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Window of Opportunity

Reading Time: 8 Minutes

Published June 3, 2024

Morning Report — Not Your Typical Medical Newsletter

We get it, you see a lot of medical newsletters, so hear us out. Once a month, we’ll highlight important medical news sprinkled with witty commentary, fun facts, giveaways, and more… because learning should be fun! Subscribe to receive the Morning Report directly.Morning Report x Corcept

Good morning! We’re starting with the mysterious case of a German man with early onset hearing loss who succumbed to liver disease at age 56.

  • Symptoms at time of death: fever, jaundice, edema, coughing, and dyspnea

  • Medical history: HBV, hearing loss, muscle cramps, renal abnormalities, and GI issues
  • Social history: never married, no children, worked as a composer, alcohol misuse
  • Family history: significant for liver disease

If you guessed that we’re talking about Ludwig van Beethoven, (1) we want you on our bar trivia team and (2) you may know that his (self-ordered) autopsy has taken 200 years to complete. Finally, a study of two locks of his hair—authenticated this time—reveal a likely contributing factor to the legendary composer’s symphony of ailments. Beyond his known genetic predispositions, HBV, and excessive drinking, substantial amounts of lead as well as arsenic and mercury in his body may have hastened his demise and precipitated his hearing loss. So, now we know. Apologies for getting Symphony No. 9 stuck in your head. 

Rethinking Rage Reduction Responses

MENTAL HEALTH MUSINGS

Your office copier jams at 4:30pm on a Friday, stoking your fury for the fourth time this week. What do you do? If this is Office Space, you give the machine a Louisville Slugger makeover. Or maybe you opt for a less destructive anger management strategy like vigorous exercise, screaming into a pillow, or meditation. But what type of activity delivers the best anger antidote?

Increasing vs decreasing arousal

A new meta-analysis of 154 studies (>10,000 participants) reveals that the secret to curbing anger involves lowering—not heightening—your arousal. Intuitive so far. Activities like deep breathing, mindfulness, meditation, and yoga (in groups or solo) led the pack in reducing arousal and subsequently diminishing anger. In contrast, arousal-boosting activities not only failed to alleviate anger but, in some cases, exacerbated it. Methods like hitting a bag and screaming into a pillow (and certainly attacking office machinery) drove up arousal, but so did activities like running, cycling, and swimming, skewering the notion of “sweating it out.” Of note, engaging in ball sports did reduce anger, presumably because of the “game” element involved. When reached for comment, John McEnroe shouted, “This study cannot be serious!”

These findings may chafe the runners and endurance athletes among us, so it’s worth noting that this study did not assess these activities’ efficacy in alleviating anxiety or depression.

Key takeaways

Finding serenity on a rage run seems as unlikely as Mick Jagger finding satisfaction. The evidence does not support “blowing off steam,” “getting it off your chest,” or any other cliché to describe venting. Per lead study author Brad Bushman, “Venting anger might sound like a good idea, but there’s not a shred of scientific evidence to support catharsis theory.” Instead, engaging in activities that “lower the temperature” like yoga and meditation shows the greatest benefit in reducing anger and its potentially harmful health effects. Namaste.

For more info and to lower your own arousal, check out Pri-Med’s CME session titled Increasing Fulfilment and Reducing Frustration in Your Practice.

Guideline Update 

The Safe Return of Menopausal Hormone Therapy?

WOMEN'S WELLNESS

Menopausal hormone therapy (MHT) continues to ride the merry-go-round of clinical research. When a 2003 study torched its reputation, citing breast cancer and cardiovascular disease (CVD) risks, the go-to therapy became a pariah in the menopausal treatment sphere. Now, that same study—the Women’s Health Initiative (WHI)—delivers a follow-up analysis that may resuscitate MHT’s image as a safe, effective treatment for many women in early menopause.

A study in contrast

The WHI follow-up analysis explored 20 years of follow-up data from 68,000 women who took part in clinical trials from 1993 to 1998. Here’s the headline from study author Dr. JoAnn Manson: “Among women below the age of 60, we found hormone therapy has low risk of adverse events and [is] safe for treating bothersome hot flashes, night sweats and other menopausal symptoms.” However, this study—unlike others—did not support the use of MHT to prevent chronic diseases like CVD, stroke, or dementia.

What accounts for the newfound safety? 

