Vol. 225 January 15, 2020 Hubslist’s 2019 Recap – Part II

January 13, 2020

Click on date to read the whole blog.

June 1: Juuling and Schooling  -All vaping solutions contain nicotine despite the label that says “contains no nicotine”, or even more cleverly “contains no nicotine tar”, which means of course “no tar”. Juul (jewel) is the most successful vaping company, so successful that it has become a verb, as in “Do you Juul?, Lets Juul.” Tobacco companies are investing in vaping because they know that the younger a person is when nicotine is introduced the more likely they will become a life-time tobacco user.

June 15: Hospital Readmission Reduction Program – At first blush it looked like this Medicare cost reduction program actually worked because “preventable” readmissions decreased for cardiac disease and pneumonia, but further analysis revealed five reasons why that wasn’t true.

July 1: Public Opinion About High Health Care Costs –Two-thirds of the U.S. public thinks that reducing health care costs is a top priority for both President Trump and Congress in 2019.  The expert opinion consensus is that the over $500 Billion (yes, that’s a “B”) cost of “unnecessary services”, “inefficient delivery” , and “excessive administrative cost” is a significant cause of the high cost of our health care, but only 23% of public poll respondents thought so.  The U.S. remains unique as the only developed nation lacking universal health care insurance for its people.

July 15: Tidbits for Summer Cookouts Fitbits- People walking only 4,400 steps a day (not the recommended 10,000 steps a day) had a lower “premature death rate”. Where did the 10,000 steps a day target come from?— a 1960 marketing campaign by a Japanese pedometer manufacturer that recognized that the Japanese character for 10,000 resembled a man walking! Screen Time – Research by Nielsen found that Americans aged 35 to 49 used social media 40 minutes more each week than millennials.  A researcher interviewing elementary school children uncovered a lot of complaints from the kids about prying their parents away from their screens. “Parents”, she sighed, “are the worst.”

August 1: Parenting “Unconventional Wisdom” – Breast feeding – The benefits of breast feeding infants are generally found in studies of mothers with a higher IQ and in a higher educational and economically class than non-breast feeding mothers. “So what is the real cause of breast-feeding benefits?” Sleep training – Many studies of sleep training show sizable improvements in maternal depression, family functioning, and no negative effects on infants. Working Moms – There is very little data about the pros and cons of mothers working outside the house except for the evidence supporting longer maternity leave which is beneficial to mother and infant in those first months.

September 1: Understanding Medical News About Famous People What is the prognosis for Andrews of the Patriots (pulmonary embolism) and Ginsburg of the Supreme Court (multiple cancers)? It is relatively save to say that Andrews will not play NFL football this season and that Ginsburg, a champion statistical outlier for 86 years, will probably be sitting on the bench when the Supreme Court resumes in October. After that, who knows? Doctors may guess, but they really don’t know either.

September 15: Vaping and Fatal Pneumonia – There are so many additives in vaping solutions that it is not absolutely certain that vitamin E acetate oil causing lipoid pneumonia is the culprit, but some of the counterfeit vaping solutions used by recent respiratory-distress patients contained more than 50% vitamin E oil!  Who would guess that we would ever say, “It appears to be much safer to just smoke a joint!”

October 1: Vitamin supplements – Here’s more evidence-based skepticism about the benefits of both vitamin C and vitamin D supplements. I have cautioned against vitamin E . . .at least the inhaled form. Is there a vitamin F supplement to continue my alphabetic progression? Yes.  Vitamin F is an outdated term for omega-3 and omega-6 fatty acids,  but I think I’ll let that subject “sleep with the fishes” for the moment.

November 1: Vaping Disease, Medical Marijuana, and CBD –  Pathologists from the Mayo Clinic in Scottsdale, Arizona found no expected microscopic hallmarks of lipoid pneumonia in patients with vaping lung disease, but did find a chemical “burn” or reaction to a toxic gas. Medical marijuana resulted in minimal decrease of pain, little improvement in sleep, and virtually no effect on anxiety or depression. Despite the fact that patients were told by the sellers that there was CBD in the purchased product one third of the study patients had NO detectable CBD in their urine!

