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News Article | April 28, 2017

(Reuters Health) - Instead of eating less saturated fat and worrying about so-called bad cholesterol, a group of doctors suggests an alternative approach for preventing heart disease. More important, they say, is to focus on decreasing insulin resistance and inflammation in the body by targeting diet, exercise and reducing stress. "If we target all those three things together (plus) a reduction of smoking then we’ll combat 80 percent of all heart disease," said Dr. Aseem Malhotra of Lister Hospital in Stevenage, UK, who coauthored an editorial in the British Journal of Sports Medicine. Saturated fats are mostly found in animal products like beef, pork, butter, cheese and other dairy. Blaming coronary artery disease on saturated fat that clogs arteries is "just plain wrong," according to Malhotra and his two coauthors, Dr. Rita Redberg of the University of California, San Francisco and Dr. Pascal Meier of University College London, UK. In their editorial, the three experts cite a 2015 review of past research that found no link between a diet full of saturated fats and an increased risk of coronary heart disease, type 2 diabetes, stroke due to clogged arteries, death from coronary heart disease, or death from any cause. Furthermore, Malhotra told Reuters Health, the traditional advice to reduce levels of "bad" low-density lipoprotein (LDL) cholesterol through diet and exercise "is flawed." He and his colleagues point to studies in which people who replaced saturated fat with vegetable oils containing omega-6 fatty acids did lower their LDL and total cholesterol levels but still ended up with a higher rate of death. They also cite the well-known PREDIMED trial, in which people eating a Mediterranean diet with fats from olive oil or nuts were at lower risk of heart problems than people following a low-fat diet. Another trial found better outcomes in people following a Mediterranean diet than in people eating a typical French diet, despite similar LDL levels in both groups. The best way to predict heart disease risk, they write, is to look at patients' ratio of total cholesterol to "good" high-density lipoprotein (HDL) cholesterol. A high ratio is linked with insulin resistance, which leads to high blood sugar and higher risks for heart disease, type 2 diabetes and obesity. Malhotra said insulin resistance is worsened when low-fat dieting leads people to eat more refined carbohydrates like white bread and white rice, which are not found in Mediterranean diets. He and his colleagues say Mediterranean diets, exercise and reducing stress all help combat inflammation. "I think the best way to reduce risk of heart disease and stay healthy is to concentrate on a heart-healthy Mediterranean style diet, regular physical activity and not smoking," Redberg told Reuters Health by email. Dr. Stephen Kopecky, a cardiologist at the Mayo Clinic in Rochester, Minnesota, agrees with the experts' inflammation theory but isn't ready to remove the emphasis on LDL cholesterol. Kopecky told Reuters Health that LDL levels are still an important measure to watch and treat with medications. Dr. Dariush Mozaffarian, dean of the Tufts Friedman School of Nutrition Science and Policy in Boston, also says LDL levels are still important. "I think the message is correct that we need more focus on diet and reducing inflammation," Mozaffarian told Reuters Health. "It doesn’t mean we should throw out an additional tool focusing on LDL cholesterol and treatment." Prevention doesn't involve a choice between lifestyle changes or lowering cholesterol, Mozaffarian added. "It's both," he said.

News Article | April 25, 2017

Best form of prevention and treatment are 'real' food and a brisk 22 minute daily walk The widely held belief among doctors and the public that saturated fats clog up the arteries, and so cause coronary heart disease, is just "plain wrong," contend experts in an editorial published online in the British Journal of Sports Medicine. It's time to shift the focus away from lowering blood fats and cutting out dietary saturated fat, to instead emphasising the importance of eating "real food," taking a brisk daily walk, and minimising stress to stave off heart disease, they insist. Coronary artery heart disease is a chronic inflammatory condition which responds to a Mediterranean style diet rich in the anti-inflammatory compounds found in nuts, extra virgin olive oil, vegetables and oily fish, they emphasise. In support of their argument Cardiologists Dr Aseem Malhotra, of Lister Hospital, Stevenage, Professor Rita Redberg of UCSF School of Medicine, San Francisco (editor of JAMA Internal medicine) and Pascal Meier of University Hospital Geneva and University College London (editor of BMJ Open Heart) cite evidence reviews showing no association between consumption of saturated fat and heightened risk of cardiovascular disease, diabetes, and death. And the limitations of the current 'plumbing theory' are writ large in a series of clinical trials showing that inserting a stent (stainless steel mesh) to widen narrowed arteries fails to reduce the risk of heart attack or death, they say. "Decades of emphasis on the primacy of lowering plasma cholesterol, as if this was an end in itself and driving a market of 'proven to lower cholesterol' and 'low fat' foods and medications, has been misguided," they contend. Selective reporting of the data may account for these misconceptions, they suggest. A high total cholesterol to high density lipoprotein (HDL) ratio is the best predictor of cardiovascular disease risk, rather than low density lipoprotein (LDL). And this ratio can be rapidly reduced with dietary changes such as replacing refined carbohydrates with healthy high fat foods (such as nuts and olive oil), they say. A key aspect of coronary heart disease prevention is exercise, and a little goes a long way, they say. Just 30 minutes of moderate activity a day three or more times a week works wonders for reducing biological risk factors for sedentary adults, they point out. And the impact of chronic stress should not be overlooked because it puts the body's inflammatory response on permanent high alert, they say. All in all, a healthy diet, regular exercise, and stress reduction will not only boost quality of life but will curb the risk of death from cardiovascular disease and all causes, they insist. "It is time to shift the public health message in the prevention and treatment of coronary artery disease away from measuring serum lipids and reducing dietary saturated fat," they write. "Coronary artery disease is a chronic inflammatory disease and it can be reduced effectively by walking 22 minutes a day and eating real food." But, they point out: "There is no business model or market to help spread this simple yet powerful intervention."

