Friday, July 14, 2017

Diet & Statin

Dr Mark Porter: The diet that’s almost as good as statins — and I’m proof that it works
Dr Mark Porter

Published at 12:01AM, February 16 2016

Older folk can expect a longer retirement, according to a new report from Public Health England, which shows that over-65s can look forward to another 20 years on average. Yet to enjoy those extra decades you will need an adequate pension and good health. I can’t help with the former but I do have a useful tip to maintain the latter.

At the beginning of the year I embarked on a six-week trial to see whether cutting back on carbohydrates could improve my poor cholesterol profile. The results are in and I am bowled over. The finer details are in the box below, but these are the headline results: I shed half a stone in weight, my cholesterol level dropped by 20 per cent, my triglyceride level by 30 per cent and, according to the risk calculator favoured by the NHS, my odds of succumbing to an early heart attack or stroke have dropped by nearly 15 per cent. Not quite the benefit you might expect from taking a statin, but as near as dammit.

Now I am well aware that one swallow doesn’t make a summer, and just because cutting back on carbs has had such a significant effect on my blood chemistry, it doesn’t mean it will work as well for you. Yet if you are one of the five million or so middle-aged people like me who, thanks to a combination of poor family history and high cholesterol levels, are eligible for statins, I would urge you to take a close look at your diet first. So what changes did I make, and where have the benefits come from?

First some context. At 6ft 2in and 14 stone, I wasn’t particularly overweight but I had a touch of middle-age spread with a BMI of 26 (25 is the upper limit of healthy). My cholesterol was raised (anywhere between 7.3 and 8 over recent years) and, although I ate a healthy diet, I have a sweet tooth and consumed far too much bread.

The plan was simple. I cut out all fruit juices, bread, cakes, biscuits and confectionery. And I restricted other starchy foods such as rice, pasta and potatoes. I carried on taking one sugar in my coffee and I had a free day on Sundays which, on at least one occasion, included sticky toffee pudding at my local pub. I made no other changes to my diet or lifestyle and the result would qualify at the upper end of what most people would regard as a low-carb diet, but it represented a significant reduction for me.

The resulting improvement in my blood profile could have come about in a number of ways. First, the weight loss will have helped. The drop in triglycerides (high levels of which are a risk factor for heart disease) is a direct result of fewer carbs, but a big reduction in fats may also have helped; I have eaten hardly any butter in the past six weeks. Not only is butter a keen component of my favoured sandwiches and rolls, it also features in many carb-rich foods such as cakes and other treats.

One other unintentional change was that I ended up eating more meat, eggs and cheese. Yet, while you would have expected this to have raised my cholesterol level, the opposite happened. And the latest research reflects this — while eating butter is bad for your cholesterol profile, eggs, cheese and lean meats don’t seem to have much impact.

Until I started this trial I was considering statins — which I have tried in the past — but my cardiovascular risk ( has dropped below the new 10 per cent threshold, so I am not going to worry for now.

My only regret is that I wish I had tried this in my twenties. I have never subscribed to the view that sugar is public enemy no 1 — there is so much more to disease than obesity and one nutrient — but I am a convert to the view that too much sugar and other carbs (which the body converts to sugar) are not good for us. My local bakery and my favoured sandwich shop may regret my decision but it is low carbs for me from now on.

The results at a glance

After six weeks cutting back on carbs my weight fell from 14st to 13st 7lb

My fasting cholesterol level fell from 7.3 to 5.9 and my triglycerides from 2.5 to 1.5

My “good” cholesterol (HDL) fell slightly from 1.3 to 1.2

I did not monitor my blood sugar levels because these have always been well into the healthy range, but those at risk of diabetes should expect a significant drop here too.

Friday, June 30, 2017

Lithium 2017

Lithium: The Gift That Keeps on Giving in Psychiatry

Nassir Ghaemi, MD, MPH
June 16, 2017

Wide-Ranging Benefits

At the recent American Psychiatric Association annual meeting in San Diego, an update symposium was presented on the topic of "Lithium: Key Issues for Practice."[1] In a session chaired by Dr David Osser, associate professor of psychiatry at Harvard Medical School, presenters reviewed various aspects of the utility of lithium in psychiatry.
Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.
These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).

