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.

Friday, December 31, 2010

Why Is 98.6 F Normal?

Humans, like most mammals, hover around this temperature.  Given that we keep a constant temperature, why this one?

I ran across this study online (mBio, the journal of the American Society for Microbiology, Nov 9).  It's not an experimental work, but a mathematical model for what temperature would best serve mammals ( of which we are one) in terms of protection from infection, balanced by the cost of maintaining that temperature.
"Assuming that a relationship exists between endothermy and reduced susceptibility to certain classes of microbes, we hypothesized a tradeoff relationship whereby the high costs of endothermy were mitigated by protection against infectious diseases."
As with all models, the results depend on the assumptions.  As an aside, this explains why so many people argue about global warming; the predictions are based on models.

In this case, the researchers set up the model to say that, as body temperature increases, microbial diseases will find it harder to infect the host...the higher temperature making it inhospitable for the germs to grow and spread.  Countering that, the organism must work harder and harder to maintain a higher temperature, driven by caloric intake.  At some point the mammal can't eat enough to fuel the higher temperature.

So, they hypothesize there must be an optimum temperature where you get the best "fitness" to survive.  Putting it all together, their model spit out the following curve:

And found that the maximum fitness (on the y-scale) occurs at about 37 degrees C...or 98.6 F.

Nice correlation, but there are probably about a hundred other variables that play a part.

Which brings me to body temperature as a clinical indicator.  Over the years, I have seen many patients with normal body temperatures that are above or below 98.6.  It's normal...for them; and it's usually not more than a degree either way.  The figure of 98.6 was arrived at by averaging a bunch of "normal" people.  This means there will be "normals"  above and below.

Some patients get it, others don't.  Those that don't sometimes medicate a temperature that doesn't need medicating.  And doctors facilitate this by suggesting anti-pyretics (fever reducing drugs) "just in case."

As a patient, myself, I don't take anything for a low-grade fever.  (Not that I believe in "natural" healing; if it's strep, I'm taking antibiotics.)  I discuss fever with my patients, the pro's and con's of treating it, and when...and let them decide.

Doc D

Thursday, December 30, 2010

Gross-Out Nutritional Event Of The Year

A hearty (pun intended) thanks to the UK Daily Mail for letting us know.

At a time when we're all thinking about waist lines, this article on one woman's protest against weight reduction:

"Stuffed! The 30,000-calorie Christmas feast eaten by the world's fattest mum in ONE two-hour sitting"

A New Jersey woman who hopes to become the fattest woman in the world got 30,000 calories closer to her 1,000lb goal with a festive feast that could have fed dozens of revellers.  46-stone Donna Simpson, sitting in a reinforced metal chair, chowed down on the world's biggest Christmas dinner as she ate for two straight hours on Saturday.   The single mother-of-two tucked into two 25lb turkeys, two maple-glazed hams, 15lbs of potatoes (10lbs roast, 5lbs mashed), five loaves of bread, five pounds of herb stuffing, four pints of gravy, four pints of cranberry dressing and an astonishing 20lbs of vegetables.  (Mail Online, Dec 27)

Apparently she makes a living with her weight, by public appearances and a subscription website.  People pay money to watch her chow down.

The more we try to regulate what people can eat, the more we see oppositional behavior.

So, you think taking the toy out of the Happy Meal is going to make people want to eat right, or the opposite?

Doc D

Wednesday, December 29, 2010

Placebos Work....And Your Point Is?

A flurry of media articles were published over the holiday proclaiming "Placebos actually work."

A study had been published PLoS One, Dec 22) that appeared to show when you give people a placebo for their medical problem a significant number will show a benefit even when they know it's a placebo.

How could this be?  Reading the news, you might get the impression that somehow patients are able to transform an inert substance into a therapeutic success by the force of their will, or some mysterious mental power; that we should look to harness this special ability.

Readers of Nostrums know that bias comes in many forms, of which placebo is only one.  Remove the placebo effect, and those other, less visible forms, emerge.

The news reporting was disturbing, but it was the holiday.  And for once, I promised myself--and family--that there would be no interruptions (ask my kids how many times they impatiently waited on Christmas day because Dad didn't get relieved from emergency room duty until 8AM).  So I let it go.

But, the frustration remains.  Here's a short description of what news readers were told (Science Daily, Dec 23),
...80 patients suffering from irritable bowel syndrome (IBS) were divided into two groups: one group, the controls, received no treatment, while the other group received a regimen of placebos -- honestly described as "like sugar pills" -- which they were instructed to take twice daily.  ...By the end of the trial, nearly twice as many patients treated with the placebo reported adequate symptom relief as compared to the control group (59 percent vs. 35 percent). Also, on other outcome measures, patients taking the placebo doubled their rates of improvement to a degree roughly equivalent to the effects of the most powerful IBS medications.
Put aside for the moment that with a study population of 80, the difference between the results in the control group and the "treatment" group was about 10 patients.  There's little you can conclude from such small numbers.

Put aside that we're dealing with a syndrome (IBS) that is characterized by abdominal pain, bloating, and discomfort...all of which are perceived subjectively.  That's not to say it doesn't exist and make life hell for sufferers, it just means that we're dealing with symptoms that are modified by things like the individual's sensitivity to pain, mental state, etc.  It's not as easy to measure quantitatively, compared to a throat culture or a cholesterol level.

Put aside that comparing a group that got "something" to a group that got "nothing" is...well...not really comparable.

Lastly, put aside that placebo studies tend to work mainly on symptoms like pain.  Even if there is something positive from placebo use, it aint gonna cure cancer...and it didn't cure the IBS.

Here are the other caveats left untouched by the media:

1.  People who suffer from chronic pain go through cycles where their symptoms are worse for a while, then get better, and so on.  If you treat someone during the worst part of the cycle--where they are most likely to seek help--they will tend to show a benefit as they move into their improvement phase.  Study their symptoms over long enough period of time, and the treatment benefit tends to go away as they move into the next, more painful cycle.  This study was way too short (three weeks!).

2.  Ask yourself what kind of patient will agree to enter a study where they are told that the treatment they are being given is of no benefit.  Does it select out those people who say, "No way.  I'm hurting and I don't want to waste my time on something that doesn't work"? This will skew the results toward those who are desperate enough to hope for improvement, no matter what.

3.  And then there's the Hawthorne effect.  Named after the factory in which the study occurred, this phenomenon is produced when participants know they are being observed in an experiment, and behave differently.  In the original experiment, investigators raised the light level in the factory and noted an improvement in the output.  They then lowered the light level, and output improved again!  The effect is also seen in medical trials; patients tend to report results differently when they know it's an experiment.  The tendency is for patients to show some impact just from being monitored closely:  "You know, now that I think on it, I do feel better."

The placebo effect is real, but it's not mysterious.  Other sources of experimental bias are also real, and they don't go away just because you've told patients they're taking a placebo.

If you want some positive conclusion from this study, it's that people are complex and bias is almost impossible to eliminate.

Doc D

Monday, December 27, 2010

What's A Parent To Do...About Their Child's Weight?...Or Anything?

Dueling studies:  the rule rather than the exception.

Parents' Influence on Children's Eating Habits Is Limited

Mothers' Diets Have Biggest Influence on Children Eating Healthy, Study Suggests

Both of these articles appeared in the same website (Science Daily), on the same day, describing two different studies.
Is it any wonder that most of us can't figure out what to do with our lives, or our children's?
Eat this, don't eat that.  No, wait, reverse that.   Stop sitting around, exercise.  No wait, exercise doesn't help much (Yep, same website, but not today.  A few months ago).
Remember the weight loss guru who always said, "Stop the insanity!"  Despite stating a truism, she had her own guidance to promote, and it was as useful as the above...that is, almost worthless.

Many social psychologists say that experts are more often wrong than right.  But we go on, thinking that experts have special credentials to guide us in how we should live our lives.

Given that those same psychologists say that we often believe the guidance that most accords with our own pre-judgments, it's a wonder we get anything right.

It sounds like old wives tales are probably just as accurate.

