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Friday, December 10, 2010

US life expectancy drops

According to the U.S. Centers for Disease Control (CDC), for the first time in 25 years there was an actual drop in overall life expectancy in the US, calculated in the year 2008 (since the data take some time to calculate, the CDC usually puts things out a couple of years after the fact, and 2008 is the most recent year for which data were released). This is not very good news. The bright spots were infant mortality and death from stroke.

This stands as an indictment of our health care system as well as what we do as a society to prevent illness and promote wellness. We can only hope that more Americans will be adequately insured and receive more appropriate health care in the future, and that our health care system will turn more towards prevention, where its bang is likely to be much bigger for the buck.

Sublingual allergy tablets effective in preventing seasonal nasal allergy

A new meta-analysis (synthesis of all available clinical trials) in the Cochrane Library has found that under-the-tongue immune treatment (which can be done at home) is effective without the side effects of weekly allergy shots. This advance in allergy treatment is particularly good for kids, and of course whether for children or adults reduces the major hassle of driving to the allergist's office, not to mention the pain and not infrequent reactions experienced with allergy injections. Very good news for allergy sufferers.

Thursday, December 9, 2010

Getting doctors to follow our wishes with advance directives

People of all faiths and atheists should be interested in doctors ignoring patients' wishes about life support. Whether or not you are predisposed to a particular religious point of view about life support, whether your wish is to be on life support, or not to be on life support, or something in between depending on the circumstances, we need a way to make sure doctors are paying attention to what our wishes are.

Three things are particularly important for everyone: 1) filling out an advance health care directive to indicate your wishes and your desired medical agent (durable power of attorney for health care), 2) having a knowledgeable health care advocate; in addition to designating the person who cares about you most as your agent, this person if they do not have a lot of experience from the medical care system may need help from someone more knowledgeable, and 3) the importance of registering your advance directive with an organization such as US Living Will Registry so that hospitals and health care facilities can check to see if one is present when you are admitted.

Monday, November 29, 2010

Getting tested for BRCA genes

I have been asked many times whether to be tested for the gene mutations which increase risks of breast cancer, also known as BRCA genes. There are a few such gene forms identified, which together account for a large percentage of hereditary breast cancers, as discussed in this National Cancer Institute fact sheet. These genetic mutations code for faulty enzymes responsible for repairing damage to DNA that causes cancer.

The first question in deciding whether or not to get tested is whether you have had breast cancer!! If so, get tested!! If you are positive for one of the BRCA mutations, it should have a big impact on whether you decide to have a prophylactic, that is, preventive mastectomy of the other breast. Women without BRCA mutations do not survive longer if they have second mastectomies. It also affects how frequently you screen the other breast with a mammogram. I am always surprised by how many people (yes, men get it too) who have had breast cancer have not had these genetic tests! This is a situation in which the downsides are much fewer. Specifically, the documentation of increased risk which might make it hard to get health insurance, is besides the point, since the history of breast cancer already confers that risk.

If you haven't had breast cancer yourself, the next question is if you know the medical history of your first degree female relatives, your mother and your sisters, or your father's sisters and mother. If you do not, consider whether you are in one of the ethnic groups at higher risk of the genetic mutations which increase the risk of breast cancer (Ashkenazi Jews, Icelanders, Norwegians, and Dutch). If you are in one of these ethnic groups, and you don't know your personal family history, you are likely to benefit from being tested.

If you do know your mother's, your sisters', both of your grandmothers' and your father's sisters' medical histories, and know what they died of, and they lived into their older years (70s or 80s, say) without developing breast cancer, then there is little chance that you have an extra genetic risk of breast cancer. Your lifetime risk is then like the risk in the general population without a family history of breast cancer, or about 12%, and there is no special reason to be tested.

Now, if your mother or sister did get breast cancer, is there any additional advantage in getting tested for BRCA genes?

The first step is, if the person who had breast cancer is still alive, to ask that person if they were tested for these gene mutations. If they were not, you could ask if that person is willing to be tested. The reason is that if they are negative for one of the gene mutations, then you are unlikely to have an increased risk on that basis too, and testing is much less helpful and not recommended. The second reason is that if they are positive, and you then get tested and test negative, you can set aside worrying about increased risk due to your family history as you have probably not inherited that risk.

If the person in your family who has breast cancer has died or refuses to be tested, the pros of getting tested are that if you test negative, you can get screened less often than if you are positive. If you are positive, you can get screened more frequently, and using different forms of screening such as ultrasound. Also, if you are positive, you can get screened for ovarian cancer, which is not normally done otherwise, because women with BRCA genes have increased risk of ovarian cancer. You may also wish to have prophylactic bilateral mastectomies, or if you develop cancer, to get the other breast removed at the same time. The lifetime risk of developing breast cancer when one is identified as being at genetic risk is extremely high, and many women opt for this solution, even some without BRCA genes. Finally, as above, if you do develop breast cancer, evidence has shown that if you do not have a BRCA mutation, having a prophylactic second mastectomy does not improve your survival.

The biggest downside of testing for breast cancer risk genes is being identified by insurers as being at increased risk. While there is now a federal law against insurers discriminating against women on this basis, this is totally unenforceable. Women can be denied by insurers for a host of spurious reasons (one woman I know was denied because she had had a urinary tract infection treated with antibiotics in the last year!) which may be cover-ups for other risk factors. We also have no assurance that health care reforms banning exclusion of pre-existing conditions or refusal to insure people with those conditions, will remain after future changes in the political landscape. Many women will feel with some justification that it is simply better not to have this risk recorded.

The solution to this downside, of course, is to get tested anonymously outside the insurance system. Then, at least, you will not be classified as being at extra risk unless you divulge this information to a physician because you wish to do something about it (such as bilateral mastectomies). Most labs will send specimens anonymously as long as you are paying for it and not the insurance company. Now that the patent on the BRCA1 gene has been struck down, other companies besides Myriad Genetics will spring into the marketplace and testing is likely to become less expensive. This brings up a new downside: the cost of testing, which depending on how many genes are tested for, can be anywhere from a few hundred to a few thousand dollars. See this discussion in the National Cancer Institute's factsheet

Getting tested may cause other harm worth mentioning. The increased screening for breast cancer which you are likely to have if you test positive carries risk. If you get screened more, you are more likely to have a false positive mammogram, or ultrasound, or breast MRI, with unnecessary biopsies, etc. Radiation from mammography and MRIs may also cause some increased risk. There has been a lot of recent publicity around why one might want to avoid mammography and screening despite a family history of breast cancer such as this recent column in Health Affairs.

The organization Facing Our Risk of Cancer Empowered (FORCE) runs a hotline to help answer questions about breast cancer risk and screening for breast cancer genes. Local communities often have support networks as well. In Palo Alto, there is also an organization called Breast Cancer Connections which specializes in helping newly diagnosed women, but also provides a lot of information to women about risks for breast cancer.

For additional information, ask your doctor to refer you to a genetic counselor. You can check with your insurance about whether they cover a visit like this. They may only do so if you have a family history of breast cancer.

Friday, November 19, 2010

Who should be your medical care "proxy" with durable power of attorney?

When you visit a good estate attorney, he or she will usually instruct you to fill out an advance medical directive if you don't have one already. The link in the previous sentence is a sample document provided by the State of California, although the directive does not have to be in this specific format. This document allows you to leave some specific instructions, but most important, allows you to designate whom you want to represent you for medical decisions if you are unconscious or cannot make your own decisions.

Many people designate a trusted loved one, such as a child or a spouse for this role, if they have one. However, some people do not have such a person. Such people should hire a primary agent to whom to give durable power of medical attorney in case they are incapacitated. My new business, Your Health Care Advocate, provides this service. Although I don't have a website specifically for this arm of my business, you can find contact information at http://www.myadvicedr.com. Please note that if I am serving as your agent, I cannot provide any other medical services to you as this would be a conflict of interest. Conversely, if you have consulted me for medical advice, I can become your agent as long as you realize that once the agency takes effect (you become unconscious or unable to make your own decisions), I will not be able to provide other medical services or advice to you, but rather would follow your wishes or attempt to figure out what your wishes would be in making decisions or providing input for medical decisions.

One of the reasons for appointing an agent who works for you is that doctors are unlikely to follow patients' wishes about life sustaining care, as demonstrated by the SUPPORT study . In my own experience, this goes in both directions, where doctors keep patients on life support that they wouldn't have wanted, or discontinue life support earlier than patients might have liked. In a recent case, doctors were ready to discontinue a man from life support on the same day as a cardiac arrest, before they had even assessed that his brain function was gone, despite the wishes of his medical proxy, his wife, that he wished every intervention to be done to attempt to save his life. In another case of a man with congestive heart failure who had dementia from several strokes, who had expressed his wishes to his family that he did not want to be put on a ventilator except for acute pneumonia, young doctors on call came in to the intensive care unit prepared to to intubate him (put him on a ventilator) when he stopped breathing during another massive stroke, despite very poor brain and heart function before the event happened. Had an agent not been present, he would have been put on life support, as his wife was not confident enough to question the doctors. From many religious perspectives, withdrawing life support is more problematic than not using it in the first place when it is not indicated. And, of course, failing to provide it when indicated and desired is even more concerning.

