What Matters

Fecal incontinence is a devastating and isolating condition. Sales of adult diapers are a $7 billion global market and the fastest-growing household products business. Which is where a lot of our patients with this condition remain – at home.

Fecal incontinence (FI) is a condition characterized by continuous or recurrent uncontrolled passage of fecal material. The prevalence may be as high as 15%. Risk factors include physical disabilities, dementia, diabetes, urinary incontinence, chronic diarrhea, and multiparity. One-third of patients will talk to us about it. Which for some of us may be suitable, given our inability to offer good treatments.

If patients do mention it, evaluation involves taking a good history. We need to differentiate incontinence from fecal urgency and frequency. Anorectal examination should look for a bilateral anal wink (absence suggests nerve damage). Some form of endoscopic examination should be performed in most patients. Further evaluation/referral will be based upon findings.

Treatment includes improving stool consistency (e.g., fiber for loose stool) and reducing frequency (e.g., loperamide for diarrhea), and this is generally where I start. Hyoscyamine may be helpful for post-meal leakage. Scheduled defecation and amitriptyline may be of benefit to some patients.

Dr. Henri Damon of Hospices Civils de Lyon, France, and his colleagues conducted a multicenter study of perineal retraining for FI (Dig. Liver Dis. 2014;46:237-42). The intervention included perineal retraining and biofeedback. The protocol was based upon 20 sessions of 30 minutes performed within a 4-month period. The intervention was standardized. Eighty patients were included in the control group, with 77 in the biofeedback group.

The success rate was significantly higher in the biofeedback group (57% vs. 37%; P < .021). Stool frequency, leakage, and urgency significantly decreased. Perineal retraining was significantly associated with a higher chance of self-rated improvement.

The take-home message is that perineal retraining is an effective component of FI treatment. Combining it with improved perianal skin hygiene, bowel habit ritualization, and the addition of fiber as a bulking agent and loperamide for diarrhea offers the greatest hope for patients suffering from this challenging condition.

Our job is to figure out where and how our patients can access the level of expertise needed to do the training.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Fecal incontinence is a devastating and isolating condition. Sales of adult diapers are a $7 billion global market and the fastest-growing household products business. Which is where a lot of our patients with this condition remain – at home.

Fecal incontinence (FI) is a condition characterized by continuous or recurrent uncontrolled passage of fecal material. The prevalence may be as high as 15%. Risk factors include physical disabilities, dementia, diabetes, urinary incontinence, chronic diarrhea, and multiparity. One-third of patients will talk to us about it. Which for some of us may be suitable, given our inability to offer good treatments.

If patients do mention it, evaluation involves taking a good history. We need to differentiate incontinence from fecal urgency and frequency. Anorectal examination should look for a bilateral anal wink (absence suggests nerve damage). Some form of endoscopic examination should be performed in most patients. Further evaluation/referral will be based upon findings.

Treatment includes improving stool consistency (e.g., fiber for loose stool) and reducing frequency (e.g., loperamide for diarrhea), and this is generally where I start. Hyoscyamine may be helpful for post-meal leakage. Scheduled defecation and amitriptyline may be of benefit to some patients.

Dr. Henri Damon of Hospices Civils de Lyon, France, and his colleagues conducted a multicenter study of perineal retraining for FI (Dig. Liver Dis. 2014;46:237-42). The intervention included perineal retraining and biofeedback. The protocol was based upon 20 sessions of 30 minutes performed within a 4-month period. The intervention was standardized. Eighty patients were included in the control group, with 77 in the biofeedback group.

The success rate was significantly higher in the biofeedback group (57% vs. 37%; P < .021). Stool frequency, leakage, and urgency significantly decreased. Perineal retraining was significantly associated with a higher chance of self-rated improvement.

The take-home message is that perineal retraining is an effective component of FI treatment. Combining it with improved perianal skin hygiene, bowel habit ritualization, and the addition of fiber as a bulking agent and loperamide for diarrhea offers the greatest hope for patients suffering from this challenging condition.

Our job is to figure out where and how our patients can access the level of expertise needed to do the training.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Fecal incontinence is a devastating and isolating condition. Sales of adult diapers are a $7 billion global market and the fastest-growing household products business. Which is where a lot of our patients with this condition remain – at home.

Fecal incontinence (FI) is a condition characterized by continuous or recurrent uncontrolled passage of fecal material. The prevalence may be as high as 15%. Risk factors include physical disabilities, dementia, diabetes, urinary incontinence, chronic diarrhea, and multiparity. One-third of patients will talk to us about it. Which for some of us may be suitable, given our inability to offer good treatments.

If patients do mention it, evaluation involves taking a good history. We need to differentiate incontinence from fecal urgency and frequency. Anorectal examination should look for a bilateral anal wink (absence suggests nerve damage). Some form of endoscopic examination should be performed in most patients. Further evaluation/referral will be based upon findings.

Treatment includes improving stool consistency (e.g., fiber for loose stool) and reducing frequency (e.g., loperamide for diarrhea), and this is generally where I start. Hyoscyamine may be helpful for post-meal leakage. Scheduled defecation and amitriptyline may be of benefit to some patients.

Dr. Henri Damon of Hospices Civils de Lyon, France, and his colleagues conducted a multicenter study of perineal retraining for FI (Dig. Liver Dis. 2014;46:237-42). The intervention included perineal retraining and biofeedback. The protocol was based upon 20 sessions of 30 minutes performed within a 4-month period. The intervention was standardized. Eighty patients were included in the control group, with 77 in the biofeedback group.