Doc D

Thursday, December 23, 2010

Notice To Nostrums Readers

Nostrums will not be posting for the next 2-3 days.

Unless I run across somethng that gets me riled up.

I hope everyone has a great holiday!

Doc D

Sniffing Out Cancer; No Longer Dependent On Canines.

This is kinda funny if it weren't for the fact that cancer is very "not funny."

Apparently ovarian cancer tissue smells different from normal tissue.  How researchers figured that out, I don't know.  It reminds me of the Old Days in medicine when doctors would taste their patients' urine; if the urine was sweet-tasting, they made the diagnosis of diabetes.  The high blood sugar of diabetes would spill over into the urine.

But apparently these guys not only have "perceived" this difference, they published an article a while back showing that dogs (whose sense of smell is considerable) could distinguish the cancerous from normal tissue.

Thankfully, we don't have to rely on crotch-smelling dogs.  Our intrepid scientists have designed an electronic sniffer that can possibly be used in the clinical setting (see Future Oncology, June 2010) .
"Our goal is to be able to screen blood samples from apparently healthy women and so detect ovarian cancer at an early stage when it can still be cured," says [Gyorgy] Horvath [lead investigator].  (Science Daily, Dec 21)

What a relief.  I saw dog universities springing up to train Fido's in the art of Private Parts diagnosis.  What breeds would we find to be better suited to sniffing up dresses?

I envisioned written clinical policy that said male dogs could only sniff out a diagnosis if another female dog was present as a chaperone.

I'm grateful to put that nightmare to bed.

Doc D

Wednesday, December 22, 2010

Drop In Teen Birth Rate In '09 Due To Economy?

I can't argue with the stats, but connections to the economy are speculative.

The Centers for Disease Control and Prevention has published its report on the number of teen births by year since 1957.

For those of you who might question that the highest rate was back in the 50's, it's important to remember that we're not talking single parent teens, but all teens.  And back then, women married younger, so many of their children's birth certificates will show them as still in their teens.  Women are marrying later in recent decades, and a teen birth nowadays is more likely to be to an unmarried female.

Here's the graph:

Here's the part I'm not sure about:
Experts say the recent recession - from December 2007 to June 2009 - was a major factor driving down births overall, and there's good reason to think it affected would-be teen mothers.  "I'm not suggesting that teens are examining futures of 401(k)s or how the market is doing," said Sarah Brown, chief executive of the National Campaign to Prevent Teen and Unplanned Pregnancy.  "But I think they are living in families that experience that stress. They are living next door to families that lost their jobs. ... The recession has touched us all," Brown said.  (Assoc Press, Dec 21)
This interpretation fails to answer why the trend in falling teen births started twenty years ago.  Duh...

Nothing in the data source--birth certificates--tells why the rates are dropping.

The upward blip in the late eighties is interesting, too.  Remember the decade of one-night-stands?  On the other hand, abortion was legal during that period...and on the rise.

My guess is that the explosion in sexually transmitted disease since the 60's is playing a part, as is the ready availability of birth control to teenagers.

But, I have no data to support those hypotheses.

Doc D

Tuesday, December 21, 2010

STUDY: Echinacea Effective For The Common Cold? Depends On Whether You're A Believer

As expected, this randomized study showed no benefit, but what's fascinating is the opinions of the investigators involved.

For the herbally uninformed, echinacea is a best-selling over-the-counter botanical that is marketed to boost the tune of about $10 for 60 capsules.

The study is available here (Annals of Int Med, Dec 20).  A typical news story describing it can be found here (Assoc Press, Dec 20).

Using your taxpayer dollars, the investigators, led by Dr. Bruce Barrett at the University of Wisconsin, randomized over 700 adults and children to echinacea in a standard dose versus placebo over five days (there was also a no-treatment control group).  It's reportedly the largest randomized study done so far.  The data showed no statistically significant difference in severity symptoms or duration of illness.

"Barrett and other experts said the findings would probably be viewed as positive by echinacea supporters but as the "nail in the coffin" by critics."
By contrast, the executive director of the American Botanical Council, Mark Blumenthal, while admitting the study was well designed, "used a good quality product at a reasonable dosage and tested echinacea in a real-world settings" said,
"It's not a compelling result in either direction,"
You be the judge:

For Onion Peelers,
Of the 719 patients enrolled, 713 completed the protocol. Mean age was 33.7 years, 64% were female, and 88% were white. A comparison of the 2 blinded groups showed a 28-point trend (95% CI, -69 to 13 points) toward [symptom] benefit for echinacea (P = 0.089). Mean illness duration in the blinded and unblinded echinacea groups was 6.34 and 6.76 days, respectively, compared with 6.87 days in the blinded placebo group and 7.03 days in the no-pill group. A comparison of the blinded groups showed a nonsignificant 0.53-day (CI, 1.25 to 0.19 days) benefit (P = 0.075). Median change in interleukin-8 levels and neutrophil counts were also not statistically significant (30 ng/L and 1 cell/high-power field [hpf] in the no-pill group, 39 ng/L and 1 cell/hpf in the blinded placebo group, 58ng/L and 2 cells/hpf in the blinded echinacea group, and 70 ng/L and 1 cell/hpf in the open-label echinacea group).
If you read all that stuff, you may be thinking, "Wait.  You said no difference, but the above says symptom "benefit." "  Fair enough.  But look further.  The sentence says a "trend," not a difference.  The clue to this language is in the Confidence Interval  (see the "CI").  It runs from -69 to +13.  This means the variation ranged both sides of zero:  69 "symptom" points better (a scale made by assigning points to all the symptoms of sneezing, congestion, sore throat, etc) to 13 symptoms points more (i.e., worse).
Not convincing.
And that's why the herbal supporters will maintain their belief that the product works.
I think it's a waste of money.  But you can pick whichever belief you feel most comfortable with.
Doc D

Monday, December 20, 2010

What's Going On With Studies That Say We're All Sick?

What should we do about all these surveys and studies that show we're all messed up?  More illness, more trauma, more inability to cope by ourselves...Where is this headed?

Today alone, there were two news reports about alarming trends.

CDC: Majority of U.S. adults had troubled childhoods. (USA Today, Dec 20) "Almost 60% of American adults say they had difficult childhoods featuring abusive or troubled family members or parents who were absent due to separation or divorce, federal health officials report."

Mental Health Needs Seen Growing at Colleges. (NY Times, Dec 19) "National surveys show that nearly half of students who visit college and university counseling centers have serious mental illness, double the rate of a decade ago."

The two obvious explanations are (1) we really are going down the tubes as a nation, or (2) we "medicalize" much more of the everyday crises we're exposed to, and tell people they need help instead of saying, "You can overcome this."

Or it could be a mix.  We certainly call many more things a disease these days.  By contrast, some think there's more stress in our culture than there used to be--divorce, drugs, STDs, etc.

Then there's the really cynical view that all these surveys are conducted to get money for organizations who want to make a living from the public trough, through grants and taxpayer funds.  Many groups with principled titles are just fronts for political lobbying.  Academics need money to do more research;  a quick survey that says your area of study needs funding is a proven method for getting cash.

But even granting that these studies and surveys represent a meaningful interpretation of trends in mental and physical health, what does it portend for the future?  If college student mental health needs have doubled, and resources are inadequate to stem the tide (back when I was in college there were no resources.  Everybody was stressed by grades, but managed to cope), then where will we be in another few decades?   Will every single student need their own private therapist  to get through the day?

I don't think we're assessing issues like these properly, nor are we making headway with them.  Something revolutionary--and cultural--needs to take place, rather than viewing more and more people as sick and throwing more and more money at the problem.

Doc D

Sunday, December 19, 2010

Got Mercury? In Your Dental Fillings, That Is.

An FDA panel looked at allegations that the mercury content of amalgam used in dental fillings is hazardous.

That the mercury in dental fillings (the filling material is called amalgam) is harmful, has been a recurring theme; there are groups organized around the effort to lobby against mercury in dental use.  So far, the data hasn't been supportive. 