Thus, while it may superficially seem to be the most prudent avenue to appoint a family member to this role, there are some significant drawbacks to this choice.

1. If it is a child, they may not live where you do. Critical medical decisions in an emergency require very quick answers or the doctors are left to their own choices instead of getting input from anyone you instructed or anyone you trust. Telephone conversations are not that great for helping people understand critical medical situations. In this case, you may wish to designate a local alternate agent as well as the child who serves as primary agent. Consider hiring a medical agent or advocate to play this role if you do not have any friends with extensive medical knowledge.

2. If it is a spouse, he or she may already be frail and have health problems or may be emotionally fragile, or may lack self-confidence interacting with doctors. These are likely to be exacerbated by your being critically ill. This will make it difficult for them to have any meaningful input into the process. They are likely to feel overwhelmed and simply trust the doctors to carry out your wishes. Therefore, you may wish to designate or hire an alternate agent with a medical background in case your spouse feels too overwhelmed to carry out this responsibility effectively and wishes to delegate it.

3. The trusted person you designate may have little or no medical knowledge. Therefore it may be hard for them to understand the implications of the choices doctors are asking them for input on. You may wish to hire someone with a good medical background.

4. Conflict among family members often revolves around these decisions. It creates significant conflict among family members when one has decision-making authority and the others do not, and input from the others is ignored or devalued. Children also have conflicts of interest. In the worst cases, issues of inheritance and property may drive a child who has not been close with you to argue in favor of discontinuing life support, or, if you have children who live in your house, are very emotionally attached to you, or will benefit more by your survival in some way, they may militate for interventions you do not wish to have. A spouse may be somewhat narcissistic, and feel angry with you for abandoning him/her, and ignore your wishes not to intervene in certain situations.

A great alternative is to hire a medical agent who works for you to carry out your wishes and has no vested interest one way or the other.

[Of course, you may have little or no medical knowledge too, which is why I recommend that for important medical decisions, you consult a skilled doctor as a health care advocate (like me! http://www.myadvicedr.com)]

US Worst of 11 Industrialized Nations in Cost-Related Health Care Access Problems


Where does the US stand

Loved this compilation posted by a doctor on Medscape

Healthiest: the U.S . ranked 11.
top-ranking Iceland, Sweden and Finland
Obese: # 1 United States: 30.6%
Murder rate http://www.nationmaster.com/graph/cri_mur_percap-crime-murders-per-capita
# 24 United States:
Best Health System http://www.photius.com/rankings/healthranks.html
# 37 United States of America
Heart Disease Deaths: http://www.nationmaster.com/graph/hea_hea_dis_dea-health-heart-disease-deaths
# 13 United States: 106.5 per 100,000 people
Longevity: http://www.nationmaster.com/graph/hea_lif_exp_at_bir_mal-health-life-expectancy-birth-male
# 49 United States: 75.29 years 2008
Human Development Index: http://en.wikipedia.org/wiki/Human_Development_Index
#4 United States 0.902 ( 9)
Richest: http://www.worldsrichestcountries.com/
#Liechtenstein $118K USA # 10 47K
Best Place to Live: http://www.huffingtonpost.com/2009/10/05/norway-best-place-to-live_n_309698.html
Norway is # 1
The United States placed 13th.
Gender Equality: http://english.peopledaily.com.cn/90001/90777/90853/7167348.html
Iceland # 1 followed by Norway, Finland and Sweden.
The United States # 19th
Corruption: http://www.nationmaster.com/graph/gov_cor-government-corruption
US # 17
Fastest Internet: http://www.speedtest.net/global.php#0
South Korea; # 30 USA

More on red yeast rice and cholesterol

The Archives of Internal Medicine published a study which evaluated different red yeast rice supplements and found them highly variable in the amount of monacolin (sometimes spelled monocolin) they contained. This ingredient is the active ingredient lowering cholesterol, which is similar to that in lovastatin. They also found that some of the supplements contained a compound toxic to the kidneys.

The important distinction here is between red yeast rice and red yeast rice supplements. This study evaluated 12 supplements in capsule form. While the study raises a caution about purchasing extract supplements in capsule form, I stand by my previous post on the subject with respect to the whole grain. Buying the whole grain red yeast rice and preparing it just as one would prepare any other type of rice should not be subject to regulation as a drug.

Wednesday, November 10, 2010

Does chocolate lower risk of carotid atheroslerosis in women?

Another study shows some possible benefits of cchocolate: the study suggests that chocolate lowers risk of carotid atherosclerosis (the thing that causes strokes and transient ischemic attacks, or TIAs) in women.

This study has a weak study design (prospective cohort study), and there was no difference in outcomes between those consuming weekly and daily chocolate. This makes it more likely that the findings may be misleading, since there is no dose-response relationship demonstrated.

The authors (like others before, if you're a regular reader of my blog!) properly call for a randomized controlled trial of chocolate in preventing atherosclerotic vascular disease such as transient ischemic attack (TIA) and stroke.

Can't wait!

Monday, November 8, 2010

Pregnant mothers: watch those poppy seed and everything bagels!

This mother ate an "everything" bagel, tested positive for opiates in her prenatal drug test, and had her baby taken away for 5 days before she was able to fight it successfully. Much as I dearly love poppy seeds, it might be a good idea to tive them up when you're pregnant, well before you take your prenatal blood work!


Monday, November 1, 2010

More dark chocolate benefits - higher HDL in diabetics

OK, on the subject of dark chocolate my blog entries are getting to sound like a broken record (anyone out there know what a record is? NOT like breaking the record in the Guiness Book of World....)

So here's another study showing its benefits. Investigators randomized 12 patients with diabetes to eat 45 grams (a total of about an ounce and a half) of very dark chocolate (85% cocoa solids) daily or a similar amount of chocolate without the cocoa solids or polyphenols present. dyed to the same color. Patients who ate the real dark chocolate had better HDL levels and therefore better total/HDL cholesterol ratios.

People in the group that ate real chocolate did not gain weight and did not ingest more calories, because the chocolate generally resulted in their eating less snack food and eating less at the next meal than those who ate the "placebo" chocolate. They also had equivalent blood sugar and glycosylated hemoglobin levels.

This study had a small sample, but if it is repeated and borne out, it should mean that we don't have to advise our diabetic patients to stay away from anything sweet and yummy.

Thursday, October 28, 2010

red yeast rice and cholesterol

I've been meaning to post about red yeast rice for some time. Red yeast rice, is produced by cultivating the yeast strain Monascus purpureus, either spores or a prior fermented rice, on rice. Each rice grain turns bright red in its core and reddish purple on the outside.

The fully cultured rice is then either sold as the dried grain, or cooked and pasteurized to be sold as a wet paste, or dried and pulverized to be sold as a fine powder. China is the world's largest producer of red yeast rice.

Many red yeast rice products contain monacolin K, a compound identical to the drug marketed in the U.S. as lovastatin. Red yeast rice products that contain monacolin K, are banned in the by the Food and Drug Administration in the United States, which has stated that such products are identical to a drug and thus subject to regulation as a drug. In 1998, the FDA initiated action to ban a product (Cholestin) containing red yeast rice extract. The U.S. district court in Utah allowed the product to be sold without restriction. This decision was reversed on appeal to the U.S. District Court. Shortly thereafter the FDA sent warning letters to companies selling red yeast rice,and the product disappeared from the market for a few years.

In 2003 red yeast rice products began to reappear in the U.S. market (see the Wikipedia discussion referenced above) and avoid FDA requirements by making no claims about cholesterol lowering. Some contain no monacolin K. Two reviews referenced on the Wikipedia site indicate that monacolin content of red yeast rice varies widely. The FDA also issued a warning press indicating that consumers should “…not buy or eat red yeast rice products…[which] may contain an unauthorized drug that could be harmful to health.” The rationale for “…harmful to health…” was that consumers might not understand that red yeast rice might have the same side effects as prescription statin drugs.

In my view, this is absurd and is like saying that because tomatoes have potassium we are now banning tomatoes since potassium is marketed by itself as a drug and can be harmful to people with kidney failure who might not realize that they contain potassium. All Americans should be up in arms at these FDA rules. There seems to be no other reason for this than the financial well-being of the pharmaceutical companies selling statins. No pre-existing foodstuff, extract, or supplement, should be banned simply because a drug company decides to isolate and sell a compound in it for profit. If it requires regulation, then regulate it, and if it is identical to a drug, then it should be lawful just like that drug. If it does not require regulation (which I believe), then perhaps its drug cousins should be made over the counter too. Many of our OTC drugs have dangers which consumers need to know about, but regulating them through prescription is ineffective and just makes them expensive.

I welcome my reader's views on this topic!

Stick with the best thing, not the next best thing

I keep seeing advertising touting the efficacy of fruit and vegetable extracts such as Juice Plus, promoted by some local practices which call themselves "Integrative Medicine" practices. Juice Plus and similar products purport to lower your cardiovascular and cancer risk and to have research to back them up. The Juice Plus website contains links saying "feel free to look at the research" I decided to do so for my readers to see if there is research supporting its efficacy.