The success rate was significantly higher in the biofeedback group (57% vs. 37%; P < .021). Stool frequency, leakage, and urgency significantly decreased. Perineal retraining was significantly associated with a higher chance of self-rated improvement.

The take-home message is that perineal retraining is an effective component of FI treatment. Combining it with improved perianal skin hygiene, bowel habit ritualization, and the addition of fiber as a bulking agent and loperamide for diarrhea offers the greatest hope for patients suffering from this challenging condition.

Our job is to figure out where and how our patients can access the level of expertise needed to do the training.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Our relationship with vitamins and supplements may be approach-avoidance. On one hand, if they are beneficial and patients are motivated to take them, we do not complain. This is likely a marker of motivated patient who may heed other health promotional advice that we proffer. On the other hand, it is difficult to keep up with the massive amount of good and bad literature about them. Patients can challenge us on our medical knowledge, pinging our opinions about the latest findings tweeted out while we struggle to keep up with all the wheelchair forms.

Vitamins are clearly not consistently beneficial. B vitamins may increase lung cancer risk in smokers. Vitamin D, however, seems to have some of the greatest “staying power” in the clinical realm and has a good reputation as far as vitamins go. Vitamin D is probably good for the heart, but how about the head? Could low D cause dementia? If so, how?

Previous studies of the relationship between vitamin D and dementia have not shown consistent results. Thomas Littlejohns, M.Sc., and colleagues have published a fantastic piece of work (Neurology 2014 Aug. 6 [doi: 10.1212/WNL.0000000000000755]) that sheds some light. They evaluated a prospective cohort of 1,658 elderly ambulatory adults with no history of dementia, CVD, or stroke who had baseline 25-hydroxyvitamin D [25(OH)D] concentrations at baseline. Severely low levels of 25(OH)D and deficiency (≥25 to <50 nmol/L) were associated with a significantly increased risk for all-cause dementia and Alzheimer’s dementia.

Several hypotheses exist as to why vitamin D helps the brain. Vitamin D may attenuate amyloid-induced cytotoxicity and neural apoptosis. It also may reduce the risk of strokes by promoting healthy cerebral vasculature.

The Institute of Medicine recommends a serum concentration of 25(OH)D at 50 nmol/L. This study would suggest that sufficiency to this level is neuroprotective. The next step is to see if supplementation can modify baseline risk, but many of my patients may wait for these data to come out before starting their vitamin D supplements.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Our relationship with vitamins and supplements may be approach-avoidance. On one hand, if they are beneficial and patients are motivated to take them, we do not complain. This is likely a marker of motivated patient who may heed other health promotional advice that we proffer. On the other hand, it is difficult to keep up with the massive amount of good and bad literature about them. Patients can challenge us on our medical knowledge, pinging our opinions about the latest findings tweeted out while we struggle to keep up with all the wheelchair forms.

Vitamins are clearly not consistently beneficial. B vitamins may increase lung cancer risk in smokers. Vitamin D, however, seems to have some of the greatest “staying power” in the clinical realm and has a good reputation as far as vitamins go. Vitamin D is probably good for the heart, but how about the head? Could low D cause dementia? If so, how?

Previous studies of the relationship between vitamin D and dementia have not shown consistent results. Thomas Littlejohns, M.Sc., and colleagues have published a fantastic piece of work (Neurology 2014 Aug. 6 [doi: 10.1212/WNL.0000000000000755]) that sheds some light. They evaluated a prospective cohort of 1,658 elderly ambulatory adults with no history of dementia, CVD, or stroke who had baseline 25-hydroxyvitamin D [25(OH)D] concentrations at baseline. Severely low levels of 25(OH)D and deficiency (≥25 to <50 nmol/L) were associated with a significantly increased risk for all-cause dementia and Alzheimer’s dementia.

Several hypotheses exist as to why vitamin D helps the brain. Vitamin D may attenuate amyloid-induced cytotoxicity and neural apoptosis. It also may reduce the risk of strokes by promoting healthy cerebral vasculature.

The Institute of Medicine recommends a serum concentration of 25(OH)D at 50 nmol/L. This study would suggest that sufficiency to this level is neuroprotective. The next step is to see if supplementation can modify baseline risk, but many of my patients may wait for these data to come out before starting their vitamin D supplements.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Our relationship with vitamins and supplements may be approach-avoidance. On one hand, if they are beneficial and patients are motivated to take them, we do not complain. This is likely a marker of motivated patient who may heed other health promotional advice that we proffer. On the other hand, it is difficult to keep up with the massive amount of good and bad literature about them. Patients can challenge us on our medical knowledge, pinging our opinions about the latest findings tweeted out while we struggle to keep up with all the wheelchair forms.

Vitamins are clearly not consistently beneficial. B vitamins may increase lung cancer risk in smokers. Vitamin D, however, seems to have some of the greatest “staying power” in the clinical realm and has a good reputation as far as vitamins go. Vitamin D is probably good for the heart, but how about the head? Could low D cause dementia? If so, how?

Previous studies of the relationship between vitamin D and dementia have not shown consistent results. Thomas Littlejohns, M.Sc., and colleagues have published a fantastic piece of work (Neurology 2014 Aug. 6 [doi: 10.1212/WNL.0000000000000755]) that sheds some light. They evaluated a prospective cohort of 1,658 elderly ambulatory adults with no history of dementia, CVD, or stroke who had baseline 25-hydroxyvitamin D [25(OH)D] concentrations at baseline. Severely low levels of 25(OH)D and deficiency (≥25 to <50 nmol/L) were associated with a significantly increased risk for all-cause dementia and Alzheimer’s dementia.