Hailed as a victory by the anti-amalgam crowd ("the myth of safety...has been destroyed" said one advocate, quoted in the USA Today Health blog, Dec 18) the FDA panel has just agreed to do some research into the question.
"The panel, convened by the U.S. Food and Drug Administration to look into the safety of amalgam dental fillings containing mercury, advised the agency Wednesday to reevaluate the use of the material in children and pregnant women."
Does that sound like the FDA has concluded there's a hazard?  It says "reevaluate."  I guess that's a victory of sorts, but not so much for the advocates, but for science.  Clearly, we want to be very careful.  Mercury accumulates in the body to some extent; it's possible that children and the unborn may be more vulnerable.

Amalgam has been looked at more than once.  There isn't much reliable research that amalgam causes health problems.  Large scale studies don't give a definitive answer.  Much of the testimony before the FDA came from individuals.  It's reasonable to hear somebody's unsubstantiated belief, and take action to investigate.  But it's not reasonable to conclude that individuals who have neurologic or kidney disease were harmed just because they have amalgam in their mouths, when millions of other people have amalgam and aren't harmed.  It's possible those individuals have mistaken beliefs...which they will never be convinced are false.  Psychologically, it's impossible for some people to accept that they get ill for reasons that don't include influences outside their own bodies.

Over a year ago, the FDA changed mercury from a class I device to a class II.  This directs more controls over its use.  A few countries have banned the use.  Concerned groups have questioned the way FDA does its risk assessment, as have other groups with other alleged hazardous substances.  The FDA has responded with a project to re-vamp how they measure risk.

But, there's also a plausibility issue with claiming harm from amalgam.  I read somewhere that it's estimated there's more mercury exposure over the years if you eat a tuna sandwich every month (on average) than from amalgam in your teeth.  Tuna contains a very low level of mercury (as do other foods).

And while mercury is released over time from the dental amalgam, the amount is tiny.  You are probably much more exposed to several hundred other metals and volatile organic compounds in your everyday life.

In any case, if the FDA accepts its panel's recommendation, maybe we'll get some definitive research done.  For now, I'm not having the...let's see, one, two, three...four fillings removed.

My dentist says that if people ask for non-metallic products (including no gold in crowns), he says OK.  But he also warns them that the substitutes don't last as long, and if they need to be re-done, it's on their dime.

And, he’s following the scientific debate.  If the science shows there is a hazard, things will change.

Doc D

Saturday, December 18, 2010

California Whooping Cough Outbreak: Cases In The Previously Immunized?

A poorly done news article on California whooping cough cases occurring in people who allegedly* have already been immunized.

This piece from the Orange County Register Watchdog blog (Dec 16) implies that either the vaccine is no good or that there's a new strain of whooping cough that's causing concern during the outbreak in California.
Thing is, a whole lot of people who have been immunized for whooping cough are still getting whooping cough, according to an interesting piece by The Watchdog Institute and KPBS in San Diego.  For whooping cough cases where vaccination histories were known, between 44 percent and 83 percent of the sick had been immunized, the report found.
Actually, it's probably neither of those two explanations (vaccine no good, new strain).

In the old days, we said that there were several vaccines that provided lifelong immunity.  We now know that's not true.  Even those people who had the disease itself--chickenpox, for instance--can break out again later in life.  With chickenpox, the recurrence is called "shingles" (it's the same virus).  We never completely rid the body of the virus in childhood and a minority of patients lose their immunity, usually after the fifth decade, and can develop shingles.

It's no wonder then, that as we have 50 or more years of experience with vaccines like smallpox, mumps, and measles that we find the duration of immunity is just "very" long, not lifelong.  On the order of 1-2 decades from some people, longer for others.

Then there are vaccines that we've always known the immunity they conferred was short-lived:  tetanus needs to be given every ten years, the flu shot every year.

Back to whooping cough.  It's likely that, since we first began giving whooping cough vaccination, some individuals did not develop a long-lasting immunity.

But, here's the key.  There was little whooping cough disease around, so they never got exposed again.  No exposure, no illness.  Then...when an outbreak occurs, as in California, the virus is circulating widely, and more of the those vulnerable folks win the Fickle Finger of Fate Award...and get whooping cough.

No need to postulate ineffective vaccine or a new viral strain.  Occam's razor.

The writers at the OC Register didn't do their homework:  they went with the hype over the more plausible science.

None of this "disproves" a new strain, but why make up a theory for which there's no evidence, when there's a good explanation at hand?

Digression:  I worked as a volunteer in the ER when I was in high school. I once asked a doctor, "We give the DPT shot (or DTP, as some call it).  It's for diphtheria, whooping cough, and tetanus.  D stands for diphtheria, T stands for tetanus, but where does P come from?"  He said, "Whoo-*P*ing cough."  The real answer is "pertussis," the medical term for whooping cough.  Ha ha.

Doc D
*I say allegedly, because records get lost and memories are notoriously inaccurate.

Friday, December 17, 2010

Egad! There's Formaldehyde In Our Clothes!

That's why you don't have to iron them so often.

The New York Times (Dec 10) alerted us to this calamitous exposure.  We are surrounded by formaldehyde "fumes" from clothes, sheets, linens, etc.  And some people can experience a "contact dermatitis" due to an allergic reaction.

Well, wait a minute.

Yes, a tiny amount of formaldehyde is used in products that make our clothes and linens "wrinkle-free," or mostly so.  But you never smell it (no fumes) and you never swallow it, and you never breathe it.  And it won't embalm you.  Plus, as you know from your "wrinkle-free" clothing, after you wash it a few times it aint so wrinkle-free no more.

And, "contact dermatitis" is a medical catch-all for "itchy and red, and sometimes just a little itchy with no redness."  It's not a disease, it's a feeling (itchiness), sometimes accompanied by an appearance (redness).  The redness, when it occurs, is a sign of an inflammatory reaction, that could be due to allergy, or just to irritation.  People who have severe contact dermatitis have it because they are experiencing some other disease or complication.

The joke among physicians is that the whole of dermatology could be practiced with a stamp for patients' charts that said, "Diagnosis: dermatitis, Treatment: cortisone."

The rare person who is sensitive to formaldehyde avoids wrinkle-free clothes, just like those "hens teeth" people with peanut allergy (that's a different story) avoid peanuts.

Yes, if you work in a factory that makes or uses vast quantities of formaldehyde, you have to wear protective gear.  That's all prescribed by federal regulation.

So, we're left with a Scaring Ourselves To Death article from the NYT about a trivial issue.  I say this recognizing that there are a few people with dangerous allergies.

So, forget formaldehyde.  If you think you're allergic, you're probably not.  Only about 10% of people who think they're allergic actually are (the same with penicillin allergy).  Most of the time I fully evaluate somebody who thinks they're allergic, I find they've falsely associated some adverse event with the exposure because the event happened sometime around when they were exposed.  I once had a patient who was convinced a vaccine made his scalp itchy and flaky.  Even when his wife pointed out that he regularly had flare-ups of dandruff, he wasn't convinced (Belief is stronger than evidence)

Or, rather, remember an example of a hyped hazard.

Maybe the NY Times could generate a movement to kill off chiggers.  They REALLY make me itch.  Plus there are hundreds of "natural" and "organic" things that plants and animals produce that are irritating.  Let's get moving; form an Legal Reform to Outlaw Irritation in Nature movement.

Say, I used to get itchy when I jogged in cold weather. Could we outlaw cold weather?

Doc D

Thursday, December 16, 2010

A Test Grade "A" Keeps The Doctor Away?

A quick note on a study that says the higher your grades the better your health.

I won't give an extended analysis of the data.  It's more important to understand what it means when there is an "association" between two things.  What it doesn't mean is that one caused the other.

Here's a quote from the news article (NY Times Well blog, Dec 15):
When they were all in their early 60s, those who had finished in the top quartile were, over all, half as likely to have experienced the declines in health that their peers who graduated in the lowest quartile were experiencing. Asked to assess their health on a scale from ”excellent” to “poor,” the top students ranked their overall health higher, and they were only half as likely to report having a chronic ailment like diabetes, heart disease or respiratory illness.