The research I found was all based on what I would call "surrogate markers". That is, no studies demonstrate that anyone actually lives longer through using Juice Plus. All the studies focus on clinical endpoints like flow through certain vessels, or inflammatory medidators in the blood. Most of the trials, also, were not randomized controlled trials, that is, there was no control group in the study, which compared subjects to themselves at "baseline". The problem with this approach is that other changes occur when people are enrolled in studies which may have nothing to do with what is being studied.

So, while these results do not suggest that Juice Plus does any harm, they are certainly not conclusive about its benefits.

The studies do not compare Juice Plus to a diet containing lots of whole fruits and vegetables. This would be the most relevant comparison, and I remain an advocate of eating the whole fruits and vegetables instead in absence of evidence otherwise. Cheaper and more flavorful, too.

I would like to be cautious as I may have missed some literature, so if anyone including the makers of Juice Plus knows of evidence of which I am unaware, please comment on this post!

new brain death guidelines

The new guidelines for brain death in the journal Neurology this year state that they are attempting to make a very variable process for determining brain death more uniform. I am concerned about two things in the guidelines.

The first problem is accepting only one examination to determine brain death. All human evaluation is subject to error and a brain death exam is no exception. The reliability and consistency of all physical examination and diagnostic tests is not 100% and in some cases is extremely low. When declaring brain death, a judgment based on many, many tests and findings, the possibility of error increases, and requiring two examinations would make the probability of error a little lower, although not zero. Allowing brain death to be declared with only one exam greatly increases the false positive rate. I cannot agree with this strategy, inconvenient and costly as it may be for our medical system to keep someone alive who has only a slim chance of recovery.

Many of my readers may not agree, but I personally abhor the recent trend in Medicine towards allowing people to die, even when they and their families wish such efforts to be made. While I will defend to the death (now increasingly easily labelled!), that we should follow patients' wishes, those who wish to "rage, rage against the dying of the light", as Dylan Thomas urged, should be supported to do so. It is a very important moral and ethical use of our health care funds, as this care for life is an important piece of our humanity.

I have always valued the lesson taught me by one of my patients when I was a medical resident in training. She was a radiologist in her 30s who developed very severe systemic lupus erythematosis. She had hemolytic anemia (a process where her immune system destroyed her own blood cells), gangrene, and many infections of a catheter inserted for temporary dialysis. She needed constant transfusions, and her blood was infected. She had pneumonia and kidney failure. Her blood pressure was low. She kept us day and night for weeks treating her illness. We became tired and fatigued. I felt we were fighting a hopeless battle and that we should let her die. Her husband wanted us to do everything to try to save her. Her attending physician insisted that we keep at it. We did. She recovered completely. 25 years later, she is still alive. Recently on an East Coast trip, I took a detour and visited her at her home a few years ago and thanked her for what she taught me: A patient's life should not be threatened by doctors' fatigue and their feeling that dedicated family members are over the top. These family members may need to be over the top to save the lives of their dear ones. Young doctors do not appreciate the potential for recovery and the meaning of death. How can they when they so often have had so little experience of life?

Our protocols for brain death should err on the conservative side, because the doctors in charge, de facto, of these decisions in our acute care hospitals are so young and so often err the other way. What's your opinion?

Why hire a health care advocate

Here's a good article by Dr. Carolyn Clancy of Agency for Healthcare Research and Quality (AHRQ) about why you may want to have a health care advocate with you in the hospital or doctor's office.

I am proud to provide health advocacy services, among others, to my patients. If you are over 18 and live in California, and may be interested becoming part of my practice, please see www.myadvicedr.com for information about how to obtain a free consultation to see if I may be able to help you.

So how homey is a medical home?

The new health care legislation is looking to primary care doctors to create "medical homes", defined as primary care practices that provide 24/7 access to their doctors, electronic medical records with exchange of information with other providers, a patient-centered holistic approach, and coordination of care by other specialists.

A study published today funded by the Commonwealth Fund, carried out by the American Academy of Family Practice, shows that to achieve this, doctors need a lot of help, and that even with this help, they may actually not improve things, as evidenced by patients being less satisfied than before. The national demonstration project published today showed that 36 family practices made small improvements in clinical quality measures, summarized as "better preventive care and access". Access meant ability to get in for an appointment or reach someone to talk to...not related to patient's views of their access or whether they were able to go to the best specialist, surgeon, and the best hospital they could have for specific medical conditions requiring intervention). Patients with high blood pressure and diabetes had slightly better control of their blood pressure and hemoglobin A1C (a measure of blood sugar control for patients with diabetes) levels. However, patients actually rated their care worse after the practices made changes. Patients' ratings of access to care, care coordination, comprehensive care, and service relationship were worse after implementing more of the features of the "medical home". I guess the medical home can be not too homey.

In contrast, Group Health Cooperative of Puget Sound, a large health care system, mounted a successful demonstration project of the "medical home", showing it boosted quality and patient satisfaction and saved money by helping its practices become "medical homes".

The message is that big organizations will be much better able to achieve the "medical home" features in a way that does not impair service to patients. Large organizations may also already have had lower levels of patient satisfaction, so they did not fall by becoming "medical homes", which generally rely on ancillary practitioners for more things and may reduce access to doctors. For smaller practice, electronic medical records, registries and greater use of ancillary support do not necessarily mean that things will get any homier for the patient. On the contrary.

Unfortunately, big organizations may also provide perverse incentives to helping patients choose the best specialty and surgical care. We've seen this with the Medicare Advantage plans. When primary care doctors have incentives to choose doctors and specialists and hospitals in the same health care delivery system, or coverage requires them to, patients lose out, because it will limit the specialty and surgical providers and hospitals to whom primary care doctors refer their patients. Often there are financial incentives within the same system to choose providers there, and this will be even worse when payment moves to an "episode of care" approach, meaning that patients will have to go to the same system of care for an entire "episode", even if there were better providers around for specific pieces of that episode. So, for example, you will no longer be able to receive your follow up care from surgery in a different system than the surgery itself, since the payment is likely to be bundled.

Many patients would prefer to go to smaller practices for their primary care, with a more personal feel where they still feel like human beings, and prefer to be able to choose the best specialty surgical provider and hospital for their particular problem. Unfortunately, the direction in which our health care system is moving will make this model more difficult. If episode-of-care bundled payment happens, small primary care practices unaffiliated with surgeons, specialists and hospitals will be forced out of business.

The authors of the summary article reached that same conclusion and recommended that third-party payers turn to arrangements such as monthly capitation payments to make medical homes worthwhile for physicians. "Expecting practices to front the cost of transformation with the hope of more appropriate reimbursement in the future is unlikely to succeed," they write.

Friday, October 15, 2010

Get Tested for the KRAS Gene

Yale Researchers, in August 2010 Cancer Research, reported discovering a new genetic marker for ovarian cancer which is present in 61% of women with a family history of breast or ovarian cancer who were not positive for BRCA-1 or 2, the only known genetic markers until now. It was also present in these women's family members with cancer. The marker was present in 25% of all women with ovarian cancer, and was linked to an increased risk of developing ovarian cancer after menopause, as confirmed by two independent case-control analyses. The research findings strongly support the hypothesis that the KRAS-variant is a genetic marker for increased risk of developing ovarian cancer and suggest that the KRAS-variant may be a new genetic marker of cancer risk for HBOC families without other known genetic abnormalities. Why is this important? Because ovarian cancer usually doesn't get detected until it's too late. If you have a family history of breast or ovarian cancer, and you are negative for BRCA-1 or BRCA-2, testing positive for this marker means you should probably get screened more carefully for ovarian cancer. So, look for genetic testing soon for this marker.

Thursday, October 14, 2010

Walk a few miles a week to maintain your brain volume

Published online prior to publication by Pittsburgh investigator Erikson in the journal Neurology yesterday is a study reporting the link between physical activity and brain volume and function in the elderly. The 299 participants examined, averaging age 78 at the time the study began, were part of a study of cardiovascular health. The investigators looked at the relationship between physical activity, brain volume, and cognitive function. They split participants into 4 groups according to how much they walked during an average week (the range was 0-300 blocks per week). Brain scans were done 9 years later and cognitive function tests were done 13 years later. Yes, folks, you read that right, 9 and 13 years. These authors certainly cannot be accused of short follow up periods. Those who had been doing more walking maintained greater brain volume, associated with better cognitive function than those who did not walk a lot. Increasing amounts of walking up until 72 blocks per week were associated with improvements in brain volume and cognitive function. Greater amounts of walking than 72 blocks did not result in further increases in brain volume. So, keep trotting, trekkers!

Smoking marijuana helps neuropathic pain

A study from Canada by lead investigator Mark Ware and colleagues from McGill University Health Center in Montreal, published last month, reported that patients who have "neuropathy", or pain from injury to nerves, were helped by smoking marijuana. One can empathize with, and congratulate, this study team because due to our prejudices about marijuana, this was not an easy study to get approved.