Several hypotheses exist as to why vitamin D helps the brain. Vitamin D may attenuate amyloid-induced cytotoxicity and neural apoptosis. It also may reduce the risk of strokes by promoting healthy cerebral vasculature.

The Institute of Medicine recommends a serum concentration of 25(OH)D at 50 nmol/L. This study would suggest that sufficiency to this level is neuroprotective. The next step is to see if supplementation can modify baseline risk, but many of my patients may wait for these data to come out before starting their vitamin D supplements.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

The Food and Drug Administration recently approved another weight-loss drug (Contrave), a combination of naltrexone (indicated for opioid dependence) and bupropion (indicated for depression). This is the third weight-loss drug approved in the past 2 years. The FDA previously approved lorcaserin (Belviq) and topiramate/phentermine (Qsymia). This approval activity signals pharmaceutical interest in a multibillion dollar weight loss industry and perhaps, maybe less so, the FDA’s recognition of our public health crisis.

For patients who meet criteria for the use of these medications, they should be offered if they can be afforded. However, these medications may make patients behave differently.

It’s called “license.”

License is the psychological phenomenon in which people who feel they have made progress toward a goal feel liberated to make an incongruent choice. Think of a patient interested in losing weight who now takes a weight-loss pill. Despite not having lost any weight yet and perhaps just after taking the first pill, the patient then makes a choice to consume a high-calorie dessert.

Here are some data that support that this could be happening.

One team of investigators randomized subjects to being informed they were taking a placebo or a weight-loss supplement (which was actually the same placebo tablet as in the other study arm). After receiving the supplement, participants were allowed access to a reward buffet lunch at which their food consumption was recorded. Compared with controls, participants receiving a purported weight-loss supplement ate more food at the reward buffet. This effect seemed to occur through a perceived sense that they were making progress toward their weight-loss goal by taking the pill (Nutrition 2014;30:1007-14).

This is critical for us to think about and incorporate into our clinical teaching when prescribing these medications. Psychological liberation threatens any health gains we can make at a population level with any weight-loss approach. We need to help our patients understand that these medications should be used in combination with sustainable lifestyle changes or they may as well be taking a placebo.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

The Food and Drug Administration recently approved another weight-loss drug (Contrave), a combination of naltrexone (indicated for opioid dependence) and bupropion (indicated for depression). This is the third weight-loss drug approved in the past 2 years. The FDA previously approved lorcaserin (Belviq) and topiramate/phentermine (Qsymia). This approval activity signals pharmaceutical interest in a multibillion dollar weight loss industry and perhaps, maybe less so, the FDA’s recognition of our public health crisis.

For patients who meet criteria for the use of these medications, they should be offered if they can be afforded. However, these medications may make patients behave differently.

It’s called “license.”

License is the psychological phenomenon in which people who feel they have made progress toward a goal feel liberated to make an incongruent choice. Think of a patient interested in losing weight who now takes a weight-loss pill. Despite not having lost any weight yet and perhaps just after taking the first pill, the patient then makes a choice to consume a high-calorie dessert.

Here are some data that support that this could be happening.

One team of investigators randomized subjects to being informed they were taking a placebo or a weight-loss supplement (which was actually the same placebo tablet as in the other study arm). After receiving the supplement, participants were allowed access to a reward buffet lunch at which their food consumption was recorded. Compared with controls, participants receiving a purported weight-loss supplement ate more food at the reward buffet. This effect seemed to occur through a perceived sense that they were making progress toward their weight-loss goal by taking the pill (Nutrition 2014;30:1007-14).

This is critical for us to think about and incorporate into our clinical teaching when prescribing these medications. Psychological liberation threatens any health gains we can make at a population level with any weight-loss approach. We need to help our patients understand that these medications should be used in combination with sustainable lifestyle changes or they may as well be taking a placebo.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

The Food and Drug Administration recently approved another weight-loss drug (Contrave), a combination of naltrexone (indicated for opioid dependence) and bupropion (indicated for depression). This is the third weight-loss drug approved in the past 2 years. The FDA previously approved lorcaserin (Belviq) and topiramate/phentermine (Qsymia). This approval activity signals pharmaceutical interest in a multibillion dollar weight loss industry and perhaps, maybe less so, the FDA’s recognition of our public health crisis.

For patients who meet criteria for the use of these medications, they should be offered if they can be afforded. However, these medications may make patients behave differently.

It’s called “license.”

License is the psychological phenomenon in which people who feel they have made progress toward a goal feel liberated to make an incongruent choice. Think of a patient interested in losing weight who now takes a weight-loss pill. Despite not having lost any weight yet and perhaps just after taking the first pill, the patient then makes a choice to consume a high-calorie dessert.

Here are some data that support that this could be happening.

One team of investigators randomized subjects to being informed they were taking a placebo or a weight-loss supplement (which was actually the same placebo tablet as in the other study arm). After receiving the supplement, participants were allowed access to a reward buffet lunch at which their food consumption was recorded. Compared with controls, participants receiving a purported weight-loss supplement ate more food at the reward buffet. This effect seemed to occur through a perceived sense that they were making progress toward their weight-loss goal by taking the pill (Nutrition 2014;30:1007-14).