Christoforos Giakoumatos, MD, from the Harvard South Shore Psychiatry residency training program, reviewed the scientific literature on lithium's neuroprotective effects. Extensive animal studies have shown that lithium keeps neurons alive longer. Some human studies also suggest a benefit of lithium in prevention or amelioration of dementia, consistent with its neurobiological benefits. These data support further work to clarify how much, and to what extent, lithium could be useful in human neurodegenerative diseases.
Othman Mohammad, MD, also from the Harvard South Shore program, examined lithium use in children and adolescents, and reviewed a number of randomized trials that showed evidence for efficacy and short-term safety with lithium in acute manic episodes, especially in adolescents. Of note, similar randomized data did not show benefit with divalproex, indicating that there is relatively more evidence for lithium's efficacy and safety in adolescence.

Lithium's Safety Profile

Dana Wang, MD, a senior resident in the Harvard South Shore program, reviewed the kidney effects of lithium and the latest studies quantifying those harms. For instance, in recent data from Sweden, lithium was associated with end-stage renal failure in about 1% of all patients who were treated with it—an effect that occurred over a mean of more than 20 years of treatment.
The rate is somewhat higher if the sample is limited to those who take lithium for a minimum of 10 years; in that case, up to 5% of patients may develop end-stage renal disease eventually. Although these numbers are important, they also indicate that over 95% of lithium-treated persons never develop end-stage renal disease.
Multiple daily dosing of lithium is a major risk factor for such chronic renal harm, and it is a preventable one, because lithium has a half-life of 24 hours and only needs to be dosed once daily. Furthermore, keeping lithium levels low, and thus avoiding acute lithium toxicity, is another preventable risk factor for chronic renal impairment. By dosing lithium once daily at night and at the lowest dose feasible, the risk for long-term kidney harm with lithium can be reduced even further.
Dr Osser ended the symposium by discussing how to manage other lithium-related side effects. He noted that lithium causes less weight gain than divalproex or commonly used antipsychotics, such as olanzapine and quetiapine. Thus, if those agents are used, so should lithium. He also noted some ways in which weight gain can be ameliorated with lithium: for example, educating patients to avoid consuming caloric beverages (such as sodas) when managing lithium-related thirst. Water retention with lithium can be managed by using amiloride. Carbohydrate craving is an important aspect of lithium-related weight gain, and the most difficult to manage.


I provided a commentary at the end of the symposium, where I noted that our oldest drugs are our most effective: electroconvulsive therapy, lithium, monoamine oxidase inhibitors, and clozapine. All of the new drugs developed since the 1970s have not advanced greater efficacy for any major psychiatric condition. They do have fewer side effects, which is important. But the case of lithium reminds us that we should not assume that newer is better.
All patients should be told about the potential range of benefits of lithium, in terms of mortality/suicide and neuroprotection/dementia prevention, in addition to its well-proven mood benefits. If this is understood, then many patients and doctors would perhaps also understand how these benefits could outweigh the risks of lithium. Such risks should be considered limited, with about 1% long-term kidney risk and less weight gain than other commonly used agents.

Thursday, June 22, 2017


Jonas Kaufmann and Maria Agresta in Otello at the Royal Opera
Jonas Kaufmann and Maria Agresta in Otello at the Royal Opera CREDIT: ALASTAIR MUIR

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No, he didn’t cancel and yes, he was very good indeed. Despite all the anxieties attendant on this wondrous but somewhat unreliable German tenor, Jonas Kaufmann finally made his long-awaited debut in the taxing title-role of Verdi’s Otello.
His singing is technically almost unimpeachable: perfectly in tune, even between the registers, cleanly projected. None of the challenges here were fluffed or ducked, and the sensitivity of his musicality was always evident, with some particularly lovely tone and phrasing in the love duet and the “Dio mi potevi scagliar” monologue.

Thomas Atkins and Marco Vratogna in Otello
Thomas Atkins and Marco Vratogna in Otello CREDIT: ALASTAIR MUIR
But as yet his interpretation is cautious; he ventures nowhere near the character’s emotional edge. The opening “Esultate” had no clarion authority, “Si, pel ciel” didn’t raise the rafters and he didn’t let rip on “Ora e per sempre addio”. Nor is he the world’s greatest actor: his stage presence is oddly diffident, to the point that one never sensed the mighty General or even the outsider Moor (his flesh, incidentally, was barely darkened).
Otello’s downfall is moving because it comes from a lofty height: Kaufmann radiates only a dashing young Captain who loses his cool. If the interpretation is to develop, he needs to radiate a more regal demeanour, commanding the stage through stillness and a stare, as his great predecessors Jon Vickers and Placido Domingo did. 
The audience received him warmly, but no more warmly than his fellow principals. Maria Agresta made a maturely poised and elegant Desdemona – was I alone in craving more seraphic purity and more vivid enunciation? As Iago, Marco Vratogna (a late substitute for Ludovic Tézier) was brilliantly incisive and devilish – perhaps excessively so, as Otello emphatically deems him “onesto”.

