nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Tuesday, November 30, 2010

Narcissists No Longer Have A Narcissistic Personality (?)

This is the kind of silliness you get when academics start monkeying around with definitions.  The new DSM will eliminate five of the ten personality disorders.

For a long time personality disorders have been a standard, a way to categorize patients into types that allow for better treatment plans.  The DSM (Diagnostic and Statistical Manual of Mental Disorders) has provided the template for the definition of each personality disorder;  obsessive-compulsive, paranoid, schizoid, antisocial, etc.

So, no more narcissistic personality disorder in the upcoming revision of the DSM...along with four others.

Apparently the academics who sit on the committee that makes these decisions decided it was inappropriate to take a "categorical" attitude toward personality disorders (then why did they eliminate only 5 of the 10?), preferring rather to call someone with narcissistic personality as "personality disorder with narcissistic traits."

So, a big uprorar from the clinical psychiatric community (those folks who see patients rather than do research).  See here (NY Times, Nov 29).

The argument comes down to this:  there are people with personality disorders who are relatively pure in the traits they exhibit, but many have a mix.  For instance, a person who is predominantly narcissistic may also have paranoid characteristics (and many of them do).  So, the committee thought it was better to take a step back and emphasize the broad range of elements involved, sort of like a chinese menu:   two from column A, one from column B, and two from column C, all under the general heading of "personality disorder."

Admittedly, psychiatry is different.  In general medicine you don't end up with a diagnosis of "liver disease with cancerous and hepatitis traits."  You have both.  In psychiatry it is possible to define mental health as a mix of issues.

Is all this just a tempest in a teapot?  A mountain out of a molehill?  and other quaint cliches for meaningless drivel?

IMO this is like most deconstructionist efforts (in literature, art, sociology, etc).  It's taking a small and worthy idea, and making it the centerpoint of an overall scheme:  probably too much heavy lifiting to justify the change in perspective.

Will patients be treated any differently?  Doubtful.

Doc D

Monday, November 29, 2010

Flu Vaccine Acceptance

There's a free article in the New England Journal of Medicine on longstanding reluctance to accept the flu vaccine.  (For a news article see WaPo Health, Nov 26)

I've been getting the vaccine annually for over thirty years.  No problems, and no illness.  As a doctor, who gets exposed every day, I'm thankful.

As far as other vaccines go, I've seen cases of lockjaw, measles encephalitis, mumps in adults that caused sterility.  Fortunately, I began practice too late to see cases of polio, but as a child--before the vaccine--there were about 100,000 cases of polio a year in this country.

The case for vaccines seems clear.  The case for flu vaccine is slightly different; not everybody who gets the shot becomes immune, but most do and this confers a herd immunity that inhibits the transfer of the disease.  Which means many fewer people get it, and those who are vulnerable are less likely to die of it.

Again, a pretty straightforward case.

But acceptance of the vaccine among the general population remains unchanged.  Most shocking, only about half of health care workers received the H1N1, knowing full well that they were in a position to pass on the disease to the most vulnerable patients through daily contact in clinics and hospitals.

Casual contact is enough to transmit the disease.  Physical contact with the virus is the best way, but aerosol transmission works fairly well, too.  The contagious person just needs to go to the grocery store to expose a handful of people.

While vaccine deniers have some influence, it's small, according to the authors.  By contrast they find that the most reliable predictor of continued vaccination for flu  "depends on past experience with being vaccinated against seasonal influenza."  My guess is, they mean that "no experience," or experience of an adverse reaction (like sore arm, or fever) leads to non-acceptance.

That's all well and good, and efforts to educate the public should continue.

But, I'm still surprised that a large percentage of the public will allow themselves to be a walking, lethal danger to those infants and elderly in the country that might not survive the infection.

Doc D

Saturday, November 27, 2010

The Conundrum Of How You Communicate Uncertainty To Patients

What do you imagine is going on in your doctor's head when she/he sees you?  How absolute is the duty to inform fully?

More often than not, when you have a medical problem, your doctor will evaluate you and give you a semi-definite diagnosis and treatment recommendation.

However, if they were extremely honest, here's what they would say:
"I've seen many, many cases just like yours, and it's usually very hard to say exactly what's wrong. Different treatments work to varying degrees for different people with this sort of problem, it's very hard to predict which will work for any person, and most of the time none of the treatments is all that successful. I really can't predict what, if anything, is likely to work for you. I suggest we try treatment A, which usually doesn't work but which at least tends to work slightly more often on patients like you then do any of the other treatments. Come back in a month, and if it's working we'll continue it, and if it isn't we'll try something else." (From Wrong: Why experts keep failing us..., by David H. Freeman)
The referenced book is highly recommended.  From the author's experience, few people would be happy with such an approach.  They want, "Here's the diagnosis, this is the treatment, it'll fix you up." (my paraphrase).  In all probability, this second doctor is significantly inferior in diagnostic acumen than the first, and is more likely to cause frustration and a poor result.

But, rather than discuss doctor honesty, I'm more interested in what this tells us about patient's expectations.  The first, better diagnostician is failing to recognize that in addition to a solution and a cure, most people are looking for certainty and reassurance, and in almost equal measure.

But there are patients who do want the first approach.  There are actually people out there who are rational, believe it or not, and internalize rationality in their decision-making.  The trick is to correctly identify who they are before adopting one or the other (or a mix) of the approaches above.  I've done both.

You don't tell someone who may be unstable that they are going to die of cancer, lest they harm themselves.  However, you owe a reasonable person an honest assessment of a poor prognosis.  In fact, to conceal pertinent consequences is not only unethical, but legally actionable.