This is critical for us to think about and incorporate into our clinical teaching when prescribing these medications. Psychological liberation threatens any health gains we can make at a population level with any weight-loss approach. We need to help our patients understand that these medications should be used in combination with sustainable lifestyle changes or they may as well be taking a placebo.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Irritable bowel syndrome affects up to 15% of the U.S. adult population, which may be an underestimate. When patients are managing themselves well, their clinical course can be routine. When their self-management is poor, IBS can make life exceedingly challenging for both patients and their clinicians. Many of us may be stepping up our game in patients with known IBS experiencing symptoms, first by recommending a diet low in FODMAPs (fermentable oligo-, di-, and monosaccharides and polyols), which have been shown to reduce IBS symptoms.

My experience is that patients who have been struggling for years with IBS have a high degree of health literacy. And they are usually receptive to trying new things that might make their lives better. The exceptions are the occasional patients who are convinced that they do not have IBS and that their clinicians are just too poorly informed to figure out what the real cause is.

Anything else we can recommend?

Jun Sik Yoon and colleagues have published a clinical trial evaluating the effectiveness of multispecies probiotics on IBS symptoms and changes in the gut microbiota. In this randomized, placebo-controlled trial, 49 subjects (25 probiotics, 24 placebo) with clinically-diagnosed IBS received tablets twice a day for 4 weeks. The primary outcome was the proportion of individuals whose IBS symptoms were substantially relieved at 4 weeks.

Probiotics were associated with a significantly higher proportion of patients with reductions in IBS symptoms (68% vs. 37.5%; P < .05). Probiotics also improved abdominal pain/discomfort and bloating. Fecal analysis revealed increases in the microbiota obtained with the probiotics (J. Gastroenterol. Hepatol. 2014;29:52-9).

So probiotics may help our patients with IBS if a low FODMAP diet does not. But what probiotic (i.e., containing which species) should we select? Species may have different effects on gut motility. Importantly, taking probiotics with certain species does not mean that those species will set up permanent residence in the colon. In the current study, only three of the six species contained in the probiotics were still in the stool after 4 weeks. The author concluded that the alleviation in bowel symptoms was attributable to Bifidobacterium lactis, Lactobacillus rhamnosus, and Streptococcus thermophiles. So let’s tell patients to look for probiotics with these species.

Probiotics are generally safe with the only possible contraindication being their use in patients with a severely immunocompromised state, but this is debatable. But now we have another evidence-based tool for our patients struggling with symptom recrudescence.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Irritable bowel syndrome affects up to 15% of the U.S. adult population, which may be an underestimate. When patients are managing themselves well, their clinical course can be routine. When their self-management is poor, IBS can make life exceedingly challenging for both patients and their clinicians. Many of us may be stepping up our game in patients with known IBS experiencing symptoms, first by recommending a diet low in FODMAPs (fermentable oligo-, di-, and monosaccharides and polyols), which have been shown to reduce IBS symptoms.

My experience is that patients who have been struggling for years with IBS have a high degree of health literacy. And they are usually receptive to trying new things that might make their lives better. The exceptions are the occasional patients who are convinced that they do not have IBS and that their clinicians are just too poorly informed to figure out what the real cause is.

Anything else we can recommend?

Jun Sik Yoon and colleagues have published a clinical trial evaluating the effectiveness of multispecies probiotics on IBS symptoms and changes in the gut microbiota. In this randomized, placebo-controlled trial, 49 subjects (25 probiotics, 24 placebo) with clinically-diagnosed IBS received tablets twice a day for 4 weeks. The primary outcome was the proportion of individuals whose IBS symptoms were substantially relieved at 4 weeks.

Probiotics were associated with a significantly higher proportion of patients with reductions in IBS symptoms (68% vs. 37.5%; P < .05). Probiotics also improved abdominal pain/discomfort and bloating. Fecal analysis revealed increases in the microbiota obtained with the probiotics (J. Gastroenterol. Hepatol. 2014;29:52-9).

So probiotics may help our patients with IBS if a low FODMAP diet does not. But what probiotic (i.e., containing which species) should we select? Species may have different effects on gut motility. Importantly, taking probiotics with certain species does not mean that those species will set up permanent residence in the colon. In the current study, only three of the six species contained in the probiotics were still in the stool after 4 weeks. The author concluded that the alleviation in bowel symptoms was attributable to Bifidobacterium lactis, Lactobacillus rhamnosus, and Streptococcus thermophiles. So let’s tell patients to look for probiotics with these species.

Probiotics are generally safe with the only possible contraindication being their use in patients with a severely immunocompromised state, but this is debatable. But now we have another evidence-based tool for our patients struggling with symptom recrudescence.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Irritable bowel syndrome affects up to 15% of the U.S. adult population, which may be an underestimate. When patients are managing themselves well, their clinical course can be routine. When their self-management is poor, IBS can make life exceedingly challenging for both patients and their clinicians. Many of us may be stepping up our game in patients with known IBS experiencing symptoms, first by recommending a diet low in FODMAPs (fermentable oligo-, di-, and monosaccharides and polyols), which have been shown to reduce IBS symptoms.

My experience is that patients who have been struggling for years with IBS have a high degree of health literacy. And they are usually receptive to trying new things that might make their lives better. The exceptions are the occasional patients who are convinced that they do not have IBS and that their clinicians are just too poorly informed to figure out what the real cause is.

Anything else we can recommend?

Jun Sik Yoon and colleagues have published a clinical trial evaluating the effectiveness of multispecies probiotics on IBS symptoms and changes in the gut microbiota. In this randomized, placebo-controlled trial, 49 subjects (25 probiotics, 24 placebo) with clinically-diagnosed IBS received tablets twice a day for 4 weeks. The primary outcome was the proportion of individuals whose IBS symptoms were substantially relieved at 4 weeks.