Maybe these healthier people who ranked high in school were healthier back then, too.
If so, an equally germane hypothesis is that being healthy gets you better grades.  Doesn't that interpretation make just as much sense?
Or, as I've explained before, it may be that health and good grades go together more often in people that share a third, unexplored commonality--the association between grades and health is just a coincidence.
So, don't tell yourself or your kids to make good grades so they can be healthier later in life.  This research doesn't say that.
Doc D

Tuesday, December 14, 2010

Taking Multivitamins Causes Poor Sleep? Not So Fast.

The media dredged up this 3 year old study on a slow news day.

An article in the Dec 14 New York Times, with a post in their Well Blog, talks about a study that people who take supplemental vitamins may have poor sleep quality.

The study is here, but there's little data to analyze.  I get the impression that the association of Vit's and poor sleep is minor.

Just for comparison, here is what the NYT says:
There is evidence that multivitamins may disrupt nighttime sleep.
And this is what the authors say:
Five equally plausible explanations were advanced to explain this association including vitamins cause poor sleep, poor sleepers seek vitamins, and unidentified factors promote both poor sleep and vitamin use. These data are considered preliminary.
Sounds different, doesn't it?

If I had to bet (I don't, usually) I would say this "association" is not a cause-and-effect phenomenon.  It's probably just that people who tend to take vitamins and have trouble sleeping share some other, unrelated behavior.

This research should have been left to obscurity, at least until much more work is done.

Doc D

Explanatory Note On The Ruling That Health Care Reform Is Unconstitutional

A flurry in the news about the federal court ruling in Virginia.  The judge said requiring everybody to buy insurance is unconstitutional.

The news reports mostly don't explain this very well.  Here's my stab at it.

The first thing to know is that our stupid Congress wrote the law without putting in a statement that said, "Even if some piece of this can't survive legal scrutiny, the rest can go forward."  (the "severability" issue).  It's a simple sentence, and is done all the time.  They didn't do it here.  So, if one part of this law is unconstitutional, much of it is.  Dumb.

On the other hand, everybody seems to agree that if healthy people aren't contributing, there isn't enough money to pay for the sick people.

That's why the "constitutionality" issue is so important; it could undo the whole shebang.  The Constitution says Congress can regulate "commerce."  But people who don't buy insurance aren't engaging in any commerce--unless we define commerce as including not engaging in it, which sounds nutty.  There's nothing in the Constitution that says the government can make you buy a product just because you live here.

It's confusing, because other countries require citizens to have coverage.  The difference is, their "constitutions" don't limit the power of government like ours does.  You have to remember that the Founding Fathers were working to put together a document that would ensure government couldn't become over-powerful.  They fought a revolution for that reason.  It's why our constitution has so much language in it about how the government can only do certain, defined things (the "enumerated powers").

People say, what about car insurance? States require that, don't they?  But the logic is different.  If you don't drive a car, you don't have to buy auto insurance.  Millions don't.  Health insurance is being required by virtue of being alive.  You can't opt out like non-drivers do.  Many, like non-drivers, don't plan to use health care.  Plus, states can regulate some things the federal government can't.

Some people say, "Forget the Constitutiton.  Times have changed.  We just need health care for all."  But, the law works by "establishing precedents."  Some fear that a precedent that says the government can make you buy something because it's in everybody's interest could be used to legitimize forcing any purchase that the government sees as good for all.  Only the safest cars, only nutritious food, etc.  Government already tells us a lot of what we can and can't do.

Some people are OK with being told things like this because they see a benefit that outweighs the loss of individual choice.  Others aren't, saying that without the freedom to choose poorly, there is no freedom.

Stay tuned.  As I've written before, the problem with HCR was not the goals, it was the incompetence in framing it.  All of this could have been avoided.

Doc D

Monday, December 13, 2010

Massachusetts Health Care Reform Costs Continue To Spiral Up After 4 Years

If you promise to cover everybody and lower cost, what do you do when cost goes up even faster? Claim victory while pointing fingers and considering desperate measures.

Four years experience of reform in MA has caused costs to rise even faster.  Overdrawn, and running out of options, the state is considering more draconian measures.

Like Obamacare, MA requires everyone to buy insurance.  But people are avoiding enrollment until they need something big, like surgery.  Then they join, get the care, pay premiums until they recover, and disenroll.

This transfers the costs of the freeloaders to the law-abiding patients who enroll and stay enrolled.

The state has been increasingly overbudget every year, has gotten waivers for Medicaid from an accomodating Administration, and sees only a deepening crisis ahead.  On top of this, health care usage (how often people see the doctor, go to the ER, etc) is on the rise.  The number of doctors and hospitals is unchanged.  Result: delays, reduced quality.

So what do you do?  According to
spokesman Richard Powers ...[with] 97 percent of Massachusetts taxpayers insured, the program so far has been an overwhelming success. Officials are now trying to lower health-care costs. “If the rest of the nation is as lucky as Massachusetts, the entire country will be better off,” he said. (Boston Herald, Nov 19)
The view from La-La Land.  The state admits that it is gearing up to sue citizens who don't enroll.  Big Brother must have your dough to keep the system from collapsing.

Critics like Michael Cannon, of the Cato Institute claim
“It was sold as a way to cover uninsured and then reduce cost of health care. It has covered some previously uncovered people, but not as many as the commonwealth claims they have covered, and the cost of health care is rising, by every measure, while the quality is falling.” (same link)

Supporters' big hope now is "Payment Reform,"  which means doctors and hospitals won't get paid for what they do, they'll get paid for the result.  It will be interesting to see what payment reform does when an overweight alcoholic does poorly and the clinic doesn't qualify for the excess cost of taking care of this patient.  The usual remedy has been for the taxpayer to pick up the tab; I don't see insurance regulators denying payment for services rendered.

Even the state Attorney General says that payment reform, if it works, won't be enough.

Recall that the Massachusetts program was a "ground breaking" effort that Obamacare patterned itself after.

Uh...that means the rest of us get stuck with it next?

Doc D

New School Diet Law Is Good News For After-School Fast Food Companies

The President signed into law a childhood anti-obesity program that will add $4.5 billion to the taxpayers bill...and will ensure that kids go elsewhere to get the food they like.

See the AP story (Dec 13) here.  The story tells the facts in the way proponents would like it to be told.  So here's the down side.

The funds will be expended to ensure nutritional food in schools.  It adds more kids to the rolls of those who will be receiving a lunch subsidy at a time when there have been several reports that even well-to-do kids are getting lunch free (aren't there people who are more needy?).

It also funds more nutritious food, like fruits and vegetables.  Maybe my four kids were unique, or abnormal, but, not being more stupid than the average adolescent, they ALL:
(1) would go to the school cafeteria, skip the Improved Nutrition lunch, and visit with their friends, and
(2) would hit the nearest fast food place after school, on the way home.

Once they were seniors in high school, and had use of a car, they snuck out at lunch to go to the Taco Bell. This is one of those things they confess to years later.

So, go ahead.  Blow some more money on a futile effort to keep kids from doing what they're going to do (that's what critics told us about the abstinence program, remember?  Apparently motivation only counts when we're talking sex, they forgot about the impact when it comes to food).

There's no way to make kids eat celery and carrots if they can get Twinkies and Double Whoppers.  Probably a better anti-obesity plan would be to start at home.

Can you think of some alternative way to use $4.5B?  the poor? the sick? the deficit?

Doc D

First Fatalities Reported This Year From H1N1 (Swine) Flu

"I got the shot last year, so I'm OK, right?"  Wrong.

The reporting so far is that H1N1's impact this year will be typical for seasonal influenza.  The people who were particularly at risk last year are the same:  pregnant women, small children.

I saw an article from the UK that of the first several hundred cases of influenza reported, 18% are due to H1N1.  The experts don't think that there will be more cases, or new and more severe forms, at this time.

But I occasionally run across people who claim what's quoted above.