People can fool you.   Decades ago, I shared in a decision with other consultants--and the whole treatment team--where this occurred.  The patient, who had a lethal form of cancer, appeared the ideal candidate for honesty.  He made a strong case that he intended to pursue all the treatment even if the chances were not good, but needed accurate information in order to prepare, both for himself and his family.  He discussed insurance, wills, bequests, healing rifts with loved ones, experiencing his remaining life to the fullest.  He had no history of mental illness, no depressive symptoms, and was forthright and outgoing.  So we told him that the diagnosis was not good, treatment options were weak, most people succumbed, but there was always hope.

He jumped out the eighth floor window of his hospital room later that day.

Doc D

Wednesday, November 24, 2010

Weighing In At #8 (Pun Intended) On The Fattest Country List

For those who enjoy this sort of thing the Global Post (Health Beat, Nov 22) has published an article that ranks fattest countries around the world based on data from the World Health Organization.I like to call these things "Nature Notes", a way to identify bits of information that are entertaining… but basically useless.

For those who think that the United States is the world's fattest country, you're mistaken. We are actually number eight on the list: 79% of us are overweight. It's important to recognize, though, that these data put everyone with a body mass index (BMI) of 25 or more in the overweight category. For those of us you are about 20 pounds over our ideal weight—many of us--we're in that 79%. It's not until you reach a BMI of 30 that a person is classified obese.  For the average-sized person, this is somewhere in the 35-40 pounds over ideal range.

The fattest country in the world is one I've never heard of: Nauru, which is a tiny South Pacific island where 95% of the people are overweight. This seems to be related to a cultural preference for, let's call it "opulence."

By comparison the United Kingdom is 66% overweight, which is a doubling since 1980.

Of interest--in reviewing the overall list--those countries which have experienced a rise in prosperity over the last quarter-century are making it into the top 10-20 list. Countries in the Caribbean are notable in this respect. For instance, Domenica, a poor country with a population that was traditionally malnourished and starving, has improved it’s economy and quickly moved to the #10 position, at 76% overweight.

This is a pattern seen not only in the Caribbean but also in South America and some of the oil-rich countries of the Middle East. Kuwait, for instance, "weighs in" at 75%.

The formula seems clear:  prosperity leads to obesity.

See the list below of the top 10 countries. A quick Glance shows that eight of them are small Pacific Islands.

The Top Ten:

1) Nauru: 95 percent
2) Micronesia: 92 percent
3) The Cook Islands: 92 percent
4) Tonga: 92 percent
5) Niue: 84 percent
6) Samoa: 83 percent
7) Palau: 81 percent
8) United States: 79 percent
9) Kiribati: 77 percent.
10) Dominica: 76 percent

Not very impressive, is it? However, I would like to see the breakout; what percent of the 79% are in the “overweight” category and what percent in the “obese” category?

I would be very happy for the US if the great majority were in that 25-30 BMI range. But I’m not optimistic.

Doc D

Tuesday, November 23, 2010

Your Right To Bottled Water. It's All About Freedom...I Guess.

I read an article about the "water" business.  You know what I'm talking about, the business that generates billions in revenue to sell plastic with tap water in it to humans that can't think of a better use for their money.

See here in the BBC News (Nov 22)

The bottled tap water industry continues to grow by leaps and bounds.  One large company with a clearly recognizable name (think "something" Crunch) makes millions every year by harvesting city tap water in Florida, labeling it with a catchy adjective ("fresh", "vital", "purified"), all of which means nothing, and selling it to people who would rather spend a dollar than take a water bottle with them.

Although I've posted about this in the past, one statement in the article struck me.  Buying bottled water is the ultimate in capitalism's potential, and represents a freedom of choice for those who decide to "buy in."

Well, I hadn't thought of that.  I've written about how I think dietary laws are expensive, unnecessary, and futile.  People will get what they want, whether you try to restrict it or not.  They'll just find a way around it, or substitute that bad habit with another.  It's human nature.

And, if I think those laws and restrictions on people's dietary freedom are bad, then--to be consistent--I shouldn't object to those who want to buy their water in plastic made from a petroleum product.

Emerson said that "a foolish consistency is the hobgoblin of little minds."  I'm not sure that this qualifies as being "foolishly" consistent, but if you're laying down a principle--like freedom of choice--then  maybe it's not.

So, fine.  It's your call, and I shouldn't vilify that choice.   But...some ways of expressing freedom seem better than others, so I'll continue to say that bottle water is a waste of money.

Never mind that we could abolish hunger, achieve world peace, and eliminate the federal deficit if we quit spending those billions (OK, I'm exaggerating...)

And, I've been guilty (rarely), when we're on a road trip.  I would rather buy a bottle of water from a convenience store than drink from the grody water fountain (with gum stuck on it, and other unmentionables), or from the water hose out back.

[BTW, sodas are dehydrating, not only from caffeine content, but also from osmotic load.  They are no substitute for water]

But other than the occasional road trip, carry your own water bottle and fill it from home.  Save enough money over a year to buy that new pair of shoes you wanted.

Doc D

Monday, November 22, 2010

Notice to Readers

Dear Readers,  Nostrums will not post regularly this week, during the Holiday.

There may be a couple, but we will have a full house... and are already cooking and baking.

I hope you have a great season.

Doc D

Saturday, November 20, 2010

Food Safety Regulation. $1.4B In Taxes So You Don't Have To Wash Your Food

The Senate begins debate on a bill to implement a massive overhaul, regulating food safety (Wash Post, Nov 18).

Decades ago, we (me, spouse, 4 kids) raised some chickens.  For a single family we probably had way too many chickens because we couldn't keep up with all the eggs.  The birds ran free (a pre-1980 version of "free range;"  we didn't notice any difference in taste).  We kept finding eggs in the garage, under the roof, behind bushes.

