about the dangers of dehydration. However, it can also cause problems during the cooler winter months. Dry heat quickly evaporates moisture in the air, making it hard to stay hydrated or to keep any humidity in your home or office. This can dehydrate us.

Complications and symptoms of dehydration can be mild to severe, ranging from constipation, mood changes, headaches and heart palpitations to heat stroke, migraines and heart attacks.

In addition, the dry air can make our throats and sinuses dry, making us uncomfortable and more susceptible to irritations and viruses.

Let’s look at some of the consequences of dehydration and suggestions for keeping hydration up.

Headaches and migraines

In a review of studies published in the Handbook of Clinical Neurology, those who drank four cups more water had significantly fewer hours of migraine pain than those who drank less (1). Headache intensity decreased as well.

Heart palpitations

Heart palpitations are very common and are broadly felt as a racing heart rate, skipped beat, pounding sensation or fluttering. Dehydration and exercise contributing to this (2). They occur mainly when we don’t hydrate prior to exercise. If you drink one glass of water before exercise and then drink during exercise, it will help avoid palpitations. Though these symptoms are not usually life-threatening, they can make you anxious.

Heart attacks

The Adventist Health Study showed that men who drank more water had the least risk of death from heart disease (3). Group one, which drank more than five glasses of water daily, had less risk than group two, which drank more than three. Those in group three, which drank fewer than two glasses per day, saw the lowest benefit, comparatively. For women, there was no difference between groups one and two; both fared better than group three.

The reason for this effect, according to the authors, may relate to blood or plasma viscosity (thickness) and fibrinogen, a substance that helps clots form.

Decreased concentration and fatigue

Mild dehydration resulted in decreased concentration, subdued mood, fatigue and headaches in women in a small study (4). The mean age of participants was 23, and they were neither athletes nor highly sedentary. Dehydration was caused by walking on a treadmill with or without taking a diuretic (water pill) prior to the exercise. The authors concluded that adequate hydration was needed, especially during and after exercise.

I would also suggest, from my practice experience, hydration prior to exercise.

How much water?

How do we go about this? How much water we need to drink depends on circumstances, such as diet, activity levels, environment and other factors. It is not true necessarily that we all should be drinking eight glasses of water a day. In a review article, the authors analyzed the data, but did not find adequate studies to suggest that eight glasses is the magic number (5). It may actually be too much for some patients.

You may also get a significant amount of water from the foods in your diet. Nutrient-dense diets, like Mediterranean or Dietary Approaches to Stop Hypertension (DASH) diets, have a plant-rich focus. Diets with a focus on fruits and vegetables increase water consumption (6). As you may know, 95 percent of the weights of many fruits and vegetables are attributed to water. An added benefit is an increased satiety level without eating calorically dense foods.

Remember that salty foods can dehydrate you, including breads and pastries, so try to avoid these.

Caffeinated beverages

In a review, it was suggested that caffeinated coffee and tea don’t increase the risk of dehydration, even though caffeine is a mild diuretic (7). With moderate amounts of caffeinated beverages, the liquid has a more hydrating effect than its diuretic effect.

Keeping some humidity in the air

To reduce sinus inflammation and dry skin that heated air can promote, measure the humidity level in your home with a hygrometer and target keeping it between 30 and 50 percent (8). When the temperature outside drops below 10 degrees F, lower this to 25 percent.

Strategies for adding moisture to the air include using cool mist humidifiers, keeping the bathroom door open after you bathe or shower, and placing bowls of water strategically around your home, including on your stovetop when you cook. If you use a humidifier, take care to follow the manufacturer’s care instructions and clean it regularly.

It is important to stay hydrated to avoid complications — some are serious, but all are uncomfortable. Diet is a great way to ensure that you get the triple effect of high nutrients, increased hydration and sense of feeling satiated without calorie-dense foods. However, don’t go overboard with water consumption, especially if you have congestive heart failure or open-angle glaucoma (9).

References: 

(1) Handb Clin Neurol. 2010;97:161-72. (2) my.clevelandclinic.org. (3) Am J Epidemiol 2002 May 1; 155:827-33. (4) J. Nutr. February 2012 142: 382-388. (5) AJP – Regu Physiol. 2002;283:R993-R1004. (6) Am J Lifestyle Med. 2011;5(4):316-319. (7) Exerc Sport Sci Rev. 2007;35(3):135-140. (8) epa.gov (9) Br J Ophthalmol. 2005:89:1298–1301.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

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The holiday season can be a difficult time for many people, especially for those who lost a loved one recently. Stock photo

An important gift people can give each other this holiday season is a check-in call or visit.

That’s the advice of area mental health professionals, who say that the holidays in general can be stressful and that several factors, including grieving over the loss of family or friends, fear about ongoing health concerns, and uncertainty and overall anxiety, have created stressors to mental health.

“If you know someone is having a rough time, who will be without a loved one for the holidays, you can call and say, ‘I’m here,’” said Dr. Stacy Eagle, director of Psychiatry at Port Jefferson-based St. Charles Hospital. “Doing something that simple can be really helpful.”