Probiotics were associated with a significantly higher proportion of patients with reductions in IBS symptoms (68% vs. 37.5%; P < .05). Probiotics also improved abdominal pain/discomfort and bloating. Fecal analysis revealed increases in the microbiota obtained with the probiotics (J. Gastroenterol. Hepatol. 2014;29:52-9).

So probiotics may help our patients with IBS if a low FODMAP diet does not. But what probiotic (i.e., containing which species) should we select? Species may have different effects on gut motility. Importantly, taking probiotics with certain species does not mean that those species will set up permanent residence in the colon. In the current study, only three of the six species contained in the probiotics were still in the stool after 4 weeks. The author concluded that the alleviation in bowel symptoms was attributable to Bifidobacterium lactis, Lactobacillus rhamnosus, and Streptococcus thermophiles. So let’s tell patients to look for probiotics with these species.

Probiotics are generally safe with the only possible contraindication being their use in patients with a severely immunocompromised state, but this is debatable. But now we have another evidence-based tool for our patients struggling with symptom recrudescence.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

The prevalence of urinary incontinence is 17%-55% among older women and 12%-42% among younger and middle-aged women. Only 45% of women with at least weekly symptoms seek medical care to address their symptoms.

For most of us, offering conservative measures is the most reasonable approach when women present. Pelvic floor muscle training, sometimes referred to as Kegel exercises, is usually one of the first things we discuss. Many women have heard this spiel before and may report having tried but not benefited from the exercises. This real or perceived lack of benefit may be related to either poor adherence or lack of efficacy.

In theory, pelvic floor muscle training builds strength and improves muscle tone, enhances conscious awareness of muscle groups, and increases perineal support by lifting pelvic viscera. But do clinical trial data support the use of pelvic muscle training for reducing urinary incontinence?

Dr. O. Celiker Tosun of Dokuz Eylül University, Izmir, Turkey, and colleagues published the results of a randomized clinical trial evaluating the effectiveness of an individually prescribed 12-week home-based pelvic floor muscle exercise program (Clin. Rehabil. 2014 Aug. 20 [doi:10.1177/0269215514546768]). Women with stress or mixed urinary incontinence were selected from a urogynecology clinic and randomized to pelvic floor muscle training (65 patients) or a control condition (65 patients).

The pelvic floor muscle training group had significant improvement in their symptoms of urinary incontinence and pelvic floor muscle strength, compared with the control group. Symptoms of urinary incontinence were significantly decreased in the training group.

This study is important because it demonstrates the utility of pelvic floor muscle training exercises under ideal circumstances.

However, the intervention provided in this study was intense and sophisticated – and it will be difficult, if not impossible, for most of us to replicate. A physiotherapist provided the training over a 12-week period, with 30-minute sessions three times a week for the first 2 weeks. Women also kept a training diary. Adherence to the protocol was 89% in the training group.

This is very different from the handout on Kegel’s we might be giving to our patients – with adherence to recommendations likely approaching 0%.

But now that we have these data, perhaps we can talk to our female patients more consistently and convincingly about the utility of this approach for reducing incontinence. If we are lucky and have a women’s health clinic with access to this type of expertise, this might be another option – at least before we refer them for higher-risk surgical procedures.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. They should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

The prevalence of urinary incontinence is 17%-55% among older women and 12%-42% among younger and middle-aged women. Only 45% of women with at least weekly symptoms seek medical care to address their symptoms.

For most of us, offering conservative measures is the most reasonable approach when women present. Pelvic floor muscle training, sometimes referred to as Kegel exercises, is usually one of the first things we discuss. Many women have heard this spiel before and may report having tried but not benefited from the exercises. This real or perceived lack of benefit may be related to either poor adherence or lack of efficacy.

In theory, pelvic floor muscle training builds strength and improves muscle tone, enhances conscious awareness of muscle groups, and increases perineal support by lifting pelvic viscera. But do clinical trial data support the use of pelvic muscle training for reducing urinary incontinence?

Dr. O. Celiker Tosun of Dokuz Eylül University, Izmir, Turkey, and colleagues published the results of a randomized clinical trial evaluating the effectiveness of an individually prescribed 12-week home-based pelvic floor muscle exercise program (Clin. Rehabil. 2014 Aug. 20 [doi:10.1177/0269215514546768]). Women with stress or mixed urinary incontinence were selected from a urogynecology clinic and randomized to pelvic floor muscle training (65 patients) or a control condition (65 patients).

The pelvic floor muscle training group had significant improvement in their symptoms of urinary incontinence and pelvic floor muscle strength, compared with the control group. Symptoms of urinary incontinence were significantly decreased in the training group.

This study is important because it demonstrates the utility of pelvic floor muscle training exercises under ideal circumstances.

However, the intervention provided in this study was intense and sophisticated – and it will be difficult, if not impossible, for most of us to replicate. A physiotherapist provided the training over a 12-week period, with 30-minute sessions three times a week for the first 2 weeks. Women also kept a training diary. Adherence to the protocol was 89% in the training group.

This is very different from the handout on Kegel’s we might be giving to our patients – with adherence to recommendations likely approaching 0%.

But now that we have these data, perhaps we can talk to our female patients more consistently and convincingly about the utility of this approach for reducing incontinence. If we are lucky and have a women’s health clinic with access to this type of expertise, this might be another option – at least before we refer them for higher-risk surgical procedures.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. They should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

The prevalence of urinary incontinence is 17%-55% among older women and 12%-42% among younger and middle-aged women. Only 45% of women with at least weekly symptoms seek medical care to address their symptoms.