In any case, as mildly educated, but city-raised, home growers, we knew all chickens are carriers of Salmonella, the agent that causes gastroenteritis in humans.  The eggs, as they are laid, get coated with the germ.  So, we carefully disinfected the eggs before storing them for use.  And we didn't eat them raw.

To this day, we wash fresh foods like lettuce, tomatoes, etc.  Not bananas, unless we cut them up...never mind, that's a different story.

The food industry washes the eggs for you, before packaging.  But if the process is ineffective, or contaminated, and people aren't careful, illness results.  Bacteria are killed by cooking, but when raw eggs are consumed, or the the contaminated shell comes in cotact with the egg, it's a problem.

[I digress for a moment.  Remember the contaminated tomatoes incident?  People got sick, and were afraid to eat them.  Restaurants stopped serving them.  Here's a tip:  Nobody got sick at home from tomatoes that were thoroughly washed before preparing.]

The public health results of people taking responsibility for doing the sensible thing (by home-sanitizing fresh foods) is amazing.

But instead of you and I doing what we should, we're going to devote billions in taxpayer money to make sure the industry takes over, relieving us of any need to apply common sense.

Problem.  There is a body of research on accidents, ranging from nuclear reactor breakdowns to food processing contamination, that suggests the more safeguards, backups, and fail-safes put in place, the more certain it becomes that there will be incidents.  The book to read is Normal Accidents, by Charles Perrow.  It sounds counterintuitive, but Perrow makes a strong case.

Combine this with the progressive consolidation of the food industry, where a single plant sends products to a large section of the country.   It magnifies the significance of a single breakdown in the process, sending contaminated foods to  millions. 

And lastly, even if there is a small improvement in food safety, the regulatory cost both to the taxpayer and to the shopper at the grocery store (you didn't think the farmers wouldn't pass on the costs, did you?) will be significant.

Have a nice day, and enjoy your highly regulated, safety-ensured five dollar tomato.

I'm going to continue to wash them.

Doc D

Friday, November 19, 2010

Our Bizarre Reaction To Risk

You don't use plastic grocery bags?  As a responsible environmentalist you choose the reuseable bags...that contain lead.

I read this story (Assoc Press, Nov 19) about consternation over grocery bags with wry amusement.  I'm not concerned about grocery bags; do what you like.  What's interesting is how we lurch from risk to risk with no assessment of what is really risky, versus what is marginally risky.

Worried about a plane crash?  By comparison with the risk of a fatal auto accident, you're worrying about a risk that is vanishingly small.  One statistician calculated that you would have to fly once a month for thousands of years to equal the risk you take every day when getting behind the wheel.

Domestic animals raised for food have hormones in them.  Egad!...No, wait a minute, we all have hormones in our bodies.  We would die if we didn't.  What happens to all those compounds?  Uh...we excrete them.

So, what's the problem with beef that has been fed hormones?  Compared to the hormones your own body manufactures, the content in food is not that great, and gets metabolized, mostly.  Yes, frogs are probably susceptible to hormones in the water supply, but I don't eat frogs.  Industrial effluents, and their control, are a different issue.

In any case, if there's a measurable risk from the myriad of things we are confronted with in the news and research literature every day, it behooves us to take a step back and say, "How does this compare with the risk of...say...cutting myself shaving and bleeding to death?"

Looking at the numbers will convince you that we get excited about scary-sounding things that are really very unlikely, while we gobble fast food, drink too much, drive too fast, and do all the mundane--but solidly risky--things all the time.

Doc D

Thursday, November 18, 2010

The Water-Drinking Controversy In Weight Loss

A number of people have claimed that pre-meal water loading can be an adjunct to calorie-restriction in weight loss plans.

Now there's a study (ina the journal Obesity, Feb 2010, see link for abstract) that shows an impact.  It aint a great study, though.  With only 48 participants, including the controls, it doesn't have a lot of power.  Adopting a critical attitude, you start asking whether this small group has some selection bias, or other characteristics that make them not typical for the whole population.  Two that jump to mind right away are (1) these 48 people were not in the very obese category (max BMI of 40), and (2) they were middle-aged and older.

And the period over which the study occurred is only 12 weeks.  For a popular review of the research, see here.

However, for what it's worth, the experimental group drank two glasses of water prior to meals, and experienced a 44% increase in weight loss by the end of the 12 week period.  44% sounds like a lot, but in terms of pounds lost was 15.5 versus 11.  This occurred while both groups were on a hypocaloric diet...that is, reduced calories per day, but I'm not sure how much.

Nothing cosmic about water is going on here.  We reach "fullness" while eating when the expanded stomach sends a message to the brain that says, "You should stop now."  It's a mechanical effect to pre-load the stomach in advance with water, leaving less room for food.

Parenthetically, I've had patients that assuage hunger in-between meals by sipping water.  It works for some.  So, in general, this is a decent enough strategy to get a head start on limiting caloric intake.  It avoids having to take medicine, or other more bizarre products, to accomplish the goal of weight loss. 

A reasonable approach is to reduce calories below your baseline needs by about 500 a day, and drink two 8 oz glasses of water prior to eating.  Unless you have a medical condition that limits your ability to withstand calorie reduction; if you're under treatment, talk to your doctor.

An unexplained  (but fascinating) finding is that the calories consumed at the beginning of the experiemental period was lower in the water group, but by week 12, the water group was taking in just as many calories as the no-water group.  This may just be the phenomenon we run across all the time:  people find a way around restricting the content and quantity of intake (like laws to change Happy Meal contents...folks will just eat somewhere else).