Indeed, area mental health professionals said the health care system in general has been straining to meet the need for patients in a host of ages to provide timely services.

Signs

Dr. Adam Gonzalez, a licensed clinical psychologist, director of Behavioral Health at Stony Brook Medicine and founding director of the Stony Brook University Mind-Body Clinical Research Center at the Renaissance School of Medicine, suggested that people can look for signs among their friends, family members and coworkers.

“Be aware of behavioral and emotional changes like social withdrawal, increased alcohol or drug use, overeating/eating more unhealthy food, difficulty sleeping, difficulty concentrating or making decisions, difficulty with getting work done” irritability and sadness, Gonzalez explained in an email.

Broadly speaking, Eagle added that people should be aware of any change in normal functioning. An extrovert who is acting withdrawn can provide a clue about a daily struggle.

Solutions

When people notice these kinds of changes in themselves or others, doctors urged a host of responses, depending on the severity of the symptom.

People who are an imminent danger to themselves or to others can call 988, which is a suicide and crisis hotline phone number. They can also call 911 or go to an emergency room, where a psychiatrist can evaluate them and offer help.

Cari Faith Besserman, director in the Division of Community Mental Hygiene Services with the Suffolk County Department of Health, said residents can take classes such as Mental Health First Aid, which teaches laypeople to increase their awareness by recognizing signs of emotional and mental distress, how to respond safely, and educates on symptoms of illness to decrease the stigma and mystery of mental health and various stages of wellness.

Suffolk County residents also can turn to the Diagnostic Assessment and Stabilization Hub, also known as DASH, program, which provides 24/7 access to behavioral health professionals and provides somewhere to go for those experiencing a crisis. The DASH number is 631-952-3333.

For less severe but problematic or ongoing symptoms, doctors urged some restorative measures.

Eagle suggested getting proper rest, ensuring a sufficient and balanced diet and staying hydrated. Activities such as exercise, which helps increase the release of serotonin, can help reduce anxiety and improve mood.

She added that unplugging from social media, especially for adolescents and children, can improve overall mental health.

Gonzalez also urged those who are offering support to remain fully present and nonjudgmental, and listen actively when someone shares concerns or anxieties.

“Be sure to ask what they need from you,” Gonzalez urged. “For some, it may be just listening; for others, it may be advice/ feedback or helping to connect them to professional support services. It’s easy for many to slip into problem-solving mode; however, sometimes others just want to be heard and validated.”

Gonzalez added that group-based treatments are just as effective as individual therapy and encouraged patients to try skills-based groups to learn coping methods for managing stress, anxiety and depression symptoms.

Stony Brook offers a COVID-19 support group for people who have or have had COVID, especially those with long COVID symptoms. Stony Brook also offers a comprehensive mind-body treatment program called the Stress Management and Resilience Training program.

The SMART program is helpful for people who are managing co-occurring mental and physical health problems and for those who would like to enhance their overall resilience.

Overwhelming demand

On the whole, hospitals and mental health facilities are struggling to keep up with the need for help.

“Currently, the demand for psychotherapy services is overwhelming,” Gonzalez explained in an email.

Eagle added that the weeks leading up to the holidays have often been a stressful period.

This year, some groups in particular are struggling. Parents of children born in 2022 are especially concerned about respiratory syncytial virus, which is “higher than normal,” Eagle said.

Seasonal affective disorder, which occurs during the darker, colder winter months, also affects about 0.5 to 3% of the population, Eagle said.

SAD can be harder for people if they have depression or anxiety, Eagle said. “These things are definitely an issue.”

Doctors added that those who are grieving over a loss can find the holidays difficult.

“Grief can be more of an issue” around the holidays, Eagle said.

Eagle urges the continuation of traditions that families found meaningful and helpful.

Gonzalez added that people can cope with grief by keeping a picture of a person who is no longer present close by, offering a prayer in their honor, sharing positive memories, or writing them a note.

Grieving families can also consider starting new traditions that may help them move forward with their lives, Eagle suggested.

Good news

Even amid all the concerns this year, doctors said people can appreciate some good news.

“Happily, we are out of the severe hospitalizations for COVID,” Eagle said.

Communities can also celebrate resilience “as individuals and as a country,” she added.

In hospitals, visitors are able to offer comfort and spend quality time with their friends and family, which is a considerable improvement from the days when patients couldn’t have visitors.

Eagle said she is following her own advice with her friends and family.

She will try to reach out to those she knows have had a particularly bad time this year to “make sure that they are aware that someone is thinking about them,” she said.

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It’s time to change up your holiday dinner options

By David Dunaief, M.D.

Dr. David Dunaief

Many consider Thanksgiving a time to indulge and not think about the repercussions. Even if we have the best of intentions, it’s hard to resist indulging in our childhood favorites and secret family recipes spread before us in a sprawling buffet.

Unfortunately, that one meal, and perhaps subsequent leftover meals, can have striking health consequences. And if you tend to overeat, be aware that there are significant short-term consequences of gorging ourselves.