November 15: Climate Change Deja Vu from 1996 – “We are still a long way from stabilizing the global climate, a far more complex challenge than repairing the ozone layer. Even with quick action, some greenhouse gases will linger in the atmosphere for centuries. Still, close observers note that a climate of hope has crept into negotiations recently. Insurance companies, small island nations, and others with major interests in a stable climate have re-shaped the diplomatic playing field. Finally, the time for serious policymaking may be at hand.” (1996 Report)

December 1: Top 10 Dangerous Toys and Hazardous Vaping Pods – Though not lethal, yet, if ingested by toddlers the concentrated pods of marijuana for vaping devices can cause significant ICU stays for them. The even more concentrated forms of MJ in edible “dabs” (up to 90% THC) can really cause trouble. Ingesting the concentrated nicotine in vaping pods can actually be lethal to toddlers.

December 15: Changing My Medicare Health Insurance Plan Is Just like Placing a Bet  –  “Youse pays your money and youse takes your choice.” Or as one of my medical student buddies said when we were a lot younger, “Life insurance? You lose (die), you win ($). You win (live a long life), you lose ($).” Did I make the right choice in changing plans?  I’ll know in a year if I won the bet, or the house did.

 


Vol. 224 January 1, 2020 Hubslist’s 2019 Recap – Part I

January 2, 2020

Click on date to read the whole blog.

January 1: Hemp, MJ, THC, and CBD . . . Wha.a.a.a?     Hemp and marijuana are both cannabis plants. But they are not the same. CBD is being actively promoted for its “wellness” effects.The largest marijuana-producing company in Canada (Canopy) is planning to distribute hemp-derived CBD-infused “sports” beverages in the U.S.  Vogue magazine calls CBD wellness products one of the top 10 trends in 2018. The stock price of Canopy January 2019: $28.11  Stock price a year later:$19.28. The 2019 high: $52.70

January 15: Updates
In the U.S. both the average man and the average woman gained 24 pounds from 1960 to 2002. The latest independent estimate of immigrant children held in 9 U.S. centers is 15,000. Most of the children are held for 104 to 240 days in large centers with up to a thousand children. Daily low dose aspirin provided NO benefit to the elderly against all types of deaths, cancer-related deaths, dementia, physical disability, or cardiovascular events.

February 1: Things That Threaten
Repeats
from 2010 include: Watching TV increased chance of a cardiac death by 18%; Tanning Booths increased chance of malignant melanoma by 75%; Cell phone use in cars increased risk of accident by 400%; Toy injuries caused 251,000 visits to  ERs in 2018; Sleep apnea increases the chance of a driving accident by about 100%; No evidence for Brain cancer from cell phones in 2010, but i 2019 a Swedish study found that very heavy cell phone users had an increased incidence of acoustic neuroma (non-cancerous growth on hearing nerve); Many herbal supplements for sexual enhancements, body building, or weight loss had incorrectly labeled ingredients and/or unlabeled contaminants.
“New” threats: Gun Violence – Two previous blogs (2015 and 2018)  compared the story of the frog complacently sitting in the gradually boiling water with our pace of achieving gun safety. (“By Degrees”, Markerelli.com) Climate Change (try to stifle your yawn here) “Climate change is already adversely affecting human health and health systems, and projected climate change is expected to alter the geographic range and burden of a variety of climate-sensitive health outcomes and to affect the functioning of public health and health care systems.” (NEJM editorial)

February 15: Valentine’s Day  Using the Arons Protocol of 36 questions caused a journalist to promptly fall in love on one of her dates, and she wrote it up, “To Fall in Love With Anyone, Do This”, her most widely read column according to the NY Times.