For Onion Peelers,
Weight loss was ~2 kg greater in the water group than in the nonwater group, and the water group (beta = -0.87, P < 0.001) showed a 44% greater decline in weight over the 12 weeks than the nonwater group (beta = -0.60, P < 0.001). Test meal energy intake  was lower in the water-preload group than the no-preload group at baseline, but not at week 12 (baseline: WP 498 +/- 25 kcal, NP 541 +/- 27 kcal, P = 0.009; 12-week: WP 480 +/- 25 kcal, NP 506 +/- 25 kcal, P = 0.069).

One big caveat.  There are people who overdo anything.  Compulsive water drinkers, or water drinking contest participants (if you can imagine such nonsense), can develop a syndrome called water intoxication.  Nothing to worry about really; 16 oz prior to a meal is nothing.  We're talking gallons over a few hours, in order to cause problems.  But the point is, no one should assume that since two glasses helps, more will be better.

People who are prone to that type of thinking are eligible for the Darwin Award.

Doc D
The above is not intended to be treatment advice.  It's just a discussion of research results, and what they could mean.

Wednesday, November 17, 2010

Yet Another Lazy Journalist Serves Up Debunked Claims About US Health Care (sigh)

An Op-Ed in the Washington Post rehashes all the old myths about US health care.

The best that can be said for the author is that he is too lazy to dig into how statistics can be manipulated.  Readers of Nostrums have seen posts on how this occurs (here, and here.)  Readers who haven't followed Nostrums for long can go see the whole discussion on this topic.

This is just an overview.  The column (Wash Post, Nov 9) alleges the following:

1.  US citizens don't live as long (the longevity myth).

Actually, when you take out deaths for violence and auto accidents, which have nothing to do with health care quality or access, the US is #1 in longevity.  Also, if you look at people 65 and older among many countries, the US exceeds almost all countries in years of life remaining.

2.  Infants don't survive as often in the US (the infant mortality myth).

In the US, if an infant, at any level of maturity, shows signs of a heart beat or spontaneous attempt to breathe, it's considered a "live birth," and counted in the mortality statistics.  I found over twenty different schemes for counting births in other countries that limit what can be called "live."  And not just in third world nations;  this includes France, Switzerland, and Germany, among others.  The mortality stats are manipulated by calling any infant under 24 weeks not "live", using only some of the WHO criteria for a live birth, not registering a premature infant as "live" until it survives to 9 months.  The most ridiculous is the Swiss requirement that an infant be 30 cm long in order to be considered "live."   This cooks the books by eliminating those infants most at risk from the mortality data.  In the US we don't play those kinds of games.

3.  In the US the uninsured can get care only by going to the ER (the free-riding myth)

The government's own data show that the most common frequenters of the ER are its own Medicaid patients, not the uninsured.  See my post here.

4.  The US has more deaths that could have been prevented (this one's new to me, I'll call it the avoidability myth)

I haven't seen this allegation before.  In my specialty, preventive medicine, we pretty much disregard data on "avoidability" because it's unreliable, subjective, uncommon, and overlaps too much with expected causes of death to be of any use.

I keep hoping we'll get to the point where the politicians can get beyond the slogans and distortion.  But if even the journalists can't manage it, we're doomed.

How about we require journalists to be re-credentialled by a taking comprehensive exam every five years, like doctors do?

Doc D

Tuesday, November 16, 2010

Help! My Nose Is Making Me Fat

This is a strange study.  Apparently, if you are overweight, you're more likely to have a sharpened sense of smell for food.

I'm not sure whether to say "Well...duh." or that this is a significant finding.  See the BBC News (Nov 15) here for a popular report, or the original study here from the journal Chemical Senses (Nov 26, advance pub)

Our sense of smell is useful in detecting situations where we should be attracted (foods) or repulsed (corruption).  I'm sure this is intentional and helps us decide whether to pursue or avoid certain things, a survival advantage.

So, it's not surprising that among 64 volunteers, after eating, the overweight folks had better food discrimination in the satiated state than those who were thin.

For Onion Peelers,
Experiment 1 revealed that olfactory sensitivity was greater in the nonsatiated versus satiated state, with additionally increased sensitivity for the low body mass index (BMI) compared with high BMI group. Experiment 2 replicated this effect for neutral odors, but in the case of food odors, those in a satiated state had greater acuity. Additionally, whereas the high BMI group had higher acuity to food odors in the satiated versus nonsatiated state, no such differences were found for the low BMI group.

Are we going to see nose filters to treat those who are susceptible to overweight?

Doc D

Monday, November 15, 2010

No Relationship Between Access To Primary Care And The Number Of Primary Care Physicians

The argument is often made that people have trouble seeing a doctor in some areas of the country because there's an imbalance in the supply.

I'm no fan of the Darmouth Atlas, an academic policy research project whose members have little experience of the complexity of health care delivery, but this is interesting.

They call it "surprising" that there's no relationship between access and supply (only they would).

On the left you have the percent of Medicare patients who receive at least one clinical visit per year.  Along the bottom you have more PC physicians as you go from left to right.

Clearly a "scattergram," and attempts to use statistical tools to transform this blob into a linear relationship fail  (R2 = 0.07).

What other factors are there?  Culture, economic status, education, overall health...  The list is endless.  But the data argues against what the Netherlands does in their health care system:  they tell physicians where they have to practice, and limit the number per region.  A new doctor in the Netherlands has to practice where the government says, or buy out another physician's practice.  Otherwise, try a different career.

Doc D

It's Official: Unlike The Rest Of The World, Britain Will Not Pay For New Cancer Drug

The new GI cancer drug, Avastin, is too expensive and doesn't extend life long enough to justify the cost, according to Britain's govt-run health care system.

Continuing its reputation as the most life-threatening health care system on the planet, Britain's National Institue for Health and Clinical Excellence (NICE...what a misnomer) has made the recommendation that Avastin extends life for, on average, only six more weeks....insufficient to justify the huge cost.