Not surprisingly, people tend to gain weight from Thanksgiving to New Year. This is when many gain the predominant amount of weight for the entire year. However, most do not lose the weight they gain during this time (1). If you can fend off weight gain during the holidays, think of the possibilities for the rest of the year.

If you are obese and sedentary, you may already have heart disease. Overeating at a single meal increases your risk of heart attack over the near term, according to the American Heart Association (2). 

The good news is that, with a little Thanksgiving planning, you can reap significant health benefits.

What can we do to turn Thanksgiving dinner into a healthy meal? The secret is likely there on your table, hidden in the side dishes. By reconsidering how we prepare them, we can change the Thanksgiving health equation.

Refocus on plants

Phytochemicals (plant nutrients) called carotenoids have antioxidant and anti-inflammatory activity and are found mostly in fruits and vegetables. Carotenoids make up a family of more than 600 different substances, such as beta-carotene, alpha-carotene, lutein, zeaxanthin, lycopene and beta-cryptoxanthin (3).

Carotenoids help to prevent and potentially reverse diseases, such as breast cancer, amyotrophic lateral sclerosis (Lou Gehrig’s disease), age-related macular degeneration, and cardiovascular disease — heart disease and stroke. Foods that contain these substances are dark green leafy vegetables, as well as orange, yellow and red vegetables and fruits.

Focus on healthy eating

Despite the knowledge that healthy eating has long-term positive effects, there are obstacles to healthy eating. Two critical factors are presentation and perception.

Vegetables are often prepared in either an unappetizing way — steamed to the point of no return — or smothered in cheese and butter, negating their benefits, but clearing our consciences. Fruits are buttered and sugared beyond recognition or used as a garnish on more decadent dishes.

Plant-based foods like whole grains, leafy greens and fruits are relegated to side dishes or afterthoughts. 

Here are some suggestions to get you thinking about ways to shift the heavy holiday meal paradigm:

Make healthy, plant-based dishes part of the main course. You don’t have to forgo signature dishes, but supplement tradition by adding mouthwatering vegetable-based dishes. One of my favorites is steamed “sweet” vegetables — cauliflower, broccoli, snap peas, onions and garlic. To make it sweet, I sauté it in a splash of citrus-infused balsamic vinegar and add sliced apples. If you want to make this a primary dish, add diced tofu and/or garbanzo beans to make it more filling without overwhelming its delicate sweetness.

Improve vegetable choices. Why would you serve vegetables without any seasoning? In my family, we season vegetables and make sauces to drizzle over them. Personally, I’m a fan of infused vinegars. Each adds a different flavor to the vegetables. 

My 16-year-old nephew, who has never liked cooked vegetables, fell in love with my wife’s roasted Brussels sprouts and broccoli while on vacation last summer. He actually texted her a week later to ask for the recipes. Now, he makes them for himself. Good resources for appealing dishes can be found at PCRM.org, mouthwateringvegan.com, and many other resources.

Replace refined grains. A study in the American Journal of Clinical Nutrition, showed that replacing wheat or refined grains with whole wheat and whole grains significantly reduced central fat, or fat around the belly (4). Not only did participants lose subcutaneous fat found just below the skin, but also visceral adipose tissue, the fat that lines organs and causes chronic diseases such as cancer. 

For even better results, consider substituting riced cauliflower or mashed cauliflower for rice or potatoes. You can purchase frozen riced cauliflower in many grocery stores now. Just be sure to get one that’s unsalted. If you prefer mashed, I have a simple recipe for mashed cauliflower here: https://medicalcompassmd.com/post/mashed-cauliflower-recipe-vegan 

Create a healthy environment. Instead of putting out creamy dips, cheese platters and candies as snacks, choose whole grain brown rice crackers, baby carrots, cherry tomatoes and healthy dips like hummus and salsa. Help people choose wisely.

Offer healthy dessert options. Options might include dairy-free pumpkin pudding and fruit salad. The goal should be to increase your nutrient-dense choices and decrease your empty-calorie foods. 

Instead of making Thanksgiving a holiday of regret, eating foods that cause weight gain, fatigue and that increase your risk for chronic diseases, promote everyone’s health, while maintaining the theme of a traditional festive meal.

References: 

(1) N Engl J Med 2000; 342:861-867. (2) www.heart.org. (3) Crit Rev Food Sci Nutr 2010;50(8):728–760. (4) Am J Clin Nutr 2010 Nov;92(5):1165-71.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

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A study of more than 8,000 women from seven countries revealed that at the onset of the Covid-19 pandemic, stress experienced by pregnant women predicted more frequent anxiety and depressive symptoms. Photo provided by Marci Lobel, Stony Brook University
Published study of more than 8,000 women from seven Western countries reveals mental health risks at onset of pandemic

A study that assessed stress, anxiety and depressive symptoms in pregnant women from seven Western countries during the first major wave of the Covid-19 pandemic (April 17 to May 31, 2020) shows that stress from fears about Covid-19 led to anxiety and depressive symptoms above normal levels. Led by Stony Brook University Professor Marci Lobel, PhD, the findings are part of the International Covid-19 Pregnancy Experiences (I-COPE) Study and are published in Social Science & Medicine.