The error?  The flu shot doesn't last long.  Yes, there are some immunizations that provide very long immunity.  We used to think that smallpox vaccination conferred lifelong immunity.  That's now been called into question.  Tetanus lasts a decade in most people, although with a really dirty cut, it's recommended that a booster be given earlier than that.  In the military, we used to get the typhoid shot every three years, which I hated:  I took two aspirin at the time of the shot, because I got fever and chills for a day or so.  Annoying.

But, flu is different.  The complex interaction of the flu agent--and the preparation from it that goes into the shot--and our immune system doesn't lead to a similar enduring immunity.  It has to do with how long our system will make antibodies to a particular virus, or a closely related strain of it, when no further exposure is present to spur on the process.  This is called "immunologic memory."  That is, how long the body will "remember" the disease and keep its guard up.  With no "reminder," memory fades.

With many viruses (like the common cold), after a while memory fades and the immune system loses its protective stance, antibodies fade.  We're back to square one.

And you have to get a new shot to get back in shape to defeat the disease.

So, don't assume that since you got the H1N1 last year that you have protection this year.  Plus, the flu shot protects against other strains that are expected to be floating around this year.

Do my a favor and correct anyone you hear say they don't need it.

Doc D

Saturday, December 11, 2010

Doctors Get Sick Too - Part 2 - My Spinal Fusion Story

This is like those movie sequels, Return to the Valley of the Son of King Kong, or something.   I wrote a story about my appendicitis.  Here's another.

It’s disheartening, but inevitable, that our bodies wear out. One of the most vulnerable structures is the system of joints. Over the years the constant movements of one bone against another, with the intervening structures that lubricate and cushion that activity subject to pressure and injury, the parts break down, linings are worn through, and bone rubs on bone.

The process is called degenerative arthritis, due to the inflammation that comes from that rubbing of the raw surfaces against each other. We experience this is as pain…daily, unremitting, slowly progressive pain.

Live long enough and arthritis of this type will be a daily visitor, and one of the most common sites is the lower back. If you've ever looked at a picture of the bones of the spine and vertebral column you'll note there are lots of places where bones come in contact with each other at joints. Each one of these joints can wear down; several at once are a misery.

In my case the process became apparent a little over 10 years ago when I noticed that-- while stretching out to run--there was some pain on flexing and twisting my back. Sensing that this was the beginning of the aging process on the joints, I knew that my best bet was to stay active, stay flexible, stretch a lot and keep going.

That worked for a while; then it became necessary to take the occasional ibuprofen to counter the symptoms. At first it was one pill every few days or so; then it became a pill after almost every run. The next strategy: cut back on the distance. 6 mile runs became 4 mile runs, and so on.

Three years ago it became so bad I could run no more, and I underwent a series of injections of steroid to the back, followed by radiofrequency ablation of the sensory nerves that serve those areas that were subject to arthritis. This helped for a couple of years. Then the pain changed. I was now getting a sharp pain running down the back of my two legs to the bottom of my foot. It got worse as I walked. Over time the frequency and severity of it progressed to every time I walked.

This was the most depressing time of my life. Historically I loved strenuous activity. Pushing the envelope was the juice. Now, increasingly disabled, out of bed only to walk around the house, I had little left. As part of a routine checkup with my family doctor I mentioned that things had gotten to the point where the pain management techniques were not working and I could no longer exercise. He recommended referral to a spine surgeon.

At that consult I laid out all my history he took a few x-rays and in summary said "This is classic neurogenic claudication." It was like being struck in the forehead with a hammer. Of course! What was I thinking? Why had it not been apparent to me? I knew well the signs and symptoms of this syndrome.

Lesson One: The physician who diagnoses himself has a fool for a doctor. Old saying. There’s no way to be rational. There’s denial, target fixation, distraction, misplaced concentration…all the criteria for error. It’s not possible to be objective in the way you need to be with patients. There’s also emotional involvement. The same applies to a doctor’s family; I used to make sure that someone else took care of my family’s medical needs (an insistence that is sometimes hard to explain to one’s spouse, who has to take the time to get an appointment; “Why can’t you just prescribe what I need?”)

Back to the diagnosis. I felt doubly stupid because neurogenic claudication, caused by movement of one vertebra on top of another (spondylolisthesis), narrows the spinal canal, and leads to pinching of the spinal cord: these are anatomical changes that can be fixed, and the condition has a very successful surgical procedure.

And looking back over the last several years, I had been doing the little things to relieve the nerve pinching that caused the pain: like standing with your knees slightly bent, which reduces the stretch on the nerves that run from the spine down the leg. I had been doing this, and so gradually, that it never occurred to me it was an indicator.

Lesson Two: Don’t forget that when new symptoms occur, if may not be the same problem, even if the new symptoms seem related to the old.

Here’s a picture.

But still, I’m wary of back surgery. In some cases, it’s a 50-50 chance that surgery will improve the symptoms. And, cutting always leaves scarring…substituting a new pain for the old. Furthermore, we’re talking big stuff here: (1) cut away the muscles over the spine (2) remove the bone over the top of the spinal cord (3) avoid damaging the spinal nerves while pushing them out of the way to get to the vertebra behind them (4) take out the disc, (5) move the vertebra back in line, (6) put in a hollow implant (7) fill it with bone marrow taken from my hip (8) drill in four screws, left and right, on the vertebra above and below (9) put two vertical rods to connect the paired screws (10) back out and close everything up.

Don’t get me wrong. Surgery is frequently lifesaving. I wouldn’t try to avoid an appendectomy; that’s lethal. And surgery for spondylolisthesis, if severe like mine (unlike surgery for other types of back issues), has a high rate of success. But it’s just tough to cure pain with a knife. So, I waited, tried other types of steroid shots; intraspinal, this time. After two months, nothing was better.

I limped into the surgeon’s office and said, “When’s your next opening on the surgery schedule?”

Two weeks later, I reported to the hospital at 6AM, sans coffee (a cataclysm). They take me in at 8:00, I get sleepy and the next thing I know, it’s Recovery Room and the clock is on the wall across from me. 3:00 PM. Let’s see, counting pre-op, moving me, induction, ET tube, and positioning on the front end. Then moving me to Recovery, and about an hour there before I return to this world. We’re still talking 5.5 hours! What the…

Here’s why so long. After doing the research on the different surgical techniques for this procedure, and getting a second opinion, I decided that rather than do the operation directly from the low back, I wanted a different—and new—approach. The technique, in use for only a few years, is called Extreme Lateral Interbody Fusion (XLIF). The old technique was PLIF (posterior lumbar etc). There is even a TLIF (transforaminal etc). This last tries to come in at an angle, but still in the back.

XLIF is done through an incision in the flank (yeah, from the side of the body) and slides in between the muscles of the back—without cutting them—to approach the backbone (I’m all for not cutting muscles in two). An electronic probe is used to test as you go in for nerves that supply the muscles, making sure you don’t get close to them. The implant work is done, this incision is closed, and the patient is then turned from the side to prone, and using two small incisions just to each side of the midline over the lower back, you use probes to remove the bone over the top of the spinal canal, one side at a time, No cutting muscles, and the spinous process in the middle is left behind. Screws and rods then get put in.

If you’re still with me after all this minutiae, you can see the thing that decided it for me. There’s no monkeying around with the spinal cord nerves that would risk damaging them. Yes, damage the spinal cord and you won’t have pain any more; you won’t walk either. Although that risk was low, it was the Big Kahuna of bad outcomes (other than just not making it).

Someone else would have decided on a different procedure. I did the math, made my decision, and fortunately, live in the US…where patients still get to decide what’s most “effective” for them. I’m concerned that comparative effectiveness under Health Care Reform will eliminate some of these options. The risk I was avoiding was theoretical; we don’t have 20 years of data to see whether XLIF has better outcomes than PLIF. And it’s expensive. In any case, it ought to be my decision, not a government panel’s.

But that’s another story.

These new procedures are called “minimally disruptive” because there are smaller incisions, less tissue trauma, less scarring, less post-op pain, shorter hospital stay, and quicker recovery.

Thirty-six hours after surgery, having walked the halls on two occasions, with assistance and without incident, the surgeon said, “Wanna go home? Just gradually work back into full activity.”