Gale N.K.,University of Birmingham | Heath G.,University of Birmingham | Cameron E.,Aston University | Rashid S.,Lister Hospital | Redwood S.,University of Birmingham
BMC Medical Research Methodology | Year: 2013

Background: The Framework Method is becoming an increasingly popular approach to the management and analysis of qualitative data in health research. However, there is confusion about its potential application and limitations. Discussion. The article discusses when it is appropriate to adopt the Framework Method and explains the procedure for using it in multi-disciplinary health research teams, or those that involve clinicians, patients and lay people. The stages of the method are illustrated using examples from a published study. Summary. Used effectively, with the leadership of an experienced qualitative researcher, the Framework Method is a systematic and flexible approach to analysing qualitative data and is appropriate for use in research teams even where not all members have previous experience of conducting qualitative research. © 2013 Gale et al.; licensee BioMed Central Ltd.

News Article | October 26, 2016

“PEOPLE have told me what I do is dangerous. They have walked away from me at meetings,” says David Unwin, a doctor practising in Southport, UK. Unwin suggests to his patients with type 2 diabetes or who want to lose weight that they do the opposite of what official health advice recommends. He advises them to stop counting calories, eat high-fat foods – including saturated fats – and avoid carbohydrates, namely sugar and starch. Telling people to avoid sugar is uncontroversial; the rest is medical heresy. But crazy as it sounds, Unwin has found that most of his diabetes patients who follow this advice are getting their blood sugar back under control, and that some are coming off medication they have relied on for years. Those who are overweight are slimming down. This might seem like just another controversial fad diet, but a growing number of researchers, doctors and nutritionists around the world are backing it, and reporting their findings in peer-reviewed medical journals. Last month, the National Obesity Forum, a UK body for health professionals involved in weight management, made headlines when it overhauled its advice, telling people to ditch calorie-counting, low-fat foods and carbs in favour of fats. The recommendations provoked a furious backlash from mainstream scientists and dieticians, but they should concern us all. If the advice is to be believed, starchy food isn’t just bad for diabetes, it makes us fat and causes heart attacks. This is analogous to finding that smoking protects people from lung cancer, says David Haslam, an obesity specialist at the Lister Hospital in Stevenage, UK, and head of the

Wierzbicki A.S.,St Thomas Hospital Campus | Hardman T.C.,NICHE | Viljoen A.,Lister Hospital
Expert Opinion on Investigational Drugs | Year: 2012

Introduction: Pre-protein convertase subtilisin kexin (PCSK)-9 is a newly discovered protein involved in intracellular and extracellular regulation of low-density lipoprotein receptor (LDLR) expression. Autosomal dominant activating mutations in PCSK-9 cause familial hypercholesterolaemia whereas inactivating mutations in man reduce LDL cholesterol (LDL-C) and are associated with a decreased lifetime risk of cardiovascular events. Areas covered: As PCSK-9 binds to the LDLR, a number of approaches involving small molecule or peptide inhibition of binding, antibody-mediated inactivation of binding and the use of antisense oligonucleotides are being investigated as therapeutic approaches to lower LDL-C in man. This article reviews the biochemistry and physiology of PCSK-9 and details the efforts made to design novel molecules with the ability to inhibit PCSK-9 activity. Work in animal models has confirmed that reducing PCSK-9 expression can reduce atherosclerosis in mice, rats and primates. Monoclonal antibodies such as REGN-727 and AMG-145 have been shown to reduce LDL-C in patients with familial hypercholesterolaemia already treated with statins or healthy normocholesterolaemic controls. Expert opinion: PCSK-9 inhibition is a potentially interesting novel addition to the armamentarium of LDL-C reducing drugs. Its effects in reducing LDL-C will need to be confirmed to reduce CVD events in large-scale clinical trials. © 2012 Informa UK, Ltd.