The 2024 analysis corrects for several flaws in the original study:

  1. Problematic progestin: Medroxyprogesterone acetate, linked to increased breast cancer risk, has since been replaced by safer hormone types like micronized progesterone.
  2. Age window: Most participants in the original study were age >60 years, whereas hormone therapy is safest and most beneficial when initiated between ages 50 and 60 years.
  3. Faulty formulation: Oral estrogen has been linked with increased risk of blood clots, but patients at risk now have the option of using transdermal estrogen.

Key takeaways 

This new analysis offers a more nuanced narrative that tips the benefits-to-risks scale in favor of MHT for appropriate patients. By tailoring therapy to include transdermal options and bioidentical hormones, and by initiating MHT during the “window of opportunity” (ages 50 to 60), clinicians can maximize the benefits of hormone therapy while minimizing risks. As always, individualizing care and employing shared decision-making are key. With growing evidence of its safety, effectiveness, and disease protection, MHT may soon recover from the black eye induced by the original study and regain clinician and public acceptance.

For more guidance, check out Pri-Med’s CME podcast titled Menopausal Symptoms—Are You Providing the Best Care to Improve Function and Quality of Life?

FDA Updates

Casting a Shadow over Sunscreen Products

DERM DISCUSSIONS

Either the Environmental Working Group (EWG) grades harsher than your junior year chem teacher or Big Sunscreen has failed its consumers. For 18 years, the nonprofit has rigorously assessed sunscreen safety and efficacy—picking up the slack for the FDA—with products continually falling short of a passing grade. This year, only 25% of products met EWG’s stringent standards, leaving the group to take further action while throwing shade at the FDA.

First, a touch of grase

Before you question our spelling, we’re referring to “GRASE,” the FDA’s shorthand for ingredients designated “generally recognized as safe and effective.” Of the 16 ingredients commonly found in sunscreens, only two—zinc oxide and titanium dioxide—meet GRASE criteria. Two others—aminobenzoic acid and trolamine salicylate—have been deemed un-GRASE-worthy due to safety concerns, and the remaining 12 miss the GRASE threshold due to ambiguous safety data (oxybenzone is particularly worrisome). But those 12 ingredients remain in products as the FDA awaits more data—from the sunscreen manufacturers.

A blistering review

Approximately 75% of the 1,700 SPF products the EWG reviewed “may fall short of adequate sun protection, with many still containing ingredients that could pose health risks.” To empower consumers, the group is now slapping an “EWG verified” label on its honor-roll sunscreens. In a quote better suited for a Drake-vs-Lamar diss track, EWG VP Dr. Homer Sweit says, “EWG Verified sunscreens offer consumers peace of mind while the FDA drags its feet.”

Key takeaways

“Consumers deserve better,” asserts Emily Spilman, a program manager at EWG. “Fortunately for consumers, 235 sunscreens meet our rigorous standards, and we now have 51 EWG-Verified sunscreens.” These verified products not only eliminate harmful chemicals but also surpass FDA standards for UVA protection. You may want to nudge patients toward these EWG-verified sunscreen products to ensure they get adequate sun protection while avoiding ingredients that may penetrate the skin, disrupt hormones, and cause allergic reactions.

Interested in more healthcare news? Here are some other articles we don’t want you to miss:

Morning Report is written by:

  • Alissa Scott, author
  • Aylin Madore, MD, MEd, editor 
  • Ariel Reinish, MD, MEd, editor
  • Emily Ruge, Author, editor

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Please note that the summaries in Morning Report are intended to provide clinicians with a brief overview of an article, and while we do our best to select the most salient points, we ask that you please read the full article linked in each summary for clarification before making any practice-changing decisions.

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difficult to control diabetes: is cortisol at play?

Difficult-to-Control Diabetes: Is Cortisol at Play?

SPONSORED BY CORCEPT THERAPEUTICS INCORPORATED

Experts John Buse, Ralph DeFronzo, Vivian Fonseca, and Daniel Einhorn discussed the latest conclusions in hypercortisolism at the American Diabetes Association 83rd Scientific Sessions in 2023

Discover what the experts have to say about:

• The evolving spectrum of hypercortisolism • Difficult-to-control type 2 diabetes mellitus (T2DM): A potentially enriched patient population for hypercortisolism screening

• The prevalence of hypercortisolism in patients with difficult-to-control T2DM

• Hypercortisolism left untreated leading to worsened health outcomes

Watch highlights from their discussion here.

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