[Looking at other national health care systems, restrictions like these occur there, too.  Govt health acre works great when you have the flu, but get something dire and expensive to treat and you're less likely to get the newest therapies.  See my posts on this.  The countries usually couch their denial in terms of "unproven" treatment, or "not clearly an advantage" until public outcry forces them to cover it.  For more discussion, see here.]

One caveat.  UK has a cancer drug fund that people with GI cancer can apply to.  As long as the fund's money lasts, bowel cancer patients can get the drug.

So, my advice to those patients is, get your application in early before the cupboard is bare.

I've written about NICE and it's formula for making these decisions before.  I also have a problem with using average life extension as a measure of effectiveness.  The word "average" implies that some patients may not be helped at all, but that some (half, actually) will exceed the average; in a minority of cases, the extension may be very long.  It would be tragic to be one of those who would live for a year or two, but got doomed by an "average."

And just to make the calculation more complex, a simple formula that looks at the drug's use in isolation overlooks the fact that when Avastin is combined with two other chemotherapy drugs, the triple therapy leads to a 78% chance that the tumor can be reduced in size sufficient to undergo surgery that has a measurable probability of becoming life-saving.

Under the US health care law, a group called the Independent Payment Advisory Board (IPAB) will be the near equivalent.  Their task is to recommend Medicare spending reductions.  The rules have yet to be written, so it's not clear whether they will follow NICE's methodology, or just set price-controls.

And the President's new director of Medicare/Medicaid, Dr Donald Berwick, has said he "loves" the British system.

In any case, don't think we're immune from decisions like the one the UK has made.

George Orwell would have loved to write about a "scientific" planning agency that calculates the value of life in dollars per hour.

Doc D

Health Care Reform Update: Gov't Handing Out Waivers To The Law's Requirements

The U.S. is sticking to its one-step-forward-one-step-back approach to health care reform.

As of this date, the federal government's overseer of health care reform, the Dept of Health and Human Services, has issued 111 waivers to the new law's requirements, affecting about 1.2 million people, in order to stem the avalanche of insurance cancellations and premium increases the new law is producing.

At this rate we'll have a fully implemented universal health care law by 2014 that nobody has to adhere to.

Sounds a lot like where we were before.

Of course, proponents say that the new insurance offering that will come available in three years will solve all these problems.  I'm scratching my head to see how, since the services needed will cost the same if not more by then.

This sounds like a "lick and a promise" leaning toward a "pig in a poke."

Doc D

Not Medical, But Too Cool To Pass Up

Implanting gold nanoparticles into tree leaves causes the trees to luminesce.  That is, the trees become streetlights.

I spend a couple of hours each day reading journal articles and science news.  I came across this research note and couldn't help reporting it.

Taiwanese scientists were looking for a way to improve LED lights.  By chance, they discovered if you implant gold nanoparticles into the leaves of trees, interaction of chlorophyl--essential to photosynthesis--with the particles causes the trees to glow.

Not only THAT, but the light emitted actually provides a light source for photosynthesis.

I have no idea whether this will pan out.  I'm skeptical, but the sheer imaginative power of such a process is overwhelming.  Even if it's apocryphal, this is world-class science fiction material.

I can't find peer-reviewed research to document this report, but you can read the Popular Science blurb here.

Doc D

Saturday, November 13, 2010

Media Headlines: Report The Facts Or Create A Story?

I saw a report that 30% of readers obtain their information by scanning only the title of an article.

So, it was depressing to see the following.  Both articles were written on the same day, reporting on the same research into the use of a drug for acne, called isotretinoin, or Accutane.

"Study: Major acne problem may raise suicide risk" (Wash Post, Nov 12).

"Acne drug not found to increase suicide risk" (BBC News, Nov 12).

If you parse the words, the titles can be compatible.  The first is referring to an association between acne and suicide risk.  The second is referring to the lack of association between the acne drug and suicide.

What's interesting is that the first news organization chose to highlight the more dramatic finding--and the one that was incidental to the purpose of the research--and the other organization highlighted the hypothesis (less dramatic) that was under investigation.

Major acne can contribute to despression, and depressed people are at greater risk of suicide.  This is a predictable and widespread general phenomenon:  people who have a disabling or disfiguring problem are at risk.  Not much of a surprise.

But the Washington Post thinks writing a dramatic headline will grab your attention better than reporting the study's actual results.

Among the 30% of readers who are headline scanners, the likelihood that they will read one or the other article, and form different conclusions, is random.

Yellow journalism lives.

Doc D

Friday, November 12, 2010

We Don't Need No Stinking Stem Cells

A study out of Canada shows that you can cut out the middle man involved in creating one cell type from another.

There are well described techniques for creating pluripotent stem cells out of adult tissues, like skin cells.  These stem cells are "pluripotent" in the sense that they have been altered genetically to the point that they can be used to create other types of cells.  For instance, if you can take skin cells from an adult, cause them to lose the characteristics that make them skin and open up the full genetic complement of the cell, then use those cells to become the template for a different type of cell you want to encourage--like blood cells--then you can replace a person's blood or create a new blood cell line to replace a diseased one, etc.

While the process is more complex than I've described, you get the picture.  However, getting from skin, to stem, to blood cell, is tricky.

What if you could skip the stem cell part--the middle man--and go directly from skin to blood cell?

That's what this research describes (for the popular version, see Science Daily, Nov 8).

In the original study (Nature, Nov 7), the authors discuss how this technique could be useful.  Many diseases damage or destroy our body's ability to make new blood from cells in the bone marrow.  For decades, finding a matching donor to do a bone marrow transplant has been difficult, and sometimes impossible.

Imagine creating blood-producing cells from the affected individual's own skin.  This would avoid the necessity for a matching donor.  Nothing matches you.