Because neuropathic pain (for example that caused by chemotherapy for cancer) is so challenging to treat, it is great to have anything more to offer patients in the repertoire of effective treatments. The patients in the study were given marijuana to inhale in a single puff of 25 mg at one of 4 concentrations (0, 2.5%, 6% 9.4%) of tetrahydrocannabinol herbal cannabis 3 times a day for 5 days. The trial was done as a randomized controlled crossover trial of four 14 day periods of time(meaning that each of the 4 groups got a different dose of marijuana during each of the time periods) Only the 9.4% dose achieved pain relief compared to placebo. Those taking this dose also slept better and reported better quality of life.

Because of the dangers of smoking anything (and cough was one of the side effects seen), it may be better for one's health to have marijuana applied using an alternate delivery system such as a patch, and I hope this will be investigated. Pills or other oral vehicles have generally been considered too psychoactive and hallucinogenic to be usable medicinally.

The study examined a very wide range of adverse effects. Interestingly, apparently due to the fairy low dose of even the highest dose group, only one participant in the entire trial reported feeling euphoric or high.

Also reported last month were the positive effects of marijuana in early schizophrenia, which I will write about in a separate blog, so it was a big month for those who support and promote medical marijuana.

Sunday, October 10, 2010

Sleep enough if you want to lose fat when you lose weight

An article in this week's Annals of Internal Medicine studied physiologic responses in 10 dieting adults, 5 of whom slept 5 1/2 hours per night and 5 who slept 8 hours a night. The article showed that the 5 who slept less lost 55% less fat than the ones assigned to sleep more despite taking in the same number of calories and losing similar total amounts of weight. Instead they lost more non-fat body mass pounds to make up the difference.

This study included only 10 people, and excluded people who drank a lot of caffeine. Therefore, it is unclear how generalizable the study is.

This study has been extensively misreported as showing that lack of sleep leads to less weight loss while dieting rather than the percent body fat lost. Nonetheless, it suggests that if you are dieting, you may wish to make sure you get enough sleep so that you lose fat instead of non-fat mass. The study should be repeated in a larger sample.

Friday, September 17, 2010

Ineffective: glucosamine and chondroitin for arthritis

A new meta-analysis (a synthesis of many randomized cinical trials) by Juni and colleagues published in the British Medical Journal this week has found that glucosamine and chondroitin supplements, popularly prescribed and taken for arthritis,are not significantly effective in reducing the joint space narrowing that comes from arthritis nor the pain intensity of arthritis.

10 years ago I was asked to answer a question on a Johns Hopkins "Intellihealth" question and answer site about whether glucosamine and chondroitin were effective for arthritis. I said that taking these things for arthritis would be expected to be about as effective as eating kidney would be for kidney disease, or brains for neurodegenerative disorders. I was very surprised, then, when some trials showed an effect of these compounds and I had to retract my answer. So I guess I can feel a little less concerned that I misled anyone in the past, seeing from this meta-analysis that the industry-independent studies show very little or no effect and even the ones funded by the pharmaceutical and supplement industries show very tiny effects of no clinical significance.

While there doesn't seem to be anything toxic about taking these compounds, and they may have very small effects, they are expensive. I agree with the authors that insurers probably should not pay for them given the hundreds of more effective preventive interventions in medicine which right now are not being paid for by health insurance which should take higher priority, which for arthritis would include exercise or yoga classes.

Thursday, September 16, 2010

Quality Improvement Needed

News reports just came out that a doctor had been shot at Johns Hopkins and that the shooter said he was upset about the treatment his mother had received there.
Having spent 15 years as a professor there, Johns Hopkins sees a spectrum of patients from all socioeconomic strata. Wealthy patients often try to improve the quality of care by donating money to various initiatives (for example, the famous case of the 2 year old burn victim who died of dehydration in the children's hospital, whose mother funded a quality and safety program there). It will be interesting to hear the shooter's story. While violence is never justified, the hospital may be able to learn something important about quality of care for the socioeconomically disadvantaged. AS Hopkins is a center for diversity research and the impact of race, ethnicity and socioeconomic status on the quality of care, many people on the Hopkins faculty should be well-equipped to help the administration find out some of the core triggers that in the presence of a violent man with a gun may endanger staff safety. It would be sad if the only thing that was done were more measures to protect staff from patients.

Only one in twenty working out

Wow, this statistic was much worse than I thought...

The value of a second opinion

One of my patients sent this joke to me:
The doctor said, 'Joe, the good news is I can cure your headaches. The bad news is that it will require castration. You have a very rare condition, which causes your testicles to press on your spine and the pressure creates one heck of a headache. The only way to relieve the pressure is to remove the testicles.'
Joe was shocked and depressed. He wondered if he had anything to live for. He had no choice but to go under the knife. When he left the hospital, he was without a headache for the first time in 20 years, but he felt like he was missing an important part of himself. As he walked down the street, he realized that he felt like a different person. He could make a new beginning and live a new life.
He saw a men's clothing store and thought, 'That's what I need... A new suit.' He entered the shop and told the salesman, 'I'd like a new suit.'
The elderly tailor eyed him briefly and said, 'Let's see... size 44 long.'
Joe laughed, 'That's right, how did you know?'
'Been in the business 60 years!' the tailor said.
Joe tried on the suit and it fit perfectly.
As Joe admired himself in the mirror, the salesman asked, 'How about a new shirt?'
Joe thought for a moment and then said, 'Sure.'
The salesman eyed Joe and said, 'Let's see, 34 sleeves and 16-1/2 neck.'
Joe was surprised, 'That's right, how did you know?'
'Been in the business 60 years.'
Joe tried on the shirt and it fit perfectly.
Joe walked comfortably around the shop and the salesman asked, 'How about some new underwear?'
Joe thought for a moment and said, 'Sure.'
The salesman said, 'Let's see... size 36.
Joe laughed, 'Ah ha! I got you! I've worn a size 34 since I was 18 years old.'
The salesman shook his head, 'You can't wear a size 34. A size 34 would press your testicles up against the base of your spine and give you one heck of a headache.'

New suit - $400
New shirt - $36
New underwear - $6
Second Opinion - PRICELESS

Wednesday, September 15, 2010

Bah Bowflex

Nice article in LA Times on humbug that Bowflex puts out. Can't say anything better than this author did, and he has the abs to back it up (mixed metaphor?)

Tuesday, September 7, 2010

Questions to ask your doctor

Dr. Carolyn Clancy, head of the federal (U.S.) government's Agency for Healthcare Research and Quality (AHRQ) writes columns aimed at helping consumers obtain better health care. Her latest column refers people to a Question-builder site which helps consumers develop a list of questions her agency has developed which people may wish to ask their doctors. While there is no rocket science here, it is helpful to look over to remind ourselves of what we might want to ask, and most importantly, not to be intimidated or rushed into not getting your questions answered.

Friday, September 3, 2010

obesity and search engine advertising

When I searched today for BMI (body mass index) on Google (I was looking for a quick BMI calculator), the first thing you are directed to is an ad for Stanford's bariatric surgery program. I realize these placements just reflect advertising dollars, but there should be some sense of social responsibility at Google that should enter into the picture as well. How about putting some healthy diet and fitness information up front?

Friday, August 27, 2010

Effects of health care reform on small medical practices

It is clear from the content of the healthcare reform that the Obama administration wishes doctors to join large organizations which they believe can deliver more efficient care and which will be better able to translate the financial incentives and payment strategies envisioned by the legislation into actual delivery strategies to make things more efficient. Unfortunately such "efficiency" does not necessarily translate into better care. What you can expect to disappear as medical care transitions into large organizations: 1) small intimate practices 2) continuity with one doctor, 3) involvement of the doctor in routine care, 4) your ability to pick the best person to do each part of an episode of care, even if the doctors belong to different organizations. This has to do with the payment mechanism which will be adopted of bundling payments for an episode of care. This means only one organization will be able to deliver the care for the entire episode. For example, if you have a heart attack and require bypass surgery, the organization which admits you for the heart attack will be paid a lump sum for the entire episode of care, and you will not be able to choose a better surgeon in a different center.

While am in favor of health care reform including increasing coverage and preventing insurance companies from cherry-picking the lowest risk patients, I am very much against the type of payment bundling that is being promoted by the Center for Medicare and Medicaid Services and the health care reform legislation. Nothing in this type of bundling promotes high quality care. Just like the prospective payment system for hospital care, this type of payment promotes efficiency and reduced service during an episode of care. Quality measures are imperfect and tend to be very slow to incorporate and reflect new innovations and technology.

Pharmaceutical company and medical device company interests will continue to promote the use of unnecessary expensive technology. On the other hand, we are now likely to see powerful healthcare industry interests promote the underuse of needed care across the spectrum of medical care for each episode of care just as they have promoted decreased use of services during a hospitalization. But now there will be nowhere for the patient/consumer to go and no time or place at which the person CAN obtain the needed service. As with the passage of prospective payment for hospital care in the 1980s, there will be little or no incentive to provide high quality of care. The quality indicators used to date for performance bonuses for physicians (which in the future will go to the large organizations which employ these physicians) are generally inadequate and and reflect little of what makes care truly high quality.

