In the Limelight: June 2023

Abstract

This month’s feature highlights six articles that appear in the current issue of Mayo Clinic Proceedings. These articles are also featured on the Mayo Clinic Proceedings’ YouTube Channel (https://youtu.be/j8mCLd1cacE). Human behavior and lifestyle are major determinants of health and disease. In Nordic countries in general, and in Finland, in particular, the Finnish sauna, a type of passive heat therapy, is commonly used as a relaxing pastime. In the present issue of Mayo Clinic Proceedings, Kunutsor and Laukkanen assessed the health benefits of Finnish sauna; their methodology involved the review of relevant literature published in Medline and Embase from the beginning of these databases to September 2022; these studies included randomized and non-randomized controlled trials and observational studies of adults, and particular attention was directed to studies of Finnish sauna in conjunction with other factors that may determine health outcomes. A prominent such study was the Kuopio Ischemic Heart Disease study, a prospective study of more than 2200 Finnish men, which demonstrated that frequent sauna bathing, along with high levels of cardiorespiratory fitness (CRF), were associated with reduced cardiovascular diseases and all-cause mortality to a greater extent than either frequent sauna bathing or high levels of CRF alone. Not only does frequent sauna bathing synergize with CRF in conferring beneficial effects, but frequent sauna bathing may also lessen mortality associated with known risk factors. For example, frequent sauna bathing as compared with low sauna bathing mitigates the mortality risk associated with high blood pressure, systemic inflammation (defined by high-sensitivity C-reactive protein), and low socioeconomic status. Moreover, the beneficial effects of frequent sauna bathing may extend to noncardiovascular diseases such as chronic obstructive airways disease, musculoskeletal diseases, and fibromyalgia, among others. Based on their current and prior review [Laukkanen et al, Mayo Clin Proc. 2018;93(8):1111-1121], the authors suggest that the salutary effects of frequent sauna bathing may involve actions that are, among others, blood pressure-lowering, anti-inflammatory, and antioxidant in nature. The authors emphasize the added health benefits that accrue when frequent sauna bathing is combined with regular physical exercise, and that for individuals who are compromised in their physical activity, regular sauna bathing may mitigate the health risks incurred by physical inactivity; regular sauna bathing may also attenuate the adverse effects of other unhealthy conditions or risk factors. The authors also provide an overview of the beneficial effects of other forms of passive heat therapy, and include helpful tables that summarize salient studies examining the effects of a combination of Finnish sauna bathing and risk factors. In biology there is a conserved transcriptional phenomenon exhibited by eukaryotic cells – the heat shock response – whereby cells mount a cytoprotective response that stoutly safeguards them against heat and a range of other imposed stressors (Le Breton L and Mayer MP. A model for handling cell stress. eLife. 2016;5:e22850). It is tempting to speculate that the Finnish sauna provides not only a relaxing pastime, but also a leisurely way of eliciting biology’s versatile cytoprotective heat shock response. Kunutsor SK, Laukkanen JA. Does the combination of Finnish sauna bathing and other lifestyle factors confer additional health benefits? A review of the evidence. Mayo Clin Proc. 2023;98(6):915-926. Doi.10.1016/j.mayocp.2023.01.008 The history and physical examination (H&P) constitute the cornerstone in patient evaluation as the H&P point to relevant diseases that require further investigation. However, certain symptoms and signs may not necessarily be congruent with a given disease or pathologic condition, and these have been described as nonorganic or behavioral in nature. Cohen et al undertook the current study with two objectives in mind: to examine the association between cervical nonorganic pain signs and responses to epidural corticosteroid injection (ECI) and to evaluate the association between cervical nonorganic pain signs with pain syndromes and psychiatric conditions. A motivation for their study was the need to improve patient selection such that patients who undergo ECI do indeed benefit from the procedure. In this regard, Cohen et al drew upon their prior studies demonstrating that nonorganic signs associated with a lack of benefit to ECI for low back pain. In their current multicenter study, 78 patients with cervical radiculopathy underwent such injections. Cervical nonorganic signs were nine in number and classified in five categories which included noncorrelative tenderness (superficial, nonanatomic), sham stimulation (head pressure, passive rotation), distraction (paradoxical response), regional disturbances (sensory, motor), and overreaction (verbal, nonverbal). Nonorganic signs were assessed by at least two physicians at each study site. The findings demonstrate that numbers of categories and signs strongly predicted poor outcomes after ECI. Regional disturbances and overreaction were the principal categories that correlated with negative treatment outcomes. Superficial tenderness was the most common nonorganic sign. Moreover, nonorganic signs exhibited a positive association with prior and concurrent psychiatric conditions and for concurrent pain conditions. In discussing their findings, Cohen et al underscore two salient considerations. The first is that attention to the presence of nonorganic signs and psychopathology may aid in identifying those patients who will not benefit from cervical ECI; such patients are thus not subjected to an unnecessary procedure or exposed to its inherent risks; health care costs are also reduced. The second consideration emphasized by the authors is that nonorganic signs should not be construed as necessarily reflective