Pretty exciting stuff, but very preliminary.  We need to see if these converted cells are stable and remain effective.  So a lot of work is yet to be done.

But it's the first successful attempt at converting directly from one tissue type to another.

Doc D

Thursday, November 11, 2010

Cutting The Budget For Medical Research? Not Really.

I was irritated when I read an article that was saying it was outrageous to cut medical research in an effort to bring over-spending under control.

Whatever you think about governmental spending increases, good or bad, isn't my concern here.  I want to point out how superficial arguments will be used by politicians and the media to influence your opinion.

Government medical research funding was expanded greatly last year.  In some areas, funds increased by 50% or more.  This is huge for a one year increase.

Take a hypothetical example  (all notional numbers);  if last year an agency (like the National Insitutes of Health) received a funding increase of 20% over 2009, then cutting their increased funding by half leaves them ahead of the game by 10% over the last two years.

Or to be more concrete, let's say NIH funding increased from $300 million in 2008 to $500 million in 2009.  To say that a 20% cut, back to $400 million is "outrageous"  doesn't meet the sniff test.

Despite being a "cut" it's still a major increase in funding over the two year period.

I'm all for medical research, but when people try to misuse numbers to make their case, the public loses trust.

Doc D

Wednesday, November 10, 2010

FDA Getting Tough On Smokers

New strategy to educate people about cigarettes:  scare you.

The FDA is proposing some new warning pictures to be put on cigarettes packages.  You can go here to see all the graphics being proposed.  Here are several.

From the Scare-The-Crap-Outta-People School of health education.  Think it'll work?

Doc D

Monday, November 8, 2010

The Logic Of "Drug Holidays"

No, drug holidays are not about getting stoned during Christmas.

Has your doctor ever recommended a holiday from one of the medicines you've been taking for a long time?  I read this note in the LA Times Health blog (Nov 8) about how patients may have a tough time accepting the need to stop their medicines for a while.

The blog post was referring to recent evidence that suggests it is potentially harmful to stay on certain drugs for osteoporosis, in particular the bisphosphonates (Boniva, Actonel, Reclast, and Fosamax).  These are very common drugs and some patients have been taking them for a decade or more.

So, how is it that a beneficial drug is not harmful in the short term, but can be so in the long term?

Our bodies adapt to continued exposure over long periods of time.  We know that some exposures are harmful from the beginning--like cigarette smoking--and don't have a problem accepting that in the long term other even more harmful things can occur.

But an agent that's good for us at first becoming harmful later is a bit harder to explain.

Most medicines have effects that are unrelated to the mechanism of action for which they are prescribed.  Aspirin was a great medicine for lowering fever, but it also interfered with the blood clotting mechanism...and is currently prescribed for that in low dose to prevent coronary occlusion and heart attacks.  It takes about a week off  aspirin for your blood clotting mechanism to return to normal.

In the case of the osteoporosis drugs, those patients who have been on the medicine for many years may be at a very slightly increased risk of esophageal cancer; the research is not complete on this.  However, there is a risk of hip fractures after long-term use which most studies seem to confirm.

Physicians have long recommended that most patients not stay on hormone replacement therapy for many years, with similar concerns for risk of cancer and vascular disease.

But drug holidays aren't just about hormones.  Non-steroidal anti-inflammatory drugs (NSAIDS)--used for degenerative arthritis and other pain conditions--that were designed to avoid the risk of GI bleeding accompanying some drugs of this type (like ibuprofen), have been shown to lose their protective effect after long-term use.  And doctors are recommending drug holidays for these (Celebrex, for instance).

It's important to note that most drugs don't need a holiday.  You should never stop insulin, digoxin, other heart medicines, and legions of other drugs without consulting your doctor.

But the theory is that a holiday will interrupt the process by which the risk is developing, and restore normal physiology, so the drug can be re-introduced.

How good is that theory?  It's hard to prove.  A risk that took years to become measurable may take years of study to know it's been averted. In most cases, we don't have a good test to tell when the risk is gone.  In some cases it may be that re-introducing the medicine puts you right back at the level of risk you were at when you stopped. 

Overall, the principle is one of caution.  And, occasionally, you find that a patient will go on a drug holiday only to learn that they don't need to take it any more.  That's a good thing; we sometimes end up taking too many medicines of dubious benefit.

The bottom line is, if your doctor recommends you go off treatment for a while, get the full story.  Weigh the risk against the benefit and make an informed decision.  Drug holidays have a place, and an underlying logic for why they can be important.

Doc D

Sunday, November 7, 2010

Study: People Using Less Health Care

Many would jump to the conclusion that it's because of the economy.  But there are other factors.

I saw this article in the Wall St Journal Health Blog (Oct 29).  Americans sought health care with less frequency in the most recent calendar quarter.
The utilization slowdown could ultimately be a good thing as the nation grapples with how to bring runaway medical spending under control. But how good this is for consumers is an open question. But public health experts could grow concerned if it leads, for instance, to Americans cutting back on preventive visits and immunizations, which carry an upfront cost but wind up decreasing spending in the long run.
Naturally, we wouldn't want people to avoid care when they have potentially serious problems, or to experience increased pain and suffering from treatable problems...because of money.

To my knowledge, in this study, no one examined subgroups of the population to see whether the effect was more pronounced in those patients who have co-pays or deductibles.  If the reason for less health care is financial, one would expect that there would be no impact on those patients in mid-income ranges who have insurance plans with no deductibles or co-pays.  That wasn't done.