We are now down to 25% of doctors in small practices. Healthcare reform as it is currently constituted will reduce that even further. I find this very sad. As someone who has devoted my entire career to improving medical care, often working in hospitals against the perverse financial incentives of the prospective payment system, and as someone who now works as a consultant helping people find good medical care, I am keenly aware of how these new payment strategies of bundling for episodes of care will reduce consumers' ability to choose good doctors.

Thursday, August 19, 2010

new ovarian cancer screening test being studied

There's a new screening blood test for ovarian cancer whose results have been reported in an early small study to be unbelievably accurate. I'll be watching with interest to see how the larger ongoing study in 500 women pans out. But 100% accuracy even in a small number (under 100) women is an unbelievably good result and has piqued my interest.

Wednesday, August 18, 2010

Contact sports

For years, the AMA has been against boxing because of the brain injury known as "boxer's encephalopathy" (popularly known as being "punch drunk") which so often results from it. Football is also known to cause a lot of head injury and encephalopathy. A recent study by Boston University researchers dissecting the brains of 12 athletes again notes the frequency of degeneration in the brain in areas characteristic of ALS or Lou Gehrig's disease as a result of sports-related and combat-related head injury.

This prompted the New York Times to say that "maybe Lou Gehrig didn't have Lou Gehrig's disease", prompting others in the blogosphere to say "huh?" But the point the Times was making was that since Lou Gehrig had a lot of sports-related head injury, perhaps this was the cause, whereas by definition for ALS, the cause has been unknown.

Bottom line: Boxing, football, and military combat are dangerous. While the latter may be unavoidable, the first two are not, so avoid them and help your children avoid them. Our entertainment is not a good reason to sacrifice their future health.

Risks of Antacid Drugs such as Zantac and Prilosec

Some of you have asked about The New York Times article today highlighting that today many elderly people continue to take drugs that reduce stomach acid, like Zantac (an antihistamine) and Prilosec (a proton pump inhibitor), for years and years and that this may not be a good idea. Often people are first prescribed these drugs for questionable or no specific reasons (for example, see study here this study. These drugs have side effects including increased infections (both pneumonia and gastrointestinal infections) and osteoporosis (because of reduced calcium absorption).

Bottom line: If you are not taking antacid drugs for known ulcers or bad symptoms of acid reflux (which can cause pneumonia as well if really bad!), then stop them. If you are taking them for a real indication such as ulcer disease or bad acid reflux disease, then work with your doctor to see if you still need them.
These drugs have risks and the risks must be weighed against the benefits for you.

Tuesday, August 17, 2010

Emergency contraception

Emergency contraception - Make sure the late teenagers and college students in your family know about ulipristal, marketed under the trade name of Ella, an emergency contraceptive recently approved by the FDA, which will be available by prescription and protects against pregnancy for 5 days after intercourse. Also make sure they know about Plan B One Step and Next Choice, (see Mayo Clinic discussion here) which are already available over the counter and protect against pregnancy if taken within 3 days of intercourse. While I agree that abstaining from unprotected intercourse outside of a committed relationship in which the desire and intent to have a child has been articulated by both parties, the reality is that such unprotected intercourse occurs frequently despite the stated intent of young women not to accede to such requests.

Given these hormonal realities in which young men and women ignore the reproductive consequences of their actions, please educate your children about these available ways of preventing an unwanted pregnancy. While there are side effects, on average the benefit of averting an unwanted pregnancy exceeds the harm of nausea, vomiting, or some abdominal cramping or discomfort in some individuals.

Monday, August 16, 2010

Statins - Do they Work to Prevent Heart Attacks in Healthy People?

Drug manufacturers have convinced the American public that everyone with high cholesterol or diabetes should take statins to lower it and prevent heart attacks and strokes. This week a lot of publicity has emphasized how little we actually know about the effectiveness of doing so. More at this link

Friday, July 23, 2010

Get Off Your Can!

A study in online July 22 in the American Journal of Epidemiology by Alpa Patel and colleagues concludes that sitting shortens our lives, even after considering impact of being overweight and how much we exercise. The study collected questionnaire data for 14 years (1993-2006) from 123,216 healthy people (53,440 men and 69,776 women) in the American' Cancer Society's Cancer Prevention II study.

Even after considering body mass index (BMI) and smoking, women who spent six hours a day sitting had a 37 percent higher risk of dying than those who sat for less than three hours a day. Men had a 17% higher risk. Exercise lowered the risk of sitting, but more sitting meant a higher risk of death even among those who exercised. And for those who didn't exercise, sitting a lot was even worse: women who sat a lot had a 94% higher risk of dying than women who didn't, and for men, sitting conferred a 49% higher risk of death.

So start moving; you can still read this blog on your mobile while moving! Disclaimer: Don't read while walking out in the street! More dangerous to your health than sitting....

probiotics reduce pregnancy diabetes

More good news about probiotics. An article in the British Journal of Clinical Nutrition describes a randomized clinical trial of an intervention consisting of dietary counselling and probiotics. Women in the intervention group had less than half the rate of development of pregnancy diabetes, a great outcome.

Thursday, July 15, 2010

probiotics reduce kids' infections but not missed school days

A recently published study authored by Dr. Dan Merenstein (a family doc and researcher whose mentor I am honored to have been when he was doing his fellowship at Johns Hopkins), and his colleagues from Georgetown University, demonstrated that yogurt with active probiotic cultures taken daily for 120 days reduced gastrointestinal and respiratory infections (including strep throat and colds) substantially but did not result in children missing fewer days of school or day care. Just another demonstration of how truly sick children have to be these days in order for their parents to keep them home!

News reports seemed to stress the fact that there was no difference in days of school missed. Wouldn't we all go out and buy something that gave our children more days free of diarrhea and strep throat, regardless of whether they went to school or not? If you agree, go out and get your child some DanActive or other probiotic... Dr. Merenstein recommends yogurt or foods supplemented with at least 3 different active probiotic cultures.

Monday, July 12, 2010

Monterey Bay Aquarium rates seafood

Here's a link to the Monterey Bay Aquarium's West Coast Seafood Watch pocket guide. Here you will find lists of seafood which are best from the point of view of 3 considerations: Avoiding overfished species, avoiding species with high levels of mercury, and nutritional considerations such as levels of omega-3 fatty acids.

Sunday, July 11, 2010

More dark chocolate benefits

It seems like I'm running an ad for dark chocolate, but there just seems to be a lot of good news lately from studies of it. Perhaps there's an evolutionary survival reason why we humans seem to love the stuff..."Flavanol-rich" cocoa products (otherwise known as dark chocolate) may help to reduce blood pressure a little bit in people with high blood pressure, according to the results of a meta-analysis (a study that puts together the results of other studies rather than collecting new date) by a team led by Karin Ried from the University of Adelaide in Australia and reported in the June 28 issue of BMC Medicine.

Interestingly the chocolate did not reduce blood pressure in people with normal blood pressure, only those with high blood pressure.

The size of the effect in people with high blood pressure was about 5 and 3 mmHg (millimeters of mercury) for diastolic and systolic blood pressure respectively. MmHg are the usual units in which blood pressure is measured. Controlling both systolic and diastolic blood pressure is important for prevention of heart disease and stroke. Reducing blood pressure by 5 mm Hg is a clinically important effect which lowers the risk of heart attack and stroke measurably.

Again one must be cautious about these results because if one ingested the chocolate with a lot of extra sugar, such as in a hot chocolate or cocoa drink, its effects might be counteracted by the increased calories.

Also in interviews reported by Medscape, the authors were careful to caution that flavanol-rich chocolate did not significantly reduce mean blood pressure below 140 mmHg systolic or 80 mmHg diastolic.

Thursday, July 8, 2010

Don Berwick to Head CMS

Don Berwick, whom I'm honored to have worked with in the past, has been appointed by President Obama to head CMS (Center for Medicare and Medicaid Services). Don is a mesmerizing speaker and a wonderful physician and human being who has encouraged an entire generation of physicians to bring industrial quality improvement methods to health care. Don founded and has headed the Institute for Healthcare Improvement since leaving Harvard in the 1990s. He has a broad constituency in medicine across many disciplines. I believe he's an excellent physician who is committed to high quality health care in the U.S. in a non-partisan way, despite my having read that Republicans criticize him for having written positive things about England's national health insurance system. Don has praised England's recent emphasis on quality and performance improvement, and it would be pretty hard to argue with that change, whether one favors a single-payer system or not (I do only if it is structured to preserve competition among and choice of providers based on quality of care).

I am hopeful that Don's insight will help Medicare implement the healthcare reform legislation in a way that will promote and preserve quality of care in Medicare as well as the private insurance system. I am encouraged by Don's background in clinical medicine (he is a pediatrician by training although I don't know when he last practiced), and quality of care. Don is an excellent choice and I hope his philosophy can filter down to CMS' day to day operations. As we know, sometimes leaders of federal agencies don't influence their own bureaucracies too much, because managers of individual departments can subvert the intent of the agencies' directors. Don, however, is an inspiring leader who has been an effective leader in several organizations in the past, and I wish him all the best at CMS.

Don't use quninine for leg cramps

The FDA has issued a new warning
against using quinine for leg cramps because of severe hematologic (blood) problems that can result from quinine. So don't!