The Covid-19 pandemic has had unprecedented impact on public health, including mental health, and has affected social and economic conditions of people worldwide. The onset of the pandemic was especially stressful for pregnant women because of the initially unknown effects of the virus on fetuses, and because prenatal care and labor and delivery practices were greatly altered. The I-COPE Study is the first major research project to compare stress and mental health in pregnant women across these Western countries.

The study involved 8,148 pregnant women (on average about 27 weeks pregnant) from the United States, Germany, Switzerland, Spain, Poland, Italy and Israel. While the countries varied in magnitude of pandemic-related pregnancy stress – likely because of cultural differences and the specific impacts of the pandemic in each country – anxiety and depressive symptoms among the cohort were strongly predicted by pandemic-related and pregnancy-specific stress – a result the authors found was replicated within the individual countries.

”Our findings show that the stress experienced by pregnant women predicted more frequent anxiety and depressive symptoms, including symptom levels above clinically defined thresholds for poor mental health,” explains Lobel, Director of I-COPE, and a Professor in the Department of Psychology and the Department of Obstetrics, Gynecology and Reproductive Medicine at the Renaissance School of Medicine at Stony Brook University.

Among the seven countries, rates of moderate and severe anxiety symptoms ranged from 14.2 percent to 36 percent, and rates of likely depressive disorder ranged from 10.8 percent to 30.5 percent. Rates of both types of mood disturbance among women in Germany, Poland and the U.S. exceeded global ranges reported by analyses prior to the pandemic. Pregnant women who were younger or pregnant with their first child, those with high risk conditions, and those with limited access to the outdoors reported higher stress, and high stress in turn predicted the mood disturbances examined in this study.

Lobel and colleagues point out that many pre-pandemic studies – including those centered around other traumatic communal events such as the aftermath of natural disasters or terrorist attacks – also find evidence that prenatal stress is a risk factor for adverse maternal, fetal, infant, and child outcomes. Yet comparisons of these effects across multiple countries are rare, and the ability to examine them in the context of a global health crisis, when stress and its consequences are heightened, is unparalleled.

In 2021, Lobel and colleagues showed in another published study of women in the U.S. that prenatal stress during the pandemic onset also predicted worse birth outcomes, including greater likelihood of preterm birth or delivery of a newborn small for gestational age.

The authors conclude that results of the I-COPE Study confirm that stress from the pandemic is a strong, common predictor of anxiety and depressive symptoms in pregnant women. They add that the results “can be used to inform research and clinical interventions to protect against adverse consequences of prenatal stress, anxiety, and depression, as these mental health impacts pose longer-term threats to the health and well-being of women and their offspring.”

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Exercise can actually reduce a cold’s duration

By David Dunaief, M.D,

Dr. David Dunaief

With autumn upon us, cold season is sneaking up on us. Most frequently caused by the notorious human rhinovirus, a cold’s effects can range from an annoyance to more serious symptoms that put us out of commission for a week or more.

The good news is that it may be possible to reduce the symptoms — or even reduce the duration — of a common cold with supplements and lifestyle management.

Here, we’ll separate myth from fact about which supplements may be beneficial and which may not. 

How can you get symptom relief?

Let’s start with the basics to meet your most immediate need when you start experiencing cold symptoms.

If you have congestion or coughing symptoms, time-tested symptom relief may help. Sitting in a steamy bathroom, which simulates a medical mist tent, can help. Remember, dry heat is your enemy. If your home is dry, use a cool mist humidifier to put some humidity back in the air.

Consuming salt-free soups loaded with vegetables can help increase your nutrient intake and loosen congestion. I start with a sodium-free base and add in spices, onions, spinach, broccoli, and other greens until it’s more stew-like than soup-like. Caffeine-free hot teas will also help loosen congestion and keep you hydrated.

Does zinc really help?

You may have heard that zinc helps treat a cold. But what does the medical literature say? The answer is a resounding, YES!

According to a meta-analysis that included 13 trials, zinc in any form taken within 24 hours of first symptoms may reduce the duration of a cold by at least one day (1). Even more importantly, zinc may significantly reduce the severity of your symptoms throughout, improving your quality of life. This may be due to an anti-inflammatory effect.

One of the studies, which was published in the Journal of Infectious Disease, found that zinc reduced the duration of the common cold by almost 50 percent from seven days to four days, cough symptoms were reduced by greater than 60 percent and nasal discharge by 33 percent (2). Researchers used 13 grams of zinc acetate per lozenge taken three-to-four times daily for four days. This translates into 50-65 mg per day.

There are a few serious concerns with zinc. First, the dose researchers used was well above the maximum intake recommended by the National Institutes of Health, which is 40 mg per day for adults. This maximum intake number is less for those 18 and younger (3). Also, note that the FDA has warned against nasal zinc administration with sprays, which has led to permanent loss of smell for some people.

As for the studies, not all studies showed a benefit. Also, studies where there was a proven benefit may have used different formulations, delivery systems and dosages, and there is no current recommendation or consensus on what is optimal.

What about vitamin C?