You might say, "How stupid is that.  Of course it's about money.  What else could it be?"  But, actually there's some research that says people seek health care excessively when there's no price to pay.  And studies that show reduced patterns of care-seeking need to go farther than just assuming it's due to money.
Reformers who want to implement a system that makes sure all who need care can get it, approach this in one of two ways:  they promote universal care, and (1) just accept that there will be those who use the system to excess--a cost of  ensuring universal coverage, or (2) they control access so that those who access the system too often are squeezed out by triage.

HCR in the US is approaching universal coverage using the first strategy.  As other universal care systems have experienced, costs will become prohibitive and mechanisms will then be put in place to reduce "abuse" of the heatlhcare system.  In Europe, this is done by providing primary care for free up to a certain limit, then a co-pay kicks in (I think France has the best example of this), or a voucher system for care that, when used up, transitions to a partial-pay system (the government bills the patient).

And there is the third option, which the British seem particularly fond of:  reduce costs by cutting certain kinds of care, or disallowing coverage for certain expensive treatments that don't meet arbitrary criteria for how much benefit they provide.  How draconian this approach can be is illustrated by the serious consideration the UK gave to eliminating all hip replacements for one year to save several million pounds.  The logic was that those who need hips could just continue to treat their pain and disability using drugs and crutches, etc., for that period, so money would be available to fund the rest of the healthcare system.

As a goal--an ideal to be sought after--universal healthcare is laudable.  But ideas have consequences.  If we don't think this through and do it right, some of those consequences will be unintended and undesired.

Doc D

Friday, November 5, 2010

Taking Vitamin E And Risk Of Strokes

For normally healthy people, taking vitamins has never been definitively shown to improve health, with a few exceptions.

A study in the British Medical Journal (Nov 4) combined a number of studies (a meta-analysis of existing studies, not a new experiement) on Vitamin E and hemorrhagic stroke, finding a small increase in risk.

It's important to note that the word "stroke" applies to more than one type of occurence.  The word actually implies just the result, which is a loss of neurologic function, whether paralysis, loss of sensation, or reduced conscisouness...or all of the above.

When you look at what's happening in a stroke, the underlying pathology can be one of several mechanisms.  The most common two are (1) hemorrhagic, and (2) ischemic.  The former is self-explained--there is bleeding, usually from a ruptured or injured blood vessel.  The latter, is due to sudden reduction in blood flow to an area of the brain, commonly from a clot or plaque that has occluded the artery.

This study looked mainly at hemorrhagic strokes.  From the BBC News Health blog (4 Nov), the results were as follows:
The British Medical Journal study found that for every 1,250 people there is the chance of one extra haemorrhagic stroke - bleeding in the brain.  Researchers from France, Germany and the US studied nine previous trials and nearly 119,000 people.  But the level at which vitamin E becomes harmful is still unknown, experts say.
This is not a huge risk, considering that many everyday things we do are riskier, but it's at least a measurable level.

Interestingly, Vitamin E was found to be slightly protective for risk of ischaemic stroke (the more common type).  The research is also mixed on Vitamin E's effect on coronary artery disease;  some studies say it helps, some say it hurts.

For Onion Peelers,
118 765 participants (59 357 randomized to vitamin E and 59 408 to placebo). Vitamin E had no effect on the risk for total stroke (pooled relative risk 0.98 (95% confidence interval 0.91 to 1.05), P=0.53). In contrast, the risk for haemorrhagic stroke was increased (pooled relative risk 1.22 (1.00 to 1.48), P=0.045), while the risk of ischaemic stroke was reduced (pooled relative risk 0.90 (0.82 to 0.99), P=0.02).  There was no association with pre-existing disease, nor could they uncover a dose relationship.

That there was no relationship between how much Vitamin E was consumed and the degree of risk leaves us unsure of how important this finding is.  Also, note that the risk p-value just squeaked by the 0.05 threshold for significance.  I've talked before about this value.  It's arbitary, but we need some kind of line in the sand.  Otherwise, the likelihood that the findings are the result of random chance become too high.

However, the authors agree--and I agree with them--that diet and exercise are better preventive measures for stroke than supplements or vitamins.

A healthy lifestyle, as usual, beats the Magic Potions.

Doc D

Thursday, November 4, 2010

Medicare/Medicaid Announces New Rules, Cutting Physician Payments

It's official.  The government has announced 21% cuts in what it will pay doctors, beginning 1 Dec, with another 4% cut in January.

In my state, the number of doctors who are leaving Medicare has been growing.  This will only accelerate that process.  Several of my own personal physicians have indicated they will no longer be accepting Medicare unless the government fixes the payment system for good.  They're not asking for raises, like the unions do.  It's against the law for doctors to engage in collective activity.  They're just asking that we even out the inequities and move to a different way of paying for health care...rather than just price-cutting.

Most doctors already don't take Medicaid.

The fault lies entirely with Congress and three Administrations, beginning in the late 90's.  At that time, Congress passed legislation that would reduce physician payments by about 2% annually.  Cost savings were expected from a number of practice and disease management efforts, along with payment reform that would reduce overhead.  That didn't no savings accrued.

But Congress just postponed the annual cut every year by kicking the can down the road, as health costs continued to rise.

Organized medicine, in the form of the American Medical Association, supported the President's health care reform with the assurance that payment reform (the "doctor fix") would be a part of it.  When Congress was confronted with an overall extimate of the cost of reform that exceeded $1 trillion dollars, the $250 billion for the "fix" had to be cut in order to make the price tag more palatable.  The AMA felt they were.

So the old law limps along, postponing--and accumlulating--the annual cut, until now.

What this means for patients whose doctor will no longer accept Medicare is paying cash for services and being reimbursed with whatever the government is willing to pay.  Many seniors will be unable to afford that.

But, you can keep your doctor, right?  The President promised.