Wednesday, July 7, 2010

Implantable Telescope for Macular Degeneration

If you have macular degeneration, you probably aren't reading this blog. However, you might have a family member with macular degeneration. The FDA has now approved the first device, an implantable telescope, that in preliminary studies by the company has helped improve vision for patients with macular degeneration. There is an ongoing study of another several hundred patients to see how they fare. I tend not to be an early adopter for things like this, preferring to look at the complications and outcomes for a few thousand patients studied independently of the company making the device. If this technology works and does not cause a lot of retinal damage itself over time, it may be very helpful in a disease which we can do little about right now.

New Formula for Females for Maximal Workout Heart Rate

A new formula for women to calculate their maximal heart rates for workouts has been put forth by researchers at Northwestern in a study published in Circulation this week. This new formula was based on a study of 5500 healthy women who took treadmill tests in 1992 and who were followed for mortality. This formula is the first which used women to look at how heart rates with exercise were related to mortality rates, and is therefore likely to be much more accurate than the usual formula for peak heart rate which exercise professionals had used (220 minus age). The new formula, 206 - 88% of age, is a little harder to calculate. For example, for a 50 year old woman, the new formula's peak heart rate is 206 - (.88x50) = 162. If one uses 65% - 85% of the maximal heart rate of 162 for the target heart rate range for workouts, a 50 year old woman should be able to get to 138 as she becomes more fit but would not reduce, and might increase, her cardiovascular mortality by pushing herself further than that.

This study provides valuable guidance for women as they endeavor to become fit and will be a relief to women who have been trying to push themselves to the old formula's upper limit target rate.

Monday, June 28, 2010

ask for the brown rice, not the white

It has been known for some time that brown rice has a much better glycemic index (that is, they cause blood sugar to rise more slowly) than white rice. Similarly, whole wheat flour has a ower glycemic index than white flour. Nutritionists and doctors and the American Diabetes Assocation have been recommending for years that diabetics choose foods made with whole grains over those made with refined grains. Now a new study by Harvard School of Public Health researchers confirms that those who eat brown rice have a lower risk of developing diabetes than those who eat white rice. The researchers estimate that if 50 grams of white rice were replaced by 50 grams of white rice daily, a person would have a 16% lower chance of developing diabetes.

The other day I ate in a Chinese restaurant in San Francisco. I asked the waiter if I could get brown rice, but the restaurant did not serve it. Given the large number of people of Asian origin in San Francisco who frequent such restaurants, perhaps the city should develop an education program for restauranteurs about the benefits of brown rice and other whole grains.

coffee and Alzheimer's

A recent study commented on by NPR today indicates that mice who ingest large amounts of caffeine (equivalent to 5 cups of coffee a day for humans) develop a lot fewer of the characteristic brain changes of Alzheimer's disease, suggesting that caffeine may be protective against the disease. There are also some studies of humans which suggest that caffeine may be protective against Alzheimer's disease. However, before you decide to drink 4-5 cups of coffee a day, you may wish to consider the negative effects of caffeine, including increased anxiety and nervousness, tremor, faster bowel movement, and diuretic action. Nonetheless, these studies should make heavy caffeine drinkers feel better about the fact that they never really get to sleep very well....

Monday, June 21, 2010

Dr. Oz and Roizen's Real Age website

I checked out Dr. Oz and Roizen's Real Age web page. Lots of very nice stuff for risk and health assessment. Not everything is 100% accurate and up to date (for example, the program dinged me for a "cholesterol problem" because my total cholesterol was over 200, although my HDL cholesterol was 80...whereas according to my reading of the literature, my risk is not elevated with this combination. But it's pretty good. The ads also seem to be filtered so that good products are featured. My only problem with it is that taking the questionnaire can only be done in the context of setting up an identified account, and doing that means that personal health information is linked to identifiable data. If such data are not encrypted in transmission, and on their server, it would seem to me that it would violate HIPAA. In addition, the program had a link saying "switch to SSL (secure socket layer)", but when I tried to do even this, it didn't work. This is my only concern about the site. They will have to do a better job of security before I would feel comfortable recommending that you fill out any of their questionnaires unless you can fill out something without identifying yourself.

That said, the Qi Gong video was extremely nice, and there's lots of other stuff to jumpstart your diet and exercise changes!

Molasses - healthier than sugar

A friend of mine likes to make his own licorice with anise, molasses and whole wheat flour. It tastes absolutely delicious, and bears absolutely no relationship to the processed junk sold as licorice commercially these days. I wondered whether there was anything to recommend this as a healthy carbohydrate serving. The whole wheat flour is a good start. The anise is fine for most people (licorice and other anise containing foods have a mild diuretic effect and can cause a "metabolic alkalosis", that is too much base in your blood, particularly if you are taking certain medications, so if you do take medications regularly, you should ask your doctor about it). So, I began to explore the nutritional value of molasses.

It turns out that blackstrap cane molasses (a byproduct of making sugar from sugar cane, the stuff that's left after cane is twice boiled to remove sugar), may be the healthiest form of sweetener containing sugar that there is. 2 teaspoons of molasses has about the same number of calories as 1 teaspoon of sugar, but also has healthy amounts (about 25% of the FDA's recommended daily values) of iron, potassium, calcium, and manganese. Sugar and even raw honey have nothing like these quantities of healthy minerals.

So, molasses seems like something you could enjoy like jam - in small quantities as an occasional treat or dessert on some whole wheat or whole multigrain bread - and you'll get some nice nutrients when you do. Just watch the total amounts, and eat it together with something less sweet, because its biggest component is sucrose (table sugar) and diabetics and people on weight loss diets should avoid it because it has a low "glycemic index" (that is, it makes your blood sugar go up quickly and gets insulin to kick in, leading to the quick drop in blood sugar that gives you hunger pangs and makes your body want to eat more sweets). So if you do indulge, try to eat it together with other things, like whole wheat bread or some protein, that have a lower glycemic index and will ofset that quick peaking with a more gradual rise in blood sugar that will prevent the insulin from kicking in.

Modifiable factors in stroke risk

The INTERSTROKE study, an international study of stroke risk factors was recently published in the Lancet, and shows as you might have expected the modifiable risk factors which play the greatest role in stroke risk. The number one factor is high blood pressure, which can be reduced by reducing salt intake and exercising more, and if that doesn't work, taking medications to reduce blood pressure. Smoking, abdominal obesity (fat around the middle!), diet, and reduced physical activity were other factors which together with high blood pressure accounted for 80% of ischemic stroke risk (ischemic stroke means a stroke that happens because of a reduction of oxygen flow to the brain, usually due to a clot in a blood vessel), and 90% of the risk of having a hemorrhagic stroke (due to bleeding into the brain) in the study.
Additional risk factors for a clot-type stroke included diabetes, alcohol intake, psychosocial factors, the ratio of apolipoproteins B to A1, and other heart diseases (arrhythmias such as atrial fibrillation or atrial flutter, previous heart attack, and valve disease). Hypertension, smoking, abdominal obesity, diet, and alcohol intake were the most important risk factors for a stroke due to bleeding into the brain. '

Anything new here? No! But it's interesting to note that these results were the same all around the world.

Friday, June 18, 2010

Insurance Companies Invest in Fast Food

Interesting article in American Journal of Public Health (click here for an abstract of the article) describing insurance company investments in fast food companies. The surprise is that this even makes the news. First, is anyone still under the impression that health insurance companies care if you live longer or are healthy? They are basically just claims processing outfits. In fact, the higher health costs and therefore health insurance costs, the more they grow their own organizations, since they pay themselves as a percentage of premium.

Second, I experienced myself as a member of the Board of Trustees and a member of the Fund Management Committee at a health-related nonprofit that most companies are not watching carefully what their financial advisors are investing their money in. Unless an external group makes a fuss about it, even the top leadership of the company may not realize what these investments consist of. Investment and fund management committees tend to be run by finance folks and treasurers, and for these people getting the best return is the most important thing. The meetings are dominated by concern about the financial state of the organization. In the ones I was involve in, they are not paying much attention to the mission of the organization as they make their investments, beyond their basic thought that they can do better with their mission if they make money on their investments.

So this did not come as a surprise to me. An analysis of the investments of endowment at our universities, and investments of endowment by other health related organizations such as health care foundations and medical provider organizations would show exactly the same thing, I am sure.

Of course our government is also ignoring our health in the companies it subsidizes...

Monday, June 14, 2010

sign up to receive tweets

Are you on Twitter? To receive health-related tweets from myadvicedr, just click on Twitter on the left side of the blog, sign on to your account, and then indicate you'd like to follow MyAdviceDr.

Getting Physicians in your Family Involved in Your Care

Back to one of my favorite topics...(take our poll at the top left of the blog page)...whether it is a good idea for a physician in your family to be involved in your medical care. Clearly for people with physicians in their families, this occurs a lot. See, for example, this study about neurologists, most of whom prescribed for themselves and their family members. Or the 1991 study by LaPuma, showing that physicians on staff in a community hospital reported frequently treating family members. It is interesting that despite the commonly held ethical guideline that physicians should not treat their family members or should exercise care in doing so doing to many reported pitfalls, there has been no empirical data on this topic telling us if people tend to do better or worse than expected if treated by family members. Will someone do a study about this, please?