Jonas Kaufmann and Maria Agresta in Otello
Jonas Kaufmann and Maria Agresta in Otello CREDIT: ALASTAIR MUIR
Of the remainder of the performance there is little to say. Frédéric Antoun was a pleasant but slightly underpowered Cassio, and an expanded chorus made a proportionately big noise. Antonio Pappano’s conducting of this opera, a known quantity at Covent Garden, is sharply energised but falls short of the sublime.
The real disappointment was a lame, ugly and soporifically dark staging by Keith Warner that is no improvement on what it replaces. Costuming is generically Renaissance, but the black-walled chamber with movable latticed panels designed by Boris Kudlicka evokes a Stasi HQ circa 1960; at no point does Warner bring the drama any psychological life, and his direction of the denouement is particularly ludicrous. The net result is an Otello without visceral impact.
In rep until July 15. Tickets: 020 7304 4000;
The performance on 28 June will be broadcast live in HD to cinemas around the UK and the world

Friday, March 31, 2017

Die Meistersinger von Nürnberg:


Johannes Martin Kranzle as Sixtus Beckmesser, Bryn Terfel as Hans Sachs, Sebastian Holecek as Fritz Kothner
Johannes Martin Kranzle as Sixtus Beckmesser, Bryn Terfel as Hans Sachs, Sebastian Holecek as Fritz Kothner CREDIT: ALASTAIR MUIR 

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Why do certain opera directors try too hard? Why are they so afraid of a libretto’s specifications, and why do they set out to confuse rather than clarify? Such were the questions nagging me during Kasper Holten’s restless and irritating new interpretation of Wagner’s comedy.
Compared to the wonderfully economical lucidity of Richard Jones’s recent ENO production, this seems to me little more than a sophomore exercise in intellectual obfuscation, needlessly extravagant and fussed-up with superfluities. It must have cost a bomb.
The first act is set in what looks like a gentleman’s club designed in the 1920s, in which David and Magdalene are stewards. The Masters convene for a Rotarian dinner, into which Walther – an uncouth, greasy rocker – intrudes unceremoniously. So far, so good: but what sense in such a context Pogner’s decision to sell off (in effect) his daughter as a competition prize can make is unclear.

Bryn Terfel as Hans Sachs, Johannes Martin Kranzle as Sixtus Beckmesser
Bryn Terfel as Hans Sachs, Johannes Martin Kranzle as Sixtus Beckmesser CREDIT: ALASTAIR MUIR 
Things get steadily sillier. The second act takes place not in the streets on a balmy summer’s evening, but inside the club’s salon, where Sachs cobbles implausibly out of a tool-box. The delicate geography of the scene is clumsily represented without allusion to its essentially open-air nature and the final riot becomes a nightmare pageant, apparently happening inside Sachs’s head, with the Nightwatchman presiding as a cloven-hoofed Pan.
The fancy footwork gets even more intricate in the last act, culminating in Eva stomping off in rage at Walther’s surrender to the Masters’ codes. It’s all impeccably rehearsed and the acting is generally vivid, but the wood can’t be seen for trees - Wagner’s delicately humane exploration of the role of art in a bourgeois community, the creative tension between tradition and innovation, and the artist’s struggle to preserve his vision goes unaddressed.

Bryn Terfel as Hans Sachs, Rachel Willis-Sorensen as Eva
Bryn Terfel as Hans Sachs and Rachel Willis-Sorensen as Eva CREDIT: ALASTAIR MUIR
After an oddly joyless Prelude, Antonio Pappano conducts the magnificent orchestra flawlessly: I’ve never heard the architecture of the first act so beautifully shaped or the third act open in such exquisite melancholy. Allan Clayton and Hanna Hipp make an enchanting David and Magdalene, Rachel Willis-Sorensen’s Eva uttered gorgeous if verbally indistinct noises, Gwyn Hughes Jones sings most eloquently as Walther and Johannes Martin Kränzle is superb as a prissy but pitiable Beckmesser. Bryn Terfel’s downbeat Hans Sachs was slightly disappointing – vocally pallid in the first two acts, if more focused in the third. Perhaps he was as bemused as I was by the muddle of Holten’s staging.
Until 31 March. Tickets: 0207 304 4000