Under health care reform, Congress also changed the language regarding Medicare fraud, eliminating the word "intent" under the provision that governs how the government will pursue those who file claims for payment inappropriately.  This means if I see a patient, and file a claim for payment--with no intent to defraud--but mistype the code or enter my address wrong, the government can charge me with fraud.  I've heard from several doctors that Medicare is already refusing to pay if an innocent error is made, and there have been cases reported of doctors being charged by the government where there was no intent to defraud.

It's one way to lower health care costs, I guess...just don't pay for it.

Finally, HCR instituted new regulations that require your physician to report more information on your condition that, in my opinion, violates the confidentiality of the patient-physician relationship.

This is an absolute mess that is headed for disaster. 

Health care reform started with such promise.   That promise has evaporated.

Doc D

Tuesday, November 2, 2010

Claims For Healthful Benefits Of Fish Oil Supplements. UPDATE

As for many supplements, you can find lists of great things fish oil is supposed to do for you.  Almost none of them have been confirmed.

UPDATE:  I screwed up the math.  Corrected below.

I took fish oil for a while.   Some doctors recommend it for lowering triglycerides (part of the lipids in the blood, like cholesterol).  My personal experience is that it was mildly effective, but it also raised (mildly) the level of the "bad" cholesterol (LDL).  Six of one, half a dozen of the other; there was no benefit.

A new study looking at fish oil--containing the omega 3 fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)--for it's alleged benefit in preventing the progression of Alzheimer's disease got me to looking into just how many things this yucky stuff is supposed to cure.

[And, by the way, the study was fairly good, and showed no benefit...with one caveat, below.  See the free article in the Journal of the AMA, Nov 3]

If you get your expert advice from the internet, here's what fish oil is supposed to do:

- lowers blood triglyceride levels

- reduces the risk of heart attack
- reduces the risk of dangerous abnormal heart rhythms
- reduces the risk of strokes
- slows the buildup of atherosclerotic plaques
- lowers blood pressure
- reduces stiffness and joint tenderness associated with Rheumatoid arthritis

I'm not aware that any of this has been confirmed by reputable studies.

Given that there's no evidence, here's a sample calculation of the cost of self-treatment:

--For an average dose of three capsules a day, containing on avg about 650 mg of EPA and 450 mg of DHA (each), taken for 365 days.
--With a purchase price of $41.81 for 120 capsules--40 days worth (I used Nordic Naturals Ultimate, at Amazon, for pricing).

[Note that taking this for a few months is basically worthless.  It's a lifelong habit we're talking about]

Your annual cost for a placebo-effect benefit will be $381.52.

One final caveat.   The study referenced above wasn't powerful enough to be break out subgroups of people who had genetic hyperlipidemia risk (the APOE variants).  There was a suggestion that one variant might minimally slow cognitive decline in Alzheimer's, but this may be an random finding and needs focused research.

Make your own choice.  People need beliefs, no matter what the evidence for them.  Unless something dramatic comes up from the science, I'm giving it a pass.

Doc D

Monday, November 1, 2010

Govt Medical Task Force Cancels Scheduled Meeting On Eve Of Election

The US Preventive Services Task Force (USPSTF) cancelled their scheduled meeting for today, where they planned to vote against prostate cancer screening, due to unspecified "scheduling conflicts."

Testing for prostate specific antigen (PSA) has been somewhat controversial for twenty years.  The task force was going to put the test into the "not recommended for any age" category.  It currently is in the "not recommended for over age 75, but inconclusive benefit for under 75,"

One physician on the task force has announced he will resign, because "politics trumped science." (see WSJ Health Blog, 1 Nov)

Why would he say that?

Consider the following two things:
1.  Remember all the hoopla over the USPSTF's announcement to re-consider mammography, potentially recommending against screening in the 40-50 age group?  All the "death panel" allegations, stories of women whose cancer was detected in their 40's, etc.?
2.  There's a mid-term election tomorrow that doesn't bode well for the Obama administration.

Coincidence? Maybe...But, the USPSTF has no comment, or clarification, about what the scheduling conflict was.

So, let's wait for more facts.

Doc D

Britain To Give Patient Treatment Decisions Back To Doctors

Britain's National Institute for Health and Clinical Excellence has been the "rationing" arm of their National Health Service.  After mutiple scandals, that role has been taken away.

The Institute, called NICE (what a name for a body that decides not to cover some expensive treatments for its citizens), has over the years made calculations using cost and quality-adjusted life years (QALY) as a way to decide that certain treatments are not justified by the cost involved.  I've talked about how faulty these calculations can be in previous posts; just search for QALY on Nostrums.

There's something inhuman about saying someone's life is worth only a certain amount of dollars.  The second half of the calculation, involving "quality" of life, depends on somebody's idea of how to judge the value of being alive.  And, lastly, just because an expensive treatment only adds six months on average to life, ignores the fact that "average" means that half live longer...some a lot longer.

The President's new Medicare chief, Dr.Donald Berwick, has professed to "love" the NICE system.

However, NICE made the decision not to fund drug-eluting cardiac stents for several years and delayed acceptance of Herceptin, a drug shown to improve survival in non-metastatic breast cancer.  I doubt whether the British government is going to do a study of how many died needlessly from those delays.

But it saved money, I'm sure.

So, the news now is that GB has finally woken up (BBC News, 1 Nov):
A Department of Health spokesperson said: "We will introduce a new system of value-based pricing which will make effective treatments affordable to the NHS. Our plans will ensure licensed and effective drugs are available to NHS clinicians and patients.  "We will focus NICE's role on what matters most - advising clinicians on effective treatments and quality standards - rather than making decisions on whether patients should access drugs that their doctors want to prescribe."
And guess where the authority to approve drugs and other treatments will go?  To groups of doctors who are seeing the patients in their locale.

What a concept.  Doctors deciding, with their patients, what best meets their needs.

Doc D


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