According to a review of 29 trials with a combined population of over 11,000, vitamin C did not show any significant benefit in prevention or reduction of cold symptoms or duration in the general population (4). Thus, there may be no reason to take mega-doses of vitamin C for cold prevention and treatment. However, in a sub-group of serious marathon runners and other athletes, there was substantial risk reduction when taking vitamin C prophylactically; they caught 50 percent fewer colds.

Is echinacea a magic bullet?

After review of 24 controlled clinical trials, according to the Cochrane Database, the jury is still out on the effectiveness of echinacea for treatment of duration and symptoms, but the results are disappointing presently and, at best, are inconsistent (5). There are no valid randomized clinical trials showing cold prevention using echinacea.

In a randomized controlled trial with 719 patients, echinacea was no better than placebo for the treatment of the common cold (6).

Should you exercise?

People with colds need rest — at least that was the theory. However, a study published in the British Journal of Sports Medicine may have changed this perception. Participants who did aerobic exercise at least five days per week, versus one or fewer days per week, had a 43 percent reduction in the number of days with colds over two 12-week periods during the fall and winter months (7). Even more interesting is that those who perceived themselves to be highly fit had a 46 percent reduction in the number of days with colds compared to those who perceived themselves to have low fitness. The symptoms of colds were reduced significantly as well.

What’s the upshot?

For symptom relief, simple home remedies may work better than any supplements. Zinc is potentially useful in treating and preventing the common cold. Use caution with dosing, however, to reduce side effects. Echinacea and vitamin C may or may not provide benefits, but don’t stop taking them if you feel they help you. Lastly, exercise can actually reduce your cold’s duration.

References: 

(1) Open Respir Med J. 2011; 5: 51–58. (2) J Infect Dis. 2008 Mar 15;197(6):795-802. (3) ods.od.nih.gov. (4) Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000980. (5) Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD000530. (6) Ann Intern Med. 2010;153(12):769-777. (7) British Journal of Sports Medicine 2011;45:987-992.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

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Dr. Chrisy Beneri, below, suggests people leave a window cracked while entertaining such as above. Stock photo above; photo of Dr. Christy Beneri from Stony Brook Medicine

The time between Halloween and Thanksgiving often involves lists.

Dr. Chrisy Beneri. Photo from Stony Brook Medicine

Thanksgiving hosts make lists of people to invite, food to purchase, reminders of relatives who need to sit as far from each other as possible, and specialty items, like dairy-free, nut-free, gluten-free and sugar-free desserts.

This year, people should also consider adding healthcare steps to their holiday preparation, particularly as new COVID-19 variants and a host of respiratory viruses like the flu and respiratory syncytial virus, also known as RSV, threaten to put a damper on the holiday festivities or the days immediately after family gatherings.

Even as new COVID variants circulate in the area, cases of the flu have recently been climbing throughout the county, state and country.

As of the week ending Oct. 29, which is the most recent week for which the state and country produced data, Suffolk County reported 255 confirmed cases of the flu, which is up 86% from the previous week, according to the New York State Department of Health. Statewide, the number of cases reached 3,476 for the same week.

Dr. Christy Beneri, program director of Pediatric Infectious Diseases at Stony Brook Children’s Hospital, suggests that the “ideal time is now” to get COVID and flu vaccines. “It generally takes about two weeks for the immune system to show a response to the vaccine to provide protection,” which means that the clock is ticking to prepare immune systems for visits with friends and relatives who might be bringing unwitting viral passengers with them to the dinner table.

The Centers for Disease Control and Prevention recommends that people get a bivalent booster — the version from Pfizer/ BioNTech or Moderna that includes protection against some of the newer omicron variants — if it has been at least two months since their last COVID-19 vaccine or since their original booster.

Beneri urges residents to get both COVID and flu vaccines, which people can receive at the same time.

The effects of these combined shots may have increased side effects of flu-like illnesses, like fever, aches and fatigue, which generally lasts for about a day.

The CDC reported that observational studies show greater disease severity in patients with influenza and COVID than in patients with COVID alone. 

As for ways to protect guests in people’s homes, Beneri explained in an email that no specific house filters are effective at reducing the spread of disease.

“Good air flow is important,” she wrote. “Leaving some windows cracked and telling guests to wear an extra layer” could reduce the risk of spreading viruses.

Beneri added that area medical facilities have seen patients with more than one respiratory virus.

“Having multiple viruses can lead to more severe disease and thus [the] need for hospitalization for supportive care,” Beneri added.

Treatment options currently exist for COVID and influenza, which is not the case for other respiratory illnesses. The NIH COVID-19 Treatment Guidelines suggested that there are no significant drug-drug interactions between the antiviral agents used to treat the flu and antivirals used to prevent or treat COVID.

While vaccinations may not completely prevent disease, they can help reduce severe disease and hospitalization, which is “especially important with the increase in other respiratory infections, such as respiratory syncytial virus,” she explained in an email.

Boosting immunity

In general, people can enhance their health by eating well, exercising and getting a good night’s sleep, Beneri said.

She also generally recommends a multivitamin.

The COVID-19 Treatment Guidelines Panel indicates that there is not enough evidence to support the use of additional supplements, such as Vitamin C, D or zinc in patients with COVID.