Whether we believe that physicians should actually administer treatment, such as prescription, or do surgery on family members, or actually do diagnostic tests, a physician in the family can often provide excellent advice about what to do next or whom to see or where to go for treatment. It is simply foolhardy not to take advantage of medical expertise in your own family, particularly if the physician is a relative you are close to and there is mutual familial feeling and caring between you.

Retinyl palmitate in sunscreen

Although we do not have definitive evidence, it seems best to avoid sunscreens with retinyl palmitate as you head out to the beach.


Tuesday, June 8, 2010

low fat and sugar frozen dessert treats for summer

For those who can tolerate ice milk, here's a recipe that's low fat and sugar:
2 cups organic milk (use whole milk)
1 cup blueberries
1 banana
1 tbsp sugar
Mix all ingredients in blender.
We used an ice cream ball with ice and rock salt, tossed it around a little, and in 15 minutes had a very lovely ice milk for dessert. Makes 3 servings.

By the way, frozen bananas make a lovely dessert too, all by themselves. Peel bananas and freeze them in a freezer safe container. You can microwave them on defrost for 1 minute when you take them out if they are too frozen to eat. They taste delicious, just like banana ice cream. I serve them with berries.

get your children to eat their (dark green & yellow) veggies

Another study about dark green and yellow vegetables...in brief, surprise, surprise, they're good for you. In particular, children get less fat and have better bone health.

Thursday, June 3, 2010

Vitamin D insufficiency and deficiency

Vitamin D deficiency is less than 20 but 20-30 is considered "vitamin D insufficiency". I've not found very impressive data on how prevalent various symptoms are with vitamin D insufficiency as opposed to vitamin D deficiency. A National Institutes of Health fact sheet is available. http://ods.od.nih.gov/factsheets/vitamind.asp#en13It appears that "insufficient" folks can have cognitive problems, mood problems, and reduced calcium absorption, so it seems best to get more Vitamin D if your level comes back in this range. Current guidelines say to aim for a level of 50 to 80, so if you're below 50 you may wish to take a Vitamin D supplement to get your level up.

What's the right supplement? You should take Vitamin D3 since Vitamin D2 does not bind as well to the binding proteins in the blood and does not store as well in the body to increase total body stores. If you are insufficient, take 2000 IU per day of Vitamin D3 until your level comes up to the desired region. A recent study showed that people who were given one high dose of Vitamin D3 instead of a daily dose to bring up their level actually had more falls and fractures than a control group. So high single dose supplmentation is not recommended.

How can you increase it in your diet? Sardines and wild salmon are two good sources.

And, of course, 20 to 30 minutes of sunshine between 10 and 2 on bare skin, especially if you live in a climate like California's, will give you a nice dose of Vitamin D. Be careful not to burn, and if you don't want wrinkles, put it on your face and the back of your hand, and let the Vitamin D metabolism happen in the arms and legs.

What's too high? In the study in which people fell more after high doses, their levels were up to 120, and as their levels came down, the fall and fracture risk came down too. So it's recommended to keep the level between 50 and 80.

This post was written on 6/3/2010. New information may come available, so this information should not be relied upon as state of the art. A blog is no substitute for a doctor. Before acting on advice on any post on this website, check with your physician. If you wish to consult me for advice, please go to www.myadvicedr.com and follow the instructions to get a free 15 minute consultation and subscribe to the practice.

Wednesday, May 26, 2010

Saving children from Nickolodeon

Nickolodeon's AddictingGames.com was voted worst toy of the year by the Campaign for a Commercial-Free Childhood (that's clearly not happening, folks, but thanks for campaigning for it anyway...). For descriptions of Nickolodeon's site and why it's so bad for kids, as well as the other nominees, see the Campaign's TOADY (Toys Oppressive and Destructive to Young Children) award website. The TOADY award is is named to sound like the TOTY (Toy of the Year) award given by the toy industry, often with little regard to its impact on the health and well-being of children. Thanks to Simon Firth for the reference. A valuable site.

While I'm at it, I'd like to put in a plug for Kids in Mind, which I find a valuable resource for evaluating films for violent and sexual content inappropriate for children, although unfortunately they do not always have the films I've looked for.

Appetite suppressants

Try as I might, I can't make myself like appetite suppressants for weight loss. I believe they just don't work. In my experience, they help you lose weight while you're taking them, and then you gain it right back and more as soon as you go off them. In addition, appetite suppressants go against the very theory of reducing cravings by aiming for lower insulin levels. As soon as they wear off, they stimulate your appetite, starting the whole cycle going again. And they have a ton of bad side effects while you are taking them.

The other day I heard someone pitch a physician-supervised weight loss program complete with appetite suppressants and vitamin injections (probably B12). Everything else in the program sounded just fine (a plan based on keeping glycemic index low and glucose levels stable throughout the day, so that insulin levels stay low). But on the basis of those two things alone, I would not recommend the program. Even with a vegetarian diet, there are other ways to get B12, and if you are working on eating low glycemic index foods throughout the day every two to three hours, you should not have intense cravings.

Your feedback is welcome.

Sunday, May 16, 2010

Chocolate as an Iron Source

A patient of mine sent me a link to an article on the iron content of dark chocolate, indicating that chocolate has more iron than the same amount of beef , and wondering why he didn't know this and why it didn't receive more publicity.

It is true that gram for gram, dark chocolate has more iron than beef. However, I wouldn't recommend that you try to get your recommended daily iron intake from chocolate. For most of us, neither chocolate nor beef is the best way to get iron. Here's why.

The first problem is that a healthy serving size of chocolate is only about 7.5 gm. Organic dark chocolate tasting squares by Dagoba are 9 gm; Giardhelli's dark chocolate squares are about 17 gm each. According to the USDA nutrient analysis website, 7.5 grams has 45 calories, 3 grams of fat, and 2 grams of saturated fat and less than 0.89 mg of non-heme iron, or about 4% of the recommended daily allowance.

While I hesitate to say that any serving size of beef is "healthy", a 6 oz serving (185 grams) containing 40 gm of protein is 185 gm. This is 25 times the weight of the healthy serving of chocolate. 185 gm of beef (6 ounces) has 4.35 mg of iron. If you ate enough chocolate to have 4.35 mg of iron, you'd be eating 37 gm of chocolate, which would have 220 calories, with 15 gm of fat (10 of saturated fat). This would be a similar amount of iron, and also of fat and saturated fat as the beef, but with none of the protein. To eat the daily recommended allowance of iron for men and adult women after menopause (8 mg) as chocolate, we would need to eat 67 grams of chocolate, adding 405 calories, 27 grams of fat (and 18 gm saturated fat) to our diet. So, chocolate is not the best way to acquire iron, because it comes at the cost of too many fat, especially saturated fat and sugar calories. While beef has unhealthy fat too, at least it contains a good protein portion while getting those calorie and does not contain sugars.

I would recommend sticking to 7.5-10 grams of chocolate daily, and aiming to get most of our iron intake from vegetables. Getting a little extra iron from the chocolate is just a bonus.

Another reason why chocolate is not as good an iron source is that iron in chocolate is not absorbed as well as the iron in beef. Chocolate has the non-heme form of iron, which is less well absorbed than the heme variety. Beef has both heme and non-heme in about a 60/40 ratio. So, if we avoid beef for health or other reasons, we need to aim for around twice the daily value of iron that is suggested for those who are primarily eating their iron in beef.

The FDA fact sheet on iron lists the recommended daily intake of iron as 8 mg for adult women after menopause and men, and as 18 mg for adult women prior to menopause. It does not distinguish whether the iron is in the heme or non-heme form in this recommendation. The Vegetarian Resource Group has provided recommended allowances for those who will be eating iron mostly or only in the non-heme form, and suggests aiming for 14 mg daily of non-heme iron for women after menopause and men, and 33 mg daily for adult women prior to menopause.

Ascorbic acid (Vitamin C) improves non-heme iron absorption. Therefore, to get the most iron possible from one's dark chocolate square, I would suggest that you eat it with a healthy Vitamin C (ascorbic acid) - containing food, such as dried apricots or mandarin orange slices. As Michelle Francl in her "Culture of Chemistry" blog as noted, dried apricots (try to get the unsulphured kind) dipped in dark chocolate are a wonderful combination. I am also partial to clementine or mandarin orange sections dipped in dark chocolate.

Tea and coffee inhibit iron absorption due to the tannins they contain. Black tea is worse than coffee in this regard, but both are inhibitory. Therefore, it is better to drink tea and coffee between meals or well before an iron-rich meal than to have tea or coffee with or right after such a meal. For the same reason, a chocolate-covered espresso bean is probably not a good idea as an iron source, nor mixed chocolate and coffee mocha drinks. Instead drink herbal teas such as lemon tea which are rich in ascorbic acid.

Studies vary in what they find about the effects of calcium on iron absorption. Many nutritionists advise to avoid dairy products and calcium supplements around the time of iron consumption. However, some studies have shown that calcium does not inhibit non-heme iron absorption. Although there is controversy, it seems safer not to count on much of a boost in iron intake from milk chocolate, or traditional hot chocolates or hot cocoa made with milk solids.