Recovery was uneventful; symptoms of claudication were gone from day one. Except…I got too rambunctious: I started walking a half-mile a day on the fifth post-op day and injured a leg muscle. My guess is that, since anesthesia is eliminated from the body over a period of weeks, I was still feeling the effects and shouldn’t have pushed it.

Lesson Three: Follow instructions and don’t think you know better than everyone else.

A minor annoyance was lack of appetite. For four weeks I couldn’t stand the sight of food; it made me nauseated (anesthesia again, probably). I got by on 3 cans of Ensure a day. And lost 15 pounds.

But I don’t recommend it as a weight loss regimen.

Now, I can jog--a little--again. Not the 10-mile runs of two decades ago, but it’s enough. I can lift heavy boxes; dig in the garden; etc. New bone has grown into the implant and fused the two vertebrae.

But the arthritis is still there, and will continue. You take the victory you can get.

Overall, I think being an active, inquiring patient led me to the right treatment choice, something any patient can do. Being a Dr. Know-It-All caused the problems.

Doc D

PS: Disclaimer: There are companies who specialize in making and selling the tools for the procedures above. I’ve avoided using any proprietary terms or company names. None of this is an endorsement of any particular company’s product.

Thursday, December 9, 2010

Medical Cartoonville - 9 Dec 10

From Grea, at 

Doc D

Infanticide Study: Hard To Write About

Profiles of mothers who murder their babies immediately after birth.

A notorious case of multiple infanticide in France--the woman admitted to killing 8 of her infants over 17 years--led to more in-depth look at how often this occurs.  The updated estimate from the French research suggests that it is five times more frequent than originally thought.

Caveat:  This is about numbers and how you can make something sound really bad.  Remember that going from 0 in a million to 1 in a million is an infinite increase.  The actually infanticide rate they found was 2.1 per 100,000 births (up from 0.39/100,000).  Each one is tragic, but the numbers are still low. It's a lot riskier to be an African-American adolescent male.

Also, the comparison was made by shifting the focus of what was measured.  This is always dicey.  In the previous rate, the data was taken from death certificates where the cause was listed as "infaniticide."  In the updated number, all deaths within 1 day of birth were reviewed.  You can see how the new method might over- or under-estimate those deaths which were murder.  What criteria did they use to say a "one-day" death was infanticide?

More important was the study's profile of the mothers they identified as having killed their babies (see the story at BBC News, Dec 8):
The average age was 26, a third of them already had at least three children and more than half lived with the father of the newborn they killed.

About two-thirds were employed, and the group as a whole did not differ significantly from other women in terms of social level or occupation.

None were clinically diagnosed as mentally ill. All hid their pregnancies from their families and friends but none were said to be suffering from genuine "pregnancy denial". They gave birth alone and in secret.
It's useful, in a way, to know those at risk, but I don't think we'll prevent much if the births occurred outside the medical system.  It may become easier for law enforcement to identify suspected deaths, but too late.

Doc D

Tuesday, December 7, 2010

Disease X, The Unknown.

Two different news articles got me thinking about how often there is no black-and-white answer in medicine.

The first column was from the Washington Post's Medical Mystery series (Dec 6).  This is where they find somebody who can't be diagnosed and, after many erroneous opinions, ends up having some weird manifestation of a condition that occurs so rarely there are only a few hundred cases in human history.  Stupid media stuff, really.  For the Chicken Little crowd.

The other report was about a study (The Lancet, Dec 7) that showed reduced risk of some cancers with taking a baby aspirin every day.  But, we know that there is a risk of GI bleeding from aspirin, so...pick your poison.  What guidance does this provide to the individual?  In a word, none.  That many people in a large population are helped or hurt by something only gives you odds.  You may be in the minority that are contrarily hurt or helped (or unaffected) by the treatment.

I read somewhere that 3% of people with medical issues are undiagnosable.  I don't mean they haven't found the genius doctor yet.  They just don't have anything that fits with a diagnosis that anybody could recognize.  It may be that it's too early in the illness, and the recognizable pattern has not emerged, or it may be that the patient is experiencing symptoms that don't normally fit with the underlying pattern, confusing the issue.  Or it may be that the patient has symptoms for which there's no organic basis--a cognitive mismatch;  i.e., attributing pain to an organ that has no pain sensation, etc.

But, I'm not talking about those situations.  Factor them all out, and there's still a finite percent of patients that have an undiagnosable problem.

This is something that we don't like to acknowledge.

So, what's going on with them?  Is it a unique disorder, one that is particular to that person only and will never be seen again?  Or is it a phantom, something ephemeral, a ghost in the machine?  On those occasions where such a problem resolves spontaneously, do you just shrug and say, "No longer a problem," and press on?

It's rare that a patient will accept this situation.  And they are right.  Something's wrong, but the current state of the art gives us no clue.  Sometimes--very rarely--the Medical Mystery will remain so.

When every possible test has been done, and every specialist seen, and there's no mental disorder gumming up the works, the road ahead is supportive.  "We'll do what we can to limit the effects, and never stop working to figure it out."

You and your patient never have to cross that bridge into hopelessness.

Doc D

Medicine In History. The Fate Of Charles II

Medicine in History.  Officially Charles II died of complications of a stroke.  I wonder...

And, admit it, we've come far since then.  At least we now recognize the difference between science and woo...sometimes.

I take that back.

When King Charles II fell ill on the morning of February 2, 1685, a team of six doctors were immediately at his side--and it might have been the worst thing to ever happen to him.  The following are some of the procedures used on the king:

-They let (drained) sixteen ounces of blood.
-In order to "stimulate the system," they applied heated cups to the skin that formed large round blisters.
-They let eight more ounces of blood.
-They induced vomiting to cleanse his stomach, gave him an enema to purify his bowels, and made him swallow a purgative to evacuate his intestines.

This type of torturous treatment continued for four days.  More bleedings, more blistering, more purging, more vomiting, more enemas, a concoction made from pigeon droppings, a cure of "40 drops of extract of human skull" of a man who had met a violent death, a force-feeding of the gallstone of a goat, and finally, "extracts of all the herbs and animals of the kingdom."  The result? The king died.  In comparison, dealing an HMO sounds pretty good.
--from Stupid History: Tales of Stupidity, Strangeness, and Mythconceptions Throughout the Ages, by Leland Gregory, Andrews McMeel Publishing, 2007.

A very entertaining book.  Recommended.  Amazon has it here.
Doc D

Something Doctors Should Say To Themselves Every Day

Not a quote of the day.  Called the Physician's Prayer by some, but need not be said prayerfully.  After all, we live in New Age America, where people are spiritual, but not religious (whatever that means).

From inability to let alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, and science before art and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.
--Sir Robert Hutchison [1871-1960]
Doc D

Monday, December 6, 2010

Bumble Bee Chicken Salad Recall

Like all recalls, this is targeted to a specific product, made at a specific time and place.

Consumers found pieces of plastic in

(1)  the Bumble Bee Lunch on the Run Chicken Salad Complete Lunch Kit
(2)   Bumble Bee Chicken Salad with Crackers

Here's the language of the USDA news release  (Dec 5):
"8.2-ounce packages of "BUMBLE BEE LUNCH ON THE RUN CHICKEN SALAD COMPLETE LUNCH KIT." The package contains a 2.9-ounce can of Bumble Bee Chicken Salad along with crackers, mixed fruit, a cookie and a spoon. The package label indicates the product is "Mixed and Ready to Eat." The product package indicates a "Best-by" date of 07/11.

3.5-ounce packages of "BUMBLE BEE CHICKEN SALAD WITH CRACKERS." The package contains a 2.9-can of Bumble Bee Chicken Salad and crackers. The package label indicates the product is "Ready to Eat." The product package indicates a "Best-by" date of 01/12 or 02/12.

The cans of chicken salad bear the establishment number "P-169" inside the USDA mark of inspection and the lot code "0225XXQBC" printed on the package. "
Here's a page with pictures of the labels.

Take the time to check the specifics.  No reports of anyone being harmed as yet.

Doc D

Top Five Posts Over The Last Month

The most popular content on Nostrums between 5 Nov and 5 Dec.