of psychological pain or secondary gain: the evolving understanding of pain now recognizes that pain processing may occur anomalously; that biology, neurology, and psychology commingle in current constructs of pain; and that certain “nonorganic” signs may indeed emanate from an “organic” basis for pain pathobiology. The importance of the study of Cohen et al is that it not only advances management of cervical radiculopathy, but it also percipiently raises fundamental concepts regarding pain that widely apply to other diseases. Cohen SP, Doshi TL, Dolomisiewicz E, et al. Nonorganic (behavioral) signs and their association with epidural corticosteroid injection treatment outcomes and psychiatric comorbidity in cervical radiculopathy: a multicenter study. Mayo Clin Proc. 2023;98(6):868-882. Doi.10.1016/j.mayocp.2023.11.022 Rising in prevalence and incidence, atrial fibrillation (AF) significantly increases morbidity and mortality. This issue of Mayo Clinic Proceedings obliquely features this disease by providing a medley of papers involving AF. In discussing potential mechanisms that may underlie the association of AF with height and male sex, as described by Marott et al, the editorial by Shabtaie and Asirvatham broadly outlines some key features of AF. Naser et al provide the largest single center study of the occurrence of AF in patients with Graves disease. Overall, more than 10% of patients in a sample size of 1371 developed AF, a rate significantly higher than what is described in the literature for age- and sex-matched patients. For early onset AF (less than 90 days after the diagnosis of Graves disease), risk factors include age, male sex, and overt hyperthyroidism. For late onset AF (more than 90 days after the diagnosis of Graves disease), risk factors include age, heart failure, and chronic obstructive pulmonary disease. Late onset AF occurred in approximately 23% of patients with Graves disease, 50% of whom were already euthyroid, a finding that led Naser et al to emphasize the need for continued monitoring for AF despite achieving euthyroidism. As documented by Naser et al, AF in Graves disease is associated with increased risk for acute coronary syndromes, stable angina events, hospitalizations for cardiac disease, and higher overall mortality. The paper by Satish et al notes that there is a relatively high prevalence of coronary artery disease (CAD) in patients with AF. Their present study shows that the presence of even stable CAD is associated with adverse cardiac outcomes in patients with AF treated by catheter ablation: such patients with underlying stable CAD so treated for AF were more likely to be readmitted to the hospital within 90 days because of acute coronary syndromes and/or decompensated heart failure. The US and global populations are aging, and as noted by Shabtaie and Asirvatham, “there may well be an age where AF is more the rule rather than the exception.” Recognition of this disease and attempts to effectively treat it such that its complications are minimized cannot be sufficiently emphasized. Shabtaie SA, Asirvatham SJ. The long and short of the difficulties with atrial fibrillation risk prediction [editorial]. Mayo Clin Proc. 2023;98(6):821-822. Doi.10.1016/j.mayocp.2023.04.016 Marott JL, Jensen MT, Benn M, et al. Height explains sex difference in atrial fibrillation risk: Copenhagen general population study. Mayo Clin Proc. 2023;98(6):846-855. Doi.10.1016/j.mayocp.2023.12.026 Naser JA, Pislaru SV, Stan MN, Lin G. Incidence, risk factors, and outcomes of incidental atrial fibrillation in patients with Graves disease. Mayo Clin Proc. 2023;98(6):883-891. Doi.10.1016/j.mayocp.2023.12.013 Satish M, Walters RW, Alla VM, Halpern JL. Association between stable coronary artery disease and hospital readmissions following catheter ablation for atrial fibrillation. Mayo Clin Proc. 2023;98(6):892-902. Doi.10.1016/j.mayocp.2023.01.011 Nonorganic (Behavioral) Signs and Their Association With Epidural Corticosteroid Injection Treatment Outcomes and Psychiatric Comorbidity in Cervical Radiculopathy: A Multicenter StudyMayo Clinic ProceedingsVol. 98Issue 6PreviewTo determine the association between cervical nonorganic pain signs and epidural corticosteroid injection outcomes and coexisting pain and psychiatric conditions. Full-Text PDF Incidence, Risk Factors, and Outcomes of Incident Atrial Fibrillation in Patients With Graves DiseaseMayo Clinic ProceedingsVol. 98Issue 6PreviewTo describe the incidence, risk factors, and outcomes of incident atrial fibrillation (AF) in Graves disease (GD). Full-Text PDF Height Explains Sex Difference in Atrial Fibrillation Risk: Copenhagen General Population StudyMayo Clinic ProceedingsVol. 98Issue 6PreviewTo test the hypothesis that the increased risk of atrial fibrillation (AF) in men compared with women is explained by height. Full-Text PDF Does the Combination of Finnish Sauna Bathing and Other Lifestyle Factors Confer Additional Health Benefits? A Review of the EvidenceMayo Clinic ProceedingsVol. 98Issue 6PreviewSauna bathing, a tradition deeply rooted in the Finnish culture, has been used for thousands of years for leisure, relaxation, and wellness. Sauna bathing is linked with substantial health benefits beyond its use for leisure and relaxation. Several observational and interventional studies suggest that regular or frequent sauna bathing reduces the incidence of vascular and nonvascular diseases, such as hypertension, cardiovascular disease, dementia, and respiratory conditions; may improve the severity of conditions such as musculoskeletal disorders, COVID-19, headache, and influenza; and increases the life span. Full-Text PDF Open AccessAssociation Between Stable Coronary Artery Disease and Hospital Readmissions Following Catheter Ablation for Atrial FibrillationMayo Clinic ProceedingsVol. 98Issue 6PreviewTo evaluate the association of stable coronary artery disease (CAD) with readmission following hospitalization for catheter ablation (CA) for atrial fibrillation (AF). Full-Text PDF