Beneri advised residents to review any supplement use with their doctors to avoid drug interactions and possible side effects.

At this point, the bivalent vaccine has improved effectiveness for the omicron strain based on the immune response, Beneri explained.

More data, however, is expected on the vaccine efficacy in the short and longer term with the new bivalent boosters, Beneri said.

Additionally, more data should be forthcoming on treatment options, which will also be important with anticipated new waves over the holidays and new variants emerging, she added.

Combined vaccine

Recently, Pfizer/ BioNTech said it was in phase one trials for a single vaccine that would provide immune protection against COVID and the flu.

Local doctors urged patience as the pharmaceutical company and the Food and Drug Administration review the results from these trials.

“Although there may be benefits with combination vaccines from a compliance perspective, we need to weigh that against the risk of safety and efficacy,” Dr. Sunil Dhuper, chief medical officer at Port Jefferson’s St. Charles Hospital, explained in an email.

The medical community needs to ensure that the combination is neither less immunogenic nor less effective than the singular vaccines on their own, he added.

“Safety and tolerability are other important concerns with combination vaccines,” Dhuper explained. He hopes the clinical trials will answer a host of questions related to immune response, efficacy, and reactogenicity, which refers to injection site pain, redness, swelling, fever headaches and other responses to the vaccination.

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Ke Jian Liu

By Daniel Dunaief

Ke Jian “Jim” Liu, who arrived at Stony Brook University in late July, plans to help build effective, interdisciplinary research teams.

Ke Jian Liu

Most recently at the University of New Mexico, Liu joins Stony Brook as a Professor in the Renaissance School of Medicine’s Department of Pathology and Associate Director of Basic Science at the Stony Brook Cancer Center.

“In my mind, Stony Brook, research wise, is outstanding,” Liu said in an interview. “The quality of the faculty is excellent.”

Liu will rely on the team building experience he honed while serving as Distinguished Professor in the Department of Pharmaceutical Sciences and Associate Dean for Research in the College of Pharmacy at the University of New Mexico. He also worked for eight years at Dartmouth Medical School, where he focused on developing larger collaborations.

“I really enjoy working with people and building teams,” Liu said.

In a note announcing Liu’s arrival, Kenneth Shroyer, chair in the Department of Pathology, recognized Liu’s multidisciplinary approaches in his research. Shroyer explained that Liu has used techniques ranging from chemical to biochemical to biophysical, and from the molecular and cellular level to animal models, to answer specific biological questions.

Shroyer wrote that Liu would focus on opportunities for grant development within several programs. 

At the Cancer Center, Liu said he plans to continue the effort to help Stony Brook earn National Cancer Institute designation.

To achieve that designation, Stony Brook will need to continue to provide outstanding medical care, demonstrate community engagement and highlight what makes Stony Brook different from everyone else, he said.

“It takes a village to do that,” Liu said.

He praised the efforts of current Cancer Center Director Yusuf Hannun, who recently announced his plans to step down as head of the center, triggering a nationwide search for a replacement.

Liu said an ideal candidate for that position would have clinical experience.

Player coach

With a busy research effort and lofty leadership goals, Liu explained that he’s able to tackle numerous challenges at once.

“I consider myself a player coach,” he said. “I enjoy research. I have my own research grant and am working with my students and post docs.”

Liu typically maintains a lab with five to six people at different levels. His research has two branches, cancer and stroke, that most people likely consider unrelated, but for which he has found connections.

“People always think, ‘Cancer is cancer and stroke is stroke and they are two entirely different diseases,” Liu  said. As a basic researcher, however, he looks at the cells and the molecules involved in both conditions.

“At a molecular level, a molecule doesn’t care where it is,” he said. “When a disease develops, the biological fundamental process is the same. For me, it’s interesting to look at [whether] certain processes that occur in the brain also occur in cancer.”

Liu’s cancer research focuses specifically on the molecular processes that become carcinogenic when metals like arsenic enter people’s bodies. A well-described poison in numerous murder mysteries, arsenic can contaminate drinking water, get incorporated into crops like rice, or can appear in fruit juices.

When metal enters the body, it doesn’t just cause damage everywhere. It has to find a certain molecular target with which to interact.

What Liu and researchers in his lab have discovered is that the target for arsenic is often the same pathways the body uses in zinc. A transition metal, zinc provides an important element as a part of transcription factors that are critical in biological processes.

Arsenic, however, replaces zinc, which is “one of the major mechanisms for carcinogenesis,” Liu said.

Fortunately for residents of Long Island, arsenic isn’t as prevalent as it is in the midwest and the southwest.

“Long Island doesn’t have too much arsenic in drinking water,” Liu said, although people are still exposed to it through fruit juices, rice and other products.

Arsenic also causes vascular disease issues and anemia. People who develop these other conditions in response to arsenic are also at higher risk to develop cancer. The specific types of cancers arsenic causes are lung, skin and bladder cancer.

“Arsenic is the dirty bomb” in the body as it creates multiple problems, Liu said. “Arsenic interacts with those key zinc molecules.” 