1.  Doctors Ger Sick Too - My Appendicitis Story.  (19 Jun 10)  The post that won't die...everybody stop reading it. Please.  {Most popular post of the last year]

2.  What's The Difference Between Lice And Bed Bugs.  (19 Sep 10)  I think it was the pictures.  Yucky.

3.  Should Nurse Anesthetists Work Unsupervised By Doctors.  (11 Aug 10) My answer was "Yeah, sometimes."  Probably all the readers were nurses.

4.  Doctors Opting Out Of Medicare.  Some Data.  (26 Aug 10)  The numbers keep climbing, the politicos keep denying.

5.  Narcisssists No Longer Have A Narcissistic Personality (?).   (30 Nov 10)  If you've spent a decade becoming an expert, you end up arguing about definitions.

Thanks to all for your interest.

Doc D

Nonsense Of The Day: Massive Texting A Risk For Drugs, Sex, Smoking (Not Rock N Roll?)

This is one of those studies that social scientists love to publish in Pop Psychology Today, or whatever.

According to the news release from Case Western Reserve University (Nov 9),
"According to the research, hyper-texting, defined as texting more than 120 messages per school day, was reported by 19.8 percent of teens surveyed, many of whom were female, from lower socioeconomic status, minority and had no father in the home. Drawing from the data, teens who are hyper-texters are 40 percent more likely to have tried cigarettes, two times more likely to have tried alcohol, 43 percent more likely to be binge drinkers, 41 percent more likely to have used illicit drugs, 55 percent more likely to have been in a physical fight, nearly three-and-a-half times more likely to have had sex and 90 percent more likely to report four or more sexual partners."
'Nuff said.  Form your own conclusions about human nature.

Doc D

Sunday, December 5, 2010

"I'm Just A Little Overweight. Isn't That OK?" Apparently Not.

I'm feeling guilty that I haven't published an in-depth look at a piece of research in a while.  Here's one.  This post addresses the conflicting evidence over whether being a little overweight is good, bad, or neutral.

For some time now, population studies have been published that tried to pin down whether there's a higher mortality rate in those people who are overweight, but not obese.  It's clear that obesity predisposes to other health problems that can shorten life, but what about if you're just 20 pounds over your ideal?  Some studies have shown that having a little heft is actually beneficial, some have not.

A group of public health researchers decided to take a huge population base, factor out people with significant health problems, and see whether a BMI in the range of 25-30 is a mortality risk by itself.  New England Journal of Medicine, 2 Dec 2010, "Body-Mass Index and Mortality among 1.46 Million White Adults."

Recall that below 25 is not overweight, 25-30 is overweight, and over 30 is obese.

They pooled data from 19 studies.  This gave them about 1.5 million subjects (ranging in age from 19-84, 58% women).  All were White (Non-Hispanic), which is the largest subset they could have chosen.  It's a limitation, but they weren't trying to be inclusive; leaving out other ethinicities eliminates some cultural and genetic differences that could have been confounding variables.

Over a 10-year median followup there were 160,000 deaths.  Hazard ratios were calculated against BMI, and the graphs showed:

There's an increased hazard ratio both below and above optimal weight (called a J-curve).

Caveats:  (1) "Healthy" subjects meant that they didn't have heart disease or cancer--other potential causes of mortality weren't included.  (2) Healthy also was ascertained only at the beginning:  subjects could have gotten sick later.  (3)  This is a meta-analysis of pooled previous study data (we've talked about this in previous posts...not bad, just a caution.  (4) Data on height, weight, and health were from self-reporting, which is fallible.

And lastly, BMI as a measure of "fatness" is not perfect;  a short weight-lifter could have little fat, but a high BMI.

For Onion Peelers,
Here's the data for women.  With a BMI of 22.5 to 24.9 as the reference category, hazard ratios were 1.13 (95% CI, 1.09 to 1.17) for a BMI of 25.0 to 29.9; 1.44 (95% CI, 1.38 to 1.50) for a BMI of 30.0 to 34.9; 1.88 (95% CI, 1.77 to 2.00) for a BMI of 35.0 to 39.9; and 2.51 (95% CI, 2.30 to 2.73) for a BMI of 40.0 to 49.9.  Men were similar. [CI = confidence intervals]

You might be asking yourself why "healthy" people with very low BMI's are at increased risk.  The authors speculate that it's due to persons who subsequently developed a health problem, or are malnourished.

As research, this is not completely definitive (none ever is), but it's a strong indicator that even being overweight--and not obese--is a risk factor.

However, given the other thousands of risk factors we participate in, it's not anywhere near the top.

Doc D

Medical (Semi-)Cartoonville - 5 Dec 10

This is humorous, but largely fictional.  I've never told a patient they can't understand their medical records, nor seen any other physician say it.  What I have said is, "If something doesn't seem clear, or you have concerns about what the record says, let me know."

The problem is not what's there, it's what patients think is there.  For example, a complete evaluation includes an assessment of mental status; I've had patients accuse me of thinking they might be crazy just because I properly included this element, even if the assessment was normal.

Another example would be including unlikely diagnoses in the differential list.  The "differential" is a list of possible diagnoses, in descending order of likelihood, that I need to keep in mind when working up their problem.  Patients may think I'm off my rocker to list something rare (or embarassing), that they "clearly" don't have.

So you might say that the problem with patients having a copy of their medical records (which they should) is one of format or protocol...not so much content.

Saturday, December 4, 2010

Vaccine Acceptance: Only The Uneducated May Survive

This is a quick, but astonishing, post about human ignorance.

I read the sentence below in a study on the safe and highly effective human papillomavirus (HPV) vaccine.  The shot prevents two types of HPV infection implicated in the development of cervical cancer.

The study is in the American Journal of Preventive Medicine (Dec 2010), titled "Human Papillomavirus Vaccine Among Adult Women - Disparities in Awareness and Acceptance."

Here's the quotation:
"Education was associated positively with awareness [of the vaccine], but inversely associated with intention to be vaccinated."
So, if you're educated, you're more likely to be stupid.

Doc D
You may have read that the FDA has now recommended that the Lap-Band for weight loss be available to the "less fat."

(See the Wash Post, Dec 3.)

Til now, the requirement was a BMI of 40 or more (or 35 with an obesity-related medical problem).  The FDA says now it's OK for the 30-35 range.

Let's say you are 5 feet 8 inches tall.  To have a BMI of 40 you would have to weight 264 pounds.  Clearly the previous criteria were meant for very overweight people

Recall that BMI is weight divided by the square of height (in kg and meters).  25 or less is ideal, 25-30 is overweight, 30 and above is obese.  79% of Americans are over 25.

For a quick estimate of BMI go here and plug in your weight and height.

Note that it's only this specific device that's affected.  Inserted through an incision it creates a bottleneck in the stomach, so only a small amount of food can pass through at a time.

People lose a lot of weight in the first year.  Take it out and you're back to square one, if there's been no change in eating behavior.  Here's what the device looks like (two are shown):

And here's what it does:

Looks like a medieval torture device.

I'm dubious of the long-term utility of these weight loss strategies.  No metabolic, nutritional, or behavioral changes occur in conjunction with their use.

One thing they rarely mention:  not being able to eat much leaves you very hungry.  If we could tolerate the hunger, we wouldn't need the device.

Doc D

Data From The Beginning Of The Flu Season

Case numbers have started to pick up.  The wave has started in the Southeast US.

This map is current as of November 27, the latest date for which there is reporting.  You can see more stats here.

I'm not sure how this looks in black-and-white (Kindle).  Maine and the Dakotas are reporting no cases yet.  There is local activity in the SE, with Georgia being the only state to report "regional" activity.

I looked at the types.  Only 5% are the 2009 H1N1.  The rest is divided equally between seasonal influenza A and B.

There's also a global map here.  It shows that H1N1 is considerably more prevalent in Europe and Australia.  Possibly it arrived late in the season last year and had less time to disseminate.  Totally speculative.