For most of us, offering conservative measures is the most reasonable approach when women present. Pelvic floor muscle training, sometimes referred to as Kegel exercises, is usually one of the first things we discuss. Many women have heard this spiel before and may report having tried but not benefited from the exercises. This real or perceived lack of benefit may be related to either poor adherence or lack of efficacy.

In theory, pelvic floor muscle training builds strength and improves muscle tone, enhances conscious awareness of muscle groups, and increases perineal support by lifting pelvic viscera. But do clinical trial data support the use of pelvic muscle training for reducing urinary incontinence?

Dr. O. Celiker Tosun of Dokuz Eylül University, Izmir, Turkey, and colleagues published the results of a randomized clinical trial evaluating the effectiveness of an individually prescribed 12-week home-based pelvic floor muscle exercise program (Clin. Rehabil. 2014 Aug. 20 [doi:10.1177/0269215514546768]). Women with stress or mixed urinary incontinence were selected from a urogynecology clinic and randomized to pelvic floor muscle training (65 patients) or a control condition (65 patients).

The pelvic floor muscle training group had significant improvement in their symptoms of urinary incontinence and pelvic floor muscle strength, compared with the control group. Symptoms of urinary incontinence were significantly decreased in the training group.

This study is important because it demonstrates the utility of pelvic floor muscle training exercises under ideal circumstances.

However, the intervention provided in this study was intense and sophisticated – and it will be difficult, if not impossible, for most of us to replicate. A physiotherapist provided the training over a 12-week period, with 30-minute sessions three times a week for the first 2 weeks. Women also kept a training diary. Adherence to the protocol was 89% in the training group.

This is very different from the handout on Kegel’s we might be giving to our patients – with adherence to recommendations likely approaching 0%.

But now that we have these data, perhaps we can talk to our female patients more consistently and convincingly about the utility of this approach for reducing incontinence. If we are lucky and have a women’s health clinic with access to this type of expertise, this might be another option – at least before we refer them for higher-risk surgical procedures.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. They should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

An estimated 42 million (18.1%) of the U.S. adult population continues to smoke cigarettes. Effective treatments exist for patients who are willing to avail themselves of such assistance. Varenicline is one of the most effective medications that we have to combat tobacco dependence. However, it doesn’t work for everybody, and questions have remained about how safe and effective it is to combine varenicline with other smoking cessation therapies such as nicotine replacement therapy.

Varenicline binds to a specific nicotine receptor, thereby partially agonizing and blocking it. The result is decreased cravings for tobacco and increased smoking quit rates. Data from early studies conducted by our group suggested that nicotine replacement therapy (NRT) combined with varenicline was safe, but questions remained about its efficacy.

One group of researchers conducted a multicenter clinical trial evaluating the efficacy of combining varenicline and the nicotine patch for increasing smoking cessation rates. Smokers were eligible if they smoked at least 10 cigarettes per day, reported F.N. Coenraad, from the Stellenbosch University, Cape Town, South Africa, and associates. Participants were randomized to active 15-mg nicotine patches or placebo patches started 2 weeks before the target quit date. All participants received varenicline for a total of 14 weeks with a 1-week ramp-up and a 1-week taper. Use of the varenicline in combination with the nicotine patch resulted in increased rates of continuous abstinence from smoking at 12 weeks (no smoking from weeks 9 to 12: 55.4% vs. 40.9%; odds ratio, 1.85; 95% confidence interval, 1.19-2.89; P = .007) and at 24 weeks (no smoking from weeks 9 to 24: 49% vs. 32.6%; OR, 1.98; 95% CI, 1.25-3.14; P = .004) (JAMA 2014;312:155-61).

This is a fantastic study answering a lingering question in tobacco control. But what is the theoretical underpinning by which this combination works? Isn’t the NRT blocked by the varenicline? It is possible that the varenicline incompletely saturates the nicotine receptors, which are additionally saturated by the supplemented nicotine. The varenicline effect is mediated through the alpha-4 beta-2 nicotinic receptor, and it is also possible that nicotine binds to nicotine receptor types that varenicline does not bind to, which decreases withdrawal symptoms.

We aren’t exactly sure how this might be working, but a near doubling of the odds of quitting is not to be disregarded. We are also not sure whether the effect holds when one uses other types of NRT such as the nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine gum. In practice, I tend to lean toward a combination of varenicline with the nicotine inhaler since the inhaler can help with some of the behavioral aspects of smoking while the varenicline does its heavy lifting.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert reports receiving research support from Pfizer, manufacturer of varenicline and the nicotine inhaler, and consulting fees from GlaxoSmithKline, manufacturer of the nicotine patch. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

An estimated 42 million (18.1%) of the U.S. adult population continues to smoke cigarettes. Effective treatments exist for patients who are willing to avail themselves of such assistance. Varenicline is one of the most effective medications that we have to combat tobacco dependence. However, it doesn’t work for everybody, and questions have remained about how safe and effective it is to combine varenicline with other smoking cessation therapies such as nicotine replacement therapy.

Varenicline binds to a specific nicotine receptor, thereby partially agonizing and blocking it. The result is decreased cravings for tobacco and increased smoking quit rates. Data from early studies conducted by our group suggested that nicotine replacement therapy (NRT) combined with varenicline was safe, but questions remained about its efficacy.