Some plants also have large concentrations of phytates and polyphenols (of which the tannins are one type) which inhibit iron absorption. Therefore, plants like soybeans and spinach have a lot of iron, but the iron is poorly absorbed if they are eaten alone. This effect is ameliorated by Vitamin C, so the best solution is to make sure that beyond the amount you get in your one to two small squares of dark chocolate, you eat your iron-containing plants (spinach, broccoli, cauliflower,bok choy etc.) along with foods containing Vitamin C, such as sweet red peppers, oranges, lemons, limes, guavas, and lichis. Note that broccoli, cauliflower, and brussel sprouts are good sources of both iron and Vitamin C, making them excellent sources of dietary iron. Herbs such as thyme, parsley, and dill also have a lot of Vitamin C, and so can be added to the iron-rich vegetables which lack vitamin C.

If you avoid beef and you eat a lot of vegetables such as spinach, bok choy, broccoli, and cauliflower, you will probably ingest enough non-heme iron naturally. This can be augmented by combining vegetables with ascorbic acid containing foods listed above.

In summary, I would not recommend increasing your consumption beyond a small square or two of dark chocolate per day in order to attempt to increase iron consumption, and would recommend eating the dark chocolate with foods containing vitamin C, while avoiding regular tea, coffee or dairy products together with it. If you do drink regular tea, drink a lemon tea or add lemon to it, which will reduce the inhibitory effects of tannins on the iron absorption.

Sunday, May 2, 2010

laser treatment for toenail fungus

I have been asked by some of my patients recently about laser treatment for toenail fungus (onychomycosis in medical jargon). Various practices have been advertising this treatment using a new laser technology developed by Patholase Inc. in Chico, which has spun off a company called PinPointe Laser, Inc. to promote this treatment for toenail fungus. The laser treatment is not yet approved by the FDA as effective and safe for treating toenail fungus. It has received CE certification in the European Union which addresses safety rather than efficacy, as I understand it. The laser treatment has been featured on various television shows including Good Morning America. According to the company, it is 88% effective, more effective than any other treatment, although this did not mention how long a follow up period. The ads and information I saw from the company also did not specify whether this 88% referred to a mycologic cure (negative cultures for fungus) or an overall cure (normal nails after a 12 to 18 month follow up period). I have thus far been able find no evidence that this treatment works, nor how it compares to terbenafine (Lamisil), the standard treatment right now, from any systematic studies. Although the company's advertisements mention clinical trials, the results of these do not appear to be published in the medical literature as yet. It would be great to have an effective treatment out there which did not have the side effects of Lamisil and which therefore did not require constant liver function test monitoring. Your feedback welcome... please comment if you've experienced this treatment and want to share your experience, either positive or negative, with readers of this blog.

What is clear is that the treatment, because it is not yet approved by the FDA, is not covered by any insurance plan, and costs $1100-$1200 at local providers here on the Peninsula in California. Patients are advised to use a topical treatment twice a day for the entire year or year and a half that it takes for the toenail to regrow. I saw a comment on Yelp suggesting that the effectiveness is just due to the topical therapy; however, this is unlikely in my view due to the fact that in clinical trials topical therapy, even using laquers and vehicles aimed at allowing better penetration into the nail, seem to have much less than the rate of efficacy reported by the company for the laser treatment.

The company stresses that the treatment is only a one-time 30 minute event. While this is true, like terbenafine and other treatments, it takes a year to a year and half for the new normal toenails to grow out.

Fruit and Veggie Clean Guide(re Pesticides)

Here's a link to the Environmental Working Group's Clean Guide to Pesticides. Lists which fruits and vegetables have high levels of pesticides when not purchased organically. I have had this for years but a new version has recently been produced which has some differences.

Monday, April 26, 2010

Genital herpes

The Centers for Disease Control reported in its MMWR publication based on the 2005-2008 N-HANES (National Health and Nutrition Examination Survey) that 16% of 14-49 year olds have genital herpes. The prevalence among teenagers 14-19 was 1.4% (95% confidence interval 1-2%), 2.1% among females and 0.8% among males. The prevalence rises with each decade. Among 20-29 year olds, the prevalence is 10.5%, among 30-39 year olds 19.6%, and among 40-49 year olds 26.1%. The rising prevalence among those in their 30s and 40s indicates a similar proportion of people who begin negative who continue to be sexually active. Presumably, these rising prevalences reflect continuing acquisition of new sexual partners in these age groups in our society, whether through serial monogamy, divorce, or multiple partners(the breakdown by these interesting categories of single, married and divorced are not reported in the MMWR).

Take home messages: Both lower numbers of sexual partners and condom use limit the spread of genital herpes and your risk of acquiring it. Keep it zipped, say no or use a condom.

Sunday, April 18, 2010

Tuesday, April 13, 2010

Costs A Lot and Not Worth the Price

My last post was called "It don't cost nothing and it's worth the price." The EMR (electronic medical record) industry is quite another matter, an example of where most things cost a lot and are worth much less. I must exempt Amazing Charts, the $999 little guy, which is an incredible value. I tried it and considering the cost, it was good despite some limitations. But the other EMRs, some of which I've worked with in previous settings, have limitations too, and they cost much, much more.

As pointed out by the owner of Amazing Charts, Dr. Jon Bertman, on his own blog and on the Amazing Charts website, the availability of federal ARRA (American Recovery and Reinvestment Act) stimulus money has corrupted the EMR marketplace such that EMR vendors are trying to get their product to cost exactly as much as the maximum amount that physicians can get from the federal government to support the installation of an EMR. As he pointed out astutely in his blog, some conflicts of interest are at work related to connections between the Obama administration's advisors and EMR vendors. All this frantic activity with hundreds of vendors and investors in the vendors trying to sell over-priced record systems to physicians makes me glad that I don't take Medicare. I'd rather just practice medicine. Medicare and insurers generally don't pay for what I provide, that is, in depth, extensive, thoughtful internal medicine consultations and research about your medical condition.

As readers of this blog already know, I believe in the patient-centered model of medical record keeping, with patients having their own personal health records, (PHRs) to which providers such as doctor's offices and hospitals have portals and upload data about the patient. This achieves true "interoperability" (fancy word for doctors' records talking to each other and to other health care facilities), with the patient as the hub. Therefore, my main concern with an EMR is that it easily upload electronic data to a patient's personal health record. I'm waiting for Peoplechart (the PHR I recommend to many of my patients because of the availability of staff to help with the inputting of and indexing of the data), or Google Health, or Microsoft Vault, to create a physician EMR, that speaks easily to their PHRs as well as to other EMRs. I've been trying to get an EMR vendor to collaborate with a PHR vendor to do this, but so far there hasn't been any incentive for them to do so.

Monday, April 12, 2010


As a visiting doctor, watching the decline of people sent to nursing homes is painful. So often their behavior becomes an issue, resulting in the prescription of sedatives, which starts a spiral of decline. While such behavior problems are often attributed by nursing home staff to dementia, I have also seen behavioral problems among people who were not demented in the hospital prior to coming into a care facility, even when much sicker in the hospital.

While agitated behavior is often attributed to dementia, worsened by an unfamiliar environment, there are other causes in rehabilitation facilities and nursing homes. Often patients are relatively neglected compared to their prior home environment as well as the prior hospital environment. They cannot go to the bathroom alone, and need help with many things they want to do. Sometimes they do not have a means to call for help. However, when they do, staff cannot be everywhere at the same time, so even in the best of care facilities, people may feel neglected. No one likes neglect, so agitation or screaming can result. The feeling of completely social powerlessness leads to intense frustration which has little other outlet. Family members often notice that when they are present and responding to the person, the screaming or agitation stops. Intermittent positive reinforcement occurs, which results in the behavior becoming habitual.

Unfortunately, sedating people to manage their behavior has further terrible effects. Through being insufficiently helped to get up and exercise, and not being helped to the bathroom in a timely way, they lose continence, develop bedsores, and become weak through muscle atrophy. Excessive sedation also means they lose interest in their rehabilitation activities and are less aware of when they need to go to the bathroom etc, thus deteriorating even further. Delirium and confusion can be other consequences of too many drugs acting on the brain, especially in the frail elderly. This leads to more agitation and screaming, which leads to more drugs. Watching this can turn depressing quickly.

Staff requests for medications are understandable because screaming and agitated behavior can create a horrible environment for both staff and other residents.

The real solution lies in increased staffing and responsiveness by nursing home staff. Unfortunately, our society has not figured out how to care well for our elders. All of us should hope for the sake of our own lives to come, that the future will see a greater investment in making our elders comfortable instead of weakening them with under-staffing and over-sedation.

Home care is not feasible because most people are simply unable to care for a family member 24 hours in their homes, and cannot afford full time home care. This leaves working family members, those who find nursing very difficult, such as those too frail to lift a person, little choice but to put their loved one in a nursing home in such a situation. Family members find this decision extremely painful, and it signals an important turning point of decline.

Our society has a great need for better solutions for elder care. Your comments are welcome.