It's shaping up to be a typical season; which means only about 10,000 deaths.  That sounds like a lot, but is low; a severe year would be 40,000 or more.  People think of the flu as almost benign, if unpleasant.

Doc D

Friday, December 3, 2010

STUDY: Diet Now, Binge Later. Stressed Mice Do It.

This study makes me anxious.  But...that's what causes the binge eating, assuming I was a dieter earlier in life.  So, I'm trapped.

Wait a minute.  The study, in the Journal of Neuroscience (Dec 1), is looking at how mice cope with nutrition after living a calorie-restricted diet.  They become vulnerable to binge eating when stressed, more so than mice who had not been calorie-restricted.

I hate those meeces to pieces!

[You stress a mouse by not changing their litter, changing cages, and the like.  Mice tend to get neurotic from that kind of thing.]

So, if I keep my weight down with a restrictive diet, then I'll gobble like a hog if the car breaks down?  I'm better off just eating hearty now to keep from sensitizing my future craving for food?

1.  The mice were put on a 25% calorie-deficit diet.  That's a lot.  Most humans can only handle 10%.
2.  The mice lost 10-15% of body weight.  That's about 40 pounds for the average overweight American.  No wonder their physiology changed.
3.  The mice were diet-restricted for only 3 weeks.


4.  Humans are not mice.

I can't see the data in the study, so here's just a quote from the abstract:
"In examination of long-term behavioral consequences, previously restricted mice showed a significant increase in binge eating of a palatable high-fat food during stress exposure. Orexigenic hormones, melanin-concentrating hormone (MCH) and orexin, were significantly elevated in response to the high-fat diet only in previously restricted mice."
Bottom line:  no useful guidance for living in the real world.

If there's any take-home message, it's that dieting does more than just drop pounds.  In fact, the whole idea of eating less than our daily requirement may be unbalances other behavioral and nutritional aspects of fueling our bodies,

...if we're anything like mice.

Doc D

Medical Cartoonville - 3 Dec 2010

Hacking Into Medical Records.  It's a Living...

Remember Avian Flu? Probably Still Around

The media is reporting this as confirmed, but the tests aren't complete yet.

If you read the Wall Street Journal article (Health Blog, Dec 3) it sounds like avian flu cases in chickens have been confirmed.

Recall that flu virus strains are categorized by two elements.  Therefore, last year's worrisome new strain was H1N1.  Avian flu is caused by an H5N1.   Preliminary tests at a chicken farm in Japan have tested positive initially for the H5 sub-type.  More testing is underway.

I expect the findings to be confirmed, but we're not there yet.  The chickens from this farm are being destroyed as a precaution.

Avian flu in humans is highly pathogenic (dangerous).  The World Health Organization reported 115 cases back in 2006, 79 of which resulted in death.  It's possible that this high mortality wouldn't be seen in a pandemic.  The cases in '06 resulted from close exposure to poultry.  Few of the cases were human-to-human.

There is a vaccine.  The FDA approved the first avian flu vaccine back in 2007.  If we needed it in the future it would take a while to gear up production.

But it's impossible to tell for sure how bad it would be if the virus escaped into the general population.

The bigger lesson is that new diseases never really go away for good; they just hide out for a while before re-surfacing.

Doc D

Thursday, December 2, 2010

Non-invasive Body Contouring

It's been years since I looked at any studies on non-surgical body shaping.  I can't believe all the techniques and hardware out there now.

And, so far, I can't find any research on the benefits and risks.  Only liposuction has been around enough to know much about what can go right, or go wrong, in the long term.

For your interest, here's a brief compendium of some of the more popular non-surgical treatments designed to make you look better.

1.  Accent XL:  uses radiofrequency (RF) to target fat cells "Fat fluid is then absorbed by the body and removed in urine. The skin is tighter and the body is left looking slimmer."  For wrinkles, loose skin, jowls.  FDA approved.

2.  Liposonix:  Uses high-energy ultrasound (US) to liquify fat cells.  Fat is removed by the lymphatic system (and goes where? other fat cells?).  Not FDA approved.

3.  Thermage:  Uses RF to heat the under layer of the skin.  "This heat causes collagen creation, called neocollagenesis. This new collagen makes the skin look firmer & tighter and improves the overall texture of the skin."  This is for stretched skin, like chicken-neck.  Also alleged to work on cellulite.  FDA?

4.  UltraShape:  Another ultrasound approach that uses pulses to target fat cells, but spare other tissues.  Not FDA approved (but is approved in Europe).

5.  Zeltiq:  Cold has been a technique for anethestizing the skin for centuries.  This device claims to adapt the cooling process to apply enough cooling to damage fat cells, but not other skin cells.  The damaged fat cells are then policed up by the body. The manufacturers call this "cryolipolysis."  Gotta have a cool name.  FDA approved for anesthesia, not fat reduction. 
6.  Zerona:  Uses a laser, at frequencies that allegedly cause the fat to seep out of cells.  The manufacturer calls it "cool laser" technology.  For love handles and belly bulges.  FDA approved.

Once again, all of these claim:  no cutting involved, no general anesthesia, mild discomfort, and you can walk out of the office after treatment with only some temporary skin reddening.  The websites advertising these procedures show "before and after" pictures, and don't claim to do more than "improve" the situation.  If you were obese before, you will look obese after, just somewhat less so...for a while...maybe.
Even if this stuff works, and some of it sounds dubious, there's no data around on how long it lasts:  10 years? six months?  I noticed one disclaimer that  "Maintenance treatments may be needed to keep the results."  This may be like those treatments that grow hair:  yeah, they grow hair, as long you continue to use the product.  Stop, and your hair falls out.
The testimonials on the websites aren't evidence.  Clearly they aren't going to allow feedback that says, "My skin sloughed off, I got flesh-eating bacteria, and my life is ruined."  Complication and adverse reaction rates are not available.
Lastly....cost.  All of these things require one to several treatments at a total price that ranges from $2000 to $12000. 
Doc D

Wednesday, December 1, 2010

SURVEY: Private Practice On The Way Out

Some doctors will find other employment or retire with health care reform.  A significant number?

"A survey of some 2,400 MDs from around the country found nearly three quarters said they plan to retire, work part-time, stop taking new patients, become an employee, or seek a non-clinical position in the next one to three years.

But are these changes really the result of the new law?

Doctors responding to the survey seemed to think so. “Doctors strongly believe the law is not working like it needs to – for them, or for their patients,” said Lou Goodman, president of the Physicians’ Foundation, who conducted the survey." (NPR Shots, Dec 1)
First, this is not an academic survey.  Physicians' Foundation is an advocacy group for doctors in practice.  That said, the survey expresses a lot of dissatisfaction.

While health care reform is a major cause, the ongoing threat of Medicare cuts, year-in and year-out, lead the list--slightly ahead of reform--as the biggest cause.

NPR's take on the survey rests on a comment in the report that the changes in health care were needed and inevitable.  According to NPR, "Blaming the new law just gives doctors a convenient scapegoat."

We'll see.  Surveys show that, for some people, income is a reason to go through all the years of study and expense to get a degree in medicine.  But those same surveys show that humane motives and professional respect are the most important factors overall.

Maybe limitations on income will weed out the people who are pursuing medicine for the wrong reasons.  But, somebody who's disciplined enough to go through 7-10 years of post-college training could make a lot of money much easier, without all that expense and study.  So, I don't know...

Except for a few years, I was always a federal, salaried physician.  Sometimes there were not a lot of patients to see, and sometimes I was swamped.  There was no financial incentive either way, and I was most comfortable with not having to worry about seeing "enough" patients, or what I ordered (and how much it cost).

One thing we're seeing already with health care reform is physicians changing their practice patterns, joining groups or taking jobs working for hospitals in salaried positions.  They see the writing on the wall about the difficulty in trying to stay in solo practice.

Some of the pernicious influences of private practice will probably improve with that change; it removes the "push" to do more, order too much, or see as many patients as possible in a shorter time.  But, it introduces another problem:  your doctor may be an employee of an organization, and that organization may be more concerned about the financial bottom line than your health.

The pernicious part just shifts to a different location.

Doc D


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