Bretherton C.P.,Lister Hospital | Parker M.J.,Peterborough City Hospital
The bone & joint journal | Year: 2015

There has been extensive discussion about the effect of delay to surgery on mortality in patients sustaining a fracture of the hip. Despite the low level of evidence provided by many studies, a consensus has been accepted that delay of > 48 hours is detrimental to survival. The aim of this prospective observational study was to determine if early surgery confers a survival benefit at 30 days. Between 1989 and 2013, data were prospectively collected on patients sustaining a fracture of the hip at Peterborough City Hospital. They were divided into groups according to the time interval between admission and surgery. These thresholds ranged from < 6 hours to between 49 and 72 hours. The outcome which was assessed was the 30-day mortality. Adjustment for confounders was performed using multivariate binary logistic regression analysis. In all, 6638 patients aged > 60 years were included. Worsening American Society of Anaesthesiologists grade (p < 0.001), increased age (p < 0.001) and extracapsular fracture (p < 0.019) increased the risk of 30-day mortality. Increasing mobility score (p = 0.014), mini mental test score (p < 0.001) and female gender (p = 0.014) improved survival. After adjusting for these confounders, surgery before 12 hours improved survival compared with surgery after 12 hours (p = 0.013). Beyond this the increasing delay to surgery did not significantly affect the 30-day mortality. ©2015 The British Editorial Society of Bone & Joint Surgery.

This post hoc analysis of the recently reported Frequent Hemodialysis Network Trials suggests that frequent nocturnal treatment, unlike frequent daily treatment, may be associated with more rapid loss of residual kidney function than conventional hemodialysis. Differences in blood pressure control, among other factors, may be implicated. The study invites reflection on our current concepts of the importance of preserving residual kidney function and on the indications for frequent treatments, particularly nocturnal. © 2013 International Society of Nephrology.

No imaging technique is more popular or more in demand than ultrasound. But should it be considered a specialist technique to be employed only by highly trained professionals or as a readily available tool to be used by many? This paper will discuss some of the implications of having ultrasound performed by a range of individuals and will emphasize the importance of training and regulation.

Wierzbicki A.S.,Guys And St Thomas Hospitals | Viljoen A.,Lister Hospital
Expert Opinion on Biological Therapy | Year: 2013

Homozygous lipoprotein lipase (LPL) deficiency is an ultra-orphan disease associated with increased rates of pancreatitis. Current treatments based on acute plasmapheresis allied with ultra-low fat diets are inadequate as responses to fibrates or other triglyceride-lowering therapies tend to be poor. Alipogene tiparvovec is an adeno-associated virus type I (AAV1) gene therapy using a hyper-functional LPL serine447-stop (S447X) insert administered intramuscularly under general anaesthetic with allied immunosuppression. Treatment results in histological muscle expression of LPL allied with a transient 40% reduction in triglycerides and improvements in postprandial chylomicron triglyceride content. Alipogene tiparvovec is the first possibly curative treatment for LPL deficiency. © 2013 Informa UK, Ltd.

Smith A.H.,Lister Hospital
Emergency medicine journal : EMJ | Year: 2013

Massive haemorrhage still accounts for up to 40% of mortality after traumatic injury. The importance of limiting blood loss after injury in order to prevent its associated complications has led to rapid advances in the development of dressings for haemostatic control. Driven by recent military conflicts, there is increasing evidence to support their role in the civilian prehospital care environment. This review aims to summarise the key characteristics of the haemostatic dressings currently available on the market and provide an educational review of the published literature that supports their use. Medline and Embase were searched from start to January 2012. Other sources included both manufacturer and military publications. Agents not designed for use in prehospital care or that have been removed from the market due to significant safety concerns were excluded. The dressings reviewed have differing mechanisms of action. Mineral based dressings are potent activators of the intrinsic clotting cascade resulting in clot formation. Chitosan based dressings achieve haemostasis by adhering to damaged tissues and creating a physical barrier to further bleeding. Acetylated glucosamine dressings work via a combination of platelet and clotting cascade activation, agglutination of red blood cells and local vasoconstriction. Anecdotal reports strongly support the use of haemostatic dressings when bleeding cannot be controlled using pressure dressings alone; however, current research focuses on studies conducted using animal models. There is a paucity of published clinical literature that provides an evidence base for the use of one type of haemostatic dressing over another in humans.

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