One group of researchers conducted a multicenter clinical trial evaluating the efficacy of combining varenicline and the nicotine patch for increasing smoking cessation rates. Smokers were eligible if they smoked at least 10 cigarettes per day, reported F.N. Coenraad, from the Stellenbosch University, Cape Town, South Africa, and associates. Participants were randomized to active 15-mg nicotine patches or placebo patches started 2 weeks before the target quit date. All participants received varenicline for a total of 14 weeks with a 1-week ramp-up and a 1-week taper. Use of the varenicline in combination with the nicotine patch resulted in increased rates of continuous abstinence from smoking at 12 weeks (no smoking from weeks 9 to 12: 55.4% vs. 40.9%; odds ratio, 1.85; 95% confidence interval, 1.19-2.89; P = .007) and at 24 weeks (no smoking from weeks 9 to 24: 49% vs. 32.6%; OR, 1.98; 95% CI, 1.25-3.14; P = .004) (JAMA 2014;312:155-61).

This is a fantastic study answering a lingering question in tobacco control. But what is the theoretical underpinning by which this combination works? Isn’t the NRT blocked by the varenicline? It is possible that the varenicline incompletely saturates the nicotine receptors, which are additionally saturated by the supplemented nicotine. The varenicline effect is mediated through the alpha-4 beta-2 nicotinic receptor, and it is also possible that nicotine binds to nicotine receptor types that varenicline does not bind to, which decreases withdrawal symptoms.

We aren’t exactly sure how this might be working, but a near doubling of the odds of quitting is not to be disregarded. We are also not sure whether the effect holds when one uses other types of NRT such as the nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine gum. In practice, I tend to lean toward a combination of varenicline with the nicotine inhaler since the inhaler can help with some of the behavioral aspects of smoking while the varenicline does its heavy lifting.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert reports receiving research support from Pfizer, manufacturer of varenicline and the nicotine inhaler, and consulting fees from GlaxoSmithKline, manufacturer of the nicotine patch. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

An estimated 42 million (18.1%) of the U.S. adult population continues to smoke cigarettes. Effective treatments exist for patients who are willing to avail themselves of such assistance. Varenicline is one of the most effective medications that we have to combat tobacco dependence. However, it doesn’t work for everybody, and questions have remained about how safe and effective it is to combine varenicline with other smoking cessation therapies such as nicotine replacement therapy.

Varenicline binds to a specific nicotine receptor, thereby partially agonizing and blocking it. The result is decreased cravings for tobacco and increased smoking quit rates. Data from early studies conducted by our group suggested that nicotine replacement therapy (NRT) combined with varenicline was safe, but questions remained about its efficacy.

One group of researchers conducted a multicenter clinical trial evaluating the efficacy of combining varenicline and the nicotine patch for increasing smoking cessation rates. Smokers were eligible if they smoked at least 10 cigarettes per day, reported F.N. Coenraad, from the Stellenbosch University, Cape Town, South Africa, and associates. Participants were randomized to active 15-mg nicotine patches or placebo patches started 2 weeks before the target quit date. All participants received varenicline for a total of 14 weeks with a 1-week ramp-up and a 1-week taper. Use of the varenicline in combination with the nicotine patch resulted in increased rates of continuous abstinence from smoking at 12 weeks (no smoking from weeks 9 to 12: 55.4% vs. 40.9%; odds ratio, 1.85; 95% confidence interval, 1.19-2.89; P = .007) and at 24 weeks (no smoking from weeks 9 to 24: 49% vs. 32.6%; OR, 1.98; 95% CI, 1.25-3.14; P = .004) (JAMA 2014;312:155-61).

This is a fantastic study answering a lingering question in tobacco control. But what is the theoretical underpinning by which this combination works? Isn’t the NRT blocked by the varenicline? It is possible that the varenicline incompletely saturates the nicotine receptors, which are additionally saturated by the supplemented nicotine. The varenicline effect is mediated through the alpha-4 beta-2 nicotinic receptor, and it is also possible that nicotine binds to nicotine receptor types that varenicline does not bind to, which decreases withdrawal symptoms.

We aren’t exactly sure how this might be working, but a near doubling of the odds of quitting is not to be disregarded. We are also not sure whether the effect holds when one uses other types of NRT such as the nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine gum. In practice, I tend to lean toward a combination of varenicline with the nicotine inhaler since the inhaler can help with some of the behavioral aspects of smoking while the varenicline does its heavy lifting.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert reports receiving research support from Pfizer, manufacturer of varenicline and the nicotine inhaler, and consulting fees from GlaxoSmithKline, manufacturer of the nicotine patch. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

As obesity continues to ravage the health of the United States, bariatric surgery offers an effective strategy for individual patients suffering from medical complications.

When performed in adults with a body mass index of at least 30 kg/m², bariatric surgery is associated with a mean weight loss of 20%-35% of baseline weight at 2-3 years. Bariatric surgery is associated with greater reductions in obesity comorbidities, compared with lifestyle intervention and supervised weight loss. Contemporary bariatric surgeries include Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion with duodenal switch, sleeve gastrectomy, and mini–gastric bypass.

Bariatric surgical procedures affect weight loss through two mechanisms: malabsorption and restriction. Such alterations in human physiology can change the absorption of common drugs of addiction, such as alcohol. This can increase the risk for problem drinking behaviors.

Wendy C. King, Ph.D., of the department of epidemiology at the University of Pittsburgh and her colleagues conducted an analysis of data from 1,945 patients in a cohort who underwent bariatric surgery in 10 U.S. hospitals. Symptoms of alcohol use disorder (AUD) were assessed pre- and postoperatively (JAMA 2012;307:2516-25).