Overlap between stroke and cancer

In highlighting the overlaps between the two fields of research, Liu related how the brain has one of the highest concentrations of zinc in the body.

When people have strokes, their brain cells have oxidative stress, which causes a flood of zinc into the brain tissue that also damages cells.

“We are trying to understand how zinc is released and how zinc causes damage to the brain,” Liu said.

Stroke and cancer also have molecular overlaps regarding oxygen. In a stroke, a blood clot causes a blockage of blood flow. Without oxygen, a situation called hypoxia, neurons start to die.

By contrast, a tumor grows in a hypoxic environment, using energy from sugars like glucose, rather than relying on oxygen for its growth.

Liu emphasized the importance of continuing to provide oxygen to brain regions around a clot even before trying to remove the clot or restore blood flow.

A goal for his 100th year

Originally from Beijing, China, Liu and his wife Jiao Ding enjoy traveling. Their daughter Sarah Liu is a resident at Vermont Medical Center and their son Evan Liu is a PhD student at Stanford.

An avid tennis player who plays the sport at least twice a week, Liu is looking forward to attending his first U.S. Open next year.

He and his former tennis partner in New Mexico joked that their goal is to be in the top 20 in the United States when they are 100 years old.

Liu chose the American name “Jim” because it sounds similar to the second syllable of his given name, Ke Jian.

“If people can’t pronounce your name, they shy away,” he said. He believes it’s important to “make yourself adaptable.”

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Stony Brook University Hospital

Stony Brook University Hospital (SBUH) has been recognized by the U.S. Department of Health and Human Services (HHS) at the 2022 United Nations Climate Change Conference (COP27) for pledging ongoing action to decarbonize the health care sector and make health care facilities more resilient to the effects of climate change. SBUH has formally committed to pursuing the White House’s climate goal of reducing emissions by 50 percent by 2030 and achieving net zero emissions by 2050 and has already begun:

“I’m delighted that Stony Brook University Hospital has signed on to the White House/HHS Health Sector Climate Pledge as we continue to be recognized locally and nationally as a leader in sustainability efforts,” said Hal Paz, MD, Executive Vice President for Health Sciences, Stony Brook University and Chief Executive Officer, Stony Brook University Medicine. “We remain focused on these initiatives and accelerating the health system’s progress toward a climate-conscious approach to care.”

“At Stony Brook University Hospital, we have made it our mission to support sustainable healthcare initiatives and reduce our carbon footprint,” says Carol Gomes, MS, FACHE, CPHQ, CEO of Stony Brook University Hospital. “We look forward to working with the Department of Health and Human Services to continue to make environmental changes that benefit not only our planet, but also our patients, employees and communities for years to come.”

A September 2021 consensus statement from more than 200 medical journals named climate change the number one threat to global public health. It exposes millions of people in the United States to harm every year—with disproportionate impacts on historically disadvantaged communities—through increases in extreme heat waves, wildfires, flooding, vector-borne diseases and other factors that worsen chronic health conditions. The healthcare sector also contributes to climate change, accounting for approximately 8.5 percent of U.S. domestic emissions.

The HHS Office of Climate Change and Health Equity (OCCHE), part of the Office of the Assistant Secretary for Health, developed the White House/HHS Health Sector Climate Pledge to help focus industry response to climate challenges. In addition to reducing their carbon footprint, signatories also commit to producing detailed plans to prepare their facilities for both chronic and acute catastrophic climate impacts.

One hundred and two prominent health companies in the U.S. have signed the White House/HHS Health Sector Climate Pledge, including organizations representing 837 hospitals as well as leading health centers, suppliers, insurance companies, group purchasing organizations, pharmaceutical companies, and more. Federal systems like the Indian Health Service (IHS), Veterans Health Administration (VHA), and Military Health System (MHS) are working together to meet similar goals to those the private sector organizations have embraced. Combined, over 1,080 federal and private sector hospitals have made such commitments, representing over 15 percent of U.S. hospitals. 

“HHS returns this year to COP27 to report great progress,” said Admiral Rachel Levine, Assistant Secretary for Health for the Department of Health and Human Services. “Through the efforts of the Office of Climate Change and Health Equity and several other HHS agencies, we have made significant strides in introducing resources and support to help communities and care providers accelerate their work to reduce harmful emissions and increase climate resilience in the health sector.”

This year, SBUH was also named among the Top 25 in the nation for Environmental Excellence, which is the highest honor awarded by Practice Greenhealth. The hospital was previously honored for Environmental Excellence in 2021 and presented with the Top 25 award in 2020.

For more information about how Stony Brook University Hospital is responding to our nation’s climate challenges, visit stonybrookmedicine.edu/sustainability.

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METRO photo
New research on PSA outcomes can inform your screening decisions

By David Dunaief, M.D.

Dr. David Dunaief

You may see more fuzzy faces among men this month. Welcome to “Movember,” when men grow facial hair to raise awareness and research money for men’s health issues (1). An initiative of the Movember Foundation, the intention is to fund men’s health projects focused on mental health and suicide prevention, prostate cancer, and testicular cancer.