The prevalence of AUD was significantly higher at 2 years postoperatively (9.6%), compared with the preoperative period (7.6%; P less than .01). Factors associated with a higher risk of postoperative AUD included male gender, younger age, smoking, regular alcohol consumption, a history of AUD, recreational drug use, low social support, and receiving Roux-en-Y gastric bypass.

AUD can disqualify patients from bariatric surgery – but 7.6% of patients in this survey (taken independently of clinical care) reported it. The authors noted that a 2% increase in AUD associated with bariatric surgery translates into 2,000 additional people with AUD each year.

This is particularly problematic for this population, because a large number of calories are associated with alcohol intake, and alcohol intake can lower inhibitions for other types of eating behaviors – all of which can lead to weight regain.

So, what do we do?

I think it may be helpful to take alcohol use histories in the patients we are seeing in bariatric surgery follow-up, especially those who appear to be regaining weight. Some patients may not be aware of this connection. For the patients who I have told about this relationship, they recognize it, which may be the first step toward dealing with it.

Dr. Ebbert is a professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

As obesity continues to ravage the health of the United States, bariatric surgery offers an effective strategy for individual patients suffering from medical complications.

When performed in adults with a body mass index of at least 30 kg/m², bariatric surgery is associated with a mean weight loss of 20%-35% of baseline weight at 2-3 years. Bariatric surgery is associated with greater reductions in obesity comorbidities, compared with lifestyle intervention and supervised weight loss. Contemporary bariatric surgeries include Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion with duodenal switch, sleeve gastrectomy, and mini–gastric bypass.

Bariatric surgical procedures affect weight loss through two mechanisms: malabsorption and restriction. Such alterations in human physiology can change the absorption of common drugs of addiction, such as alcohol. This can increase the risk for problem drinking behaviors.

Wendy C. King, Ph.D., of the department of epidemiology at the University of Pittsburgh and her colleagues conducted an analysis of data from 1,945 patients in a cohort who underwent bariatric surgery in 10 U.S. hospitals. Symptoms of alcohol use disorder (AUD) were assessed pre- and postoperatively (JAMA 2012;307:2516-25).

The prevalence of AUD was significantly higher at 2 years postoperatively (9.6%), compared with the preoperative period (7.6%; P less than .01). Factors associated with a higher risk of postoperative AUD included male gender, younger age, smoking, regular alcohol consumption, a history of AUD, recreational drug use, low social support, and receiving Roux-en-Y gastric bypass.

AUD can disqualify patients from bariatric surgery – but 7.6% of patients in this survey (taken independently of clinical care) reported it. The authors noted that a 2% increase in AUD associated with bariatric surgery translates into 2,000 additional people with AUD each year.

This is particularly problematic for this population, because a large number of calories are associated with alcohol intake, and alcohol intake can lower inhibitions for other types of eating behaviors – all of which can lead to weight regain.

So, what do we do?

I think it may be helpful to take alcohol use histories in the patients we are seeing in bariatric surgery follow-up, especially those who appear to be regaining weight. Some patients may not be aware of this connection. For the patients who I have told about this relationship, they recognize it, which may be the first step toward dealing with it.

Dr. Ebbert is a professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

As obesity continues to ravage the health of the United States, bariatric surgery offers an effective strategy for individual patients suffering from medical complications.

When performed in adults with a body mass index of at least 30 kg/m², bariatric surgery is associated with a mean weight loss of 20%-35% of baseline weight at 2-3 years. Bariatric surgery is associated with greater reductions in obesity comorbidities, compared with lifestyle intervention and supervised weight loss. Contemporary bariatric surgeries include Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion with duodenal switch, sleeve gastrectomy, and mini–gastric bypass.

Bariatric surgical procedures affect weight loss through two mechanisms: malabsorption and restriction. Such alterations in human physiology can change the absorption of common drugs of addiction, such as alcohol. This can increase the risk for problem drinking behaviors.

Wendy C. King, Ph.D., of the department of epidemiology at the University of Pittsburgh and her colleagues conducted an analysis of data from 1,945 patients in a cohort who underwent bariatric surgery in 10 U.S. hospitals. Symptoms of alcohol use disorder (AUD) were assessed pre- and postoperatively (JAMA 2012;307:2516-25).

The prevalence of AUD was significantly higher at 2 years postoperatively (9.6%), compared with the preoperative period (7.6%; P less than .01). Factors associated with a higher risk of postoperative AUD included male gender, younger age, smoking, regular alcohol consumption, a history of AUD, recreational drug use, low social support, and receiving Roux-en-Y gastric bypass.

AUD can disqualify patients from bariatric surgery – but 7.6% of patients in this survey (taken independently of clinical care) reported it. The authors noted that a 2% increase in AUD associated with bariatric surgery translates into 2,000 additional people with AUD each year.

This is particularly problematic for this population, because a large number of calories are associated with alcohol intake, and alcohol intake can lower inhibitions for other types of eating behaviors – all of which can lead to weight regain.

So, what do we do?

I think it may be helpful to take alcohol use histories in the patients we are seeing in bariatric surgery follow-up, especially those who appear to be regaining weight. Some patients may not be aware of this connection. For the patients who I have told about this relationship, they recognize it, which may be the first step toward dealing with it.

Dr. Ebbert is a professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.

Tamsulosin works, and prednisolone may also be helpful. Anything else?

Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).

In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.

The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.

The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.

In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).

Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.

Tamsulosin works, and prednisolone may also be helpful. Anything else?

Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).

In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.

The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.

The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.

In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).

Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.

Tamsulosin works, and prednisolone may also be helpful. Anything else?

Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).

In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.

The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.

The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.

In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).

Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.