Its prostate cancer initiatives focus on early detection, treatment options, and quality of life considerations for different treatments. Here, I’ll add prevention options to the conversation.

Regardless of your family history, you can reduce your risk of prostate cancer with simple lifestyle modifications. Factors that contribute to increased risk include obesity, animal fat, and supplements. Equally as important, factors that reduce risk include vegetables, especially cruciferous vegetables, and tomato sauce or cooked tomatoes.

I’ll also share new research to inform your decision-making about prostate-specific antigen (PSA) screening.

Obesity’s effect

According to a review of the literature, obesity may slightly decrease the risk of nonaggressive prostate cancer; however, it may also increase your risk of aggressive disease (2). Because larger prostates make biopsies less effective, the authors attribute the lower incidence of nonaggressive cancer to the possibility that it is more difficult to detect it in obese men. Ultimately, those who are obese have a greater risk of dying from prostate cancer when it is diagnosed.

Animal fat

There appears to be a direct effect between the amount of animal fat we consume and incidence of prostate cancer. In the Health Professionals Follow-up Study, those who consumed the highest amount of animal fat had a 63 percent increased risk of in advanced or metastatic prostate cancer, compared to those who consumed the least (3).

Also, in this study, red meat had an even greater, approximately 2.5-fold, increased risk of advanced disease. If you continue to eat red meat, reduce your frequency as much as possible, targeting once a month or quarter.

In another large, prospective observational study, the authors concluded that red and processed meats increase the risk of advanced prostate cancer through heme iron, barbecuing/grilling and nitrate/nitrite content (4).

Cooked tomatoes

Tomato sauce has been shown to potentially reduce the risk of prostate cancer. However, uncooked tomatoes have not shown the same beneficial effects. It is believed that lycopene, which is a type of carotenoid found in tomatoes, is central to this benefit. Tomatoes need to be cooked to release lycopene (5). 

As part of this larger study, 32 patients with localized prostate cancer consumed 30 mg of lycopene per day via tomato sauce-based dishes over a three-week period before radical prostatectomy. Key cancer indicators improved, and tissue tested before and after the intervention showed dramatic improvements in DNA damage in leukocyte and prostate tissue (6). 

In a prospective study involving 47,365 men who were followed for 12 years, prostate cancer risk was reduced by 16 percent with higher lycopene intake from a variety of sources (7). When the authors looked at tomato sauce alone, they saw a reduction in risk of 23 percent when comparing those who consumed at least two servings a week to those who consumed less than one serving a month. The reduction in severe, or metastatic, prostate cancer risk was even greater, at 35 percent. There was a statistically significant reduction in risk with a very modest amount of tomato sauce.

Although tomato sauce may be beneficial, many brands are loaded with salt, which creates its own bevy of health risks. I recommend to patients that they either make their own sauce or purchase prepared sauce made without salt.

Cruciferous vegetables

While results among studies vary, they all agree: consumption of vegetables, especially cruciferous vegetables, help reduce prostate cancer risk.

In a case-control study, participants who consumed at least three servings of cruciferous vegetables per week, versus those who consumed less than one per week, saw a 41 percent reduction in prostate cancer risk (8). What’s even more impressive is the effect was twice that of tomato sauce, yet the intake was similarly modest. Cruciferous vegetables include broccoli, cauliflower, bok choy, kale and arugula, to name a few.

A separate study of 1338 patients with prostate cancer in a larger cancer screening trial concluded that, while vegetable and fruit consumption did not appear to lower outright prostate cancer risk, increased consumption of cruciferous vegetables — specifically broccoli and cauliflower — did reduce the risk of aggressive prostate cancer, particularly of more serious stage 3 and 4 tumors (9). These results were seen with consumption of just one or more servings of each per week, when compared to less than one per month.

What about PSA screening?

In a recently published retrospective analysis of 128 Veteran’s Administration facilities, those where PSA screening was less frequent found higher rates of metastatic prostate cancer (10). During the study period from 2005 to 2019, researchers found an inverse relationship between PSA screening rates and metastatic prostate cancer. When screening rates decreased, rates of metastatic cancer increased five years later, while in facilities where screening rates increased, metastatic cancer rates decreased. While the study authors caution about extending these findings to the general population, they do suggest they could help inform conversations between men and their physicians about the value of PSA screening. 

When it comes to preventing prostate cancer and improving prostate cancer outcomes, lifestyle modifications, including making dietary changes, can reduce your risk significantly.

References: 

(1) www.movember.com. (2) Epidemiol Rev. 2007;29:88. (3) J Natl Cancer Inst. 1993;85(19):1571. (4) Am J Epidemiol. 2009;170(9):1165. (5) Exp Biol Med (Maywood). 2002; 227:914-919. (6) J Natl Cancer Inst. 2002;94(5):391. (7) Exp Biol Med (Maywood). 2002 Nov;227(10):886-93. (8) J Natl Cancer Inst. 2000;92(1):61. (9) J Natl Cancer Inst. 2007;99(15):1200-1209. (10) JAMA Oncol. Published online October 24, 2022.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.

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