March 15: Jargon Update:
Elderly” is OUT – Few “older adults” want to be called “elderly”. “Seniors” is acceptable, even though it implies that those under 65 are “juniors”. “Perennials”, in contrast with “millennials”, implies that one may not need to be replanted every Spring. The Boston Commission on Affairs of the Elderly changed its name to the Age Strong Commission, becoming a candidate for “Best New Politically Correct Term of the Year” award.
“Organic”, “natural”, “healthy” – All still remain relatively undefined by the U.S.  Department of Agricultural, so any company can put those labels on almost any food.
“Moral injury” is a substitute term for “burn out” of our physicians.  “The increasingly complex web of medical providers’ highly conflicted allegiances. . . results in the moral injury . . . of not being able to provide high-quality care and healing in the context of health care. . . . Electronic health records track productivity and business metrics, but significantly reduce face-to-face interactions.”
Sexual orientation is “who you go to bed with. Gender is who you go to bed as.”
“Safe-school officers” are combat veterans wearing body armor while carrying a 9mm Glock handgun and a sawed-off automatic rifle roaming the halls of the Manatee School for the Arts in Palmetto, Florida. The principal hired the combat veterans because “I don’t want this to be the first time they’ve had someone shooting at them.”

April 1: Alzheimer’s: There’s an App For That – Dr. Atul Gawande, CEO of Haven, the new healthcare-innovation company, announced that their first “new model of care” is an app for patients with Alzheimer’s. The app’s name is “FIGAWI”, after that ancient Indian tribe that gets lost in the fog on the way to Nantucket from Cape Cod every Memorial Day weekend . I’d give you the website where you can download it, but I can’t remember it.

April 15: A Modest Proposal to Eradicate Measles: Measles was declared “eradicated” in 2000. Since January 1, 2019 the U.S. has had 465 cases in 19 states. One way to get things done in America – to effect change – is to sue somebody—your spouse, your neighbor, the police, the National Enquirer, the President, whomever. We should sue an anti-vaxxer, the parent of an unvaccinated child who spreads measles to other people for civil damages!

May 1: Extend the Modest Proposal to Tetanus: Oregon reported its first case of tetanus in thirty years in 2017. An unvaccinated 6 year old developed tetanus and the total bill for his care exceeded $1 million. What if the parents of the Oregon tetanus-afflicted child were sued by the tax payers in Oregon to “recover” those medical care costs that they paid for?

May 15: Fake nutritious food- Foods that sound healthier than they really are include: veggie sticks, rice cakes (arsenic?), spinach wrap, protein powder, turkey burgers, bran muffins, instant oatmeal, and granola. Most have high sugar or high salt or both.

Part II in two weeks.

 

 


Vol. 223 December 15, 2019 A Health Insurance Premium Is Just A Bet

December 15, 2019


“Private insurance is a defective product. Their business model is based on collecting premiums, avoiding sick people, and denying coverage for expensive services whenever possible. Insurers boast in their reports to shareholders about their low “medical loss ratio” (MLR), the low share of premiums they pay for for care.”
-David Himmelstein, MD and Steffie Woolhandler, MD,
Hunter College and Harvard Medical School

I have been covered by Medicare for 15 years and have no complaints about it. Medicare has been “berry, berry good to me”. For 15 years I have also purchased a Medicare Supplement policy and a Part D prescription drug coverage policy from a private insurance company. The combined premium for those two private insurance policies is about $1700 a year. This year, having been attracted by the ads for Medicare Advantage HMO plans providing the same coverage for zero ($0) premiums and being a low utilizer myself  of medical services and prescription drugs, I decided to explore joining a zero premium Medicare Advantage HMO plan.

How hard could that be? I like my primary care physician and the few specialists I go to; my local hospital and the tertiary hospitals I favor all participate in Medicare Advantage plans;  I am a physician, a retired medical care administrator, and I have actually served on the board of a health insurance company so I am familiar with insurance jargon; and I don’t have diabetes, cardiac disease, or chronic pulmonary disease, so I suspect that I will look like a good candidate to an insurance company.  I anticipated that I could readily figure out if joining a Medicare Advantage HMO would save me money while providing the excellent coverage I have grown accustomed to.

It was NOT easy.

I focussed on only two private companies, Blue Cross and Harvard Pilgrim, both reputable companies in Massachusetts. I ignored the other companies that sent me all sorts of spam and junk snail mail during the limited enrollment window. So, why was it not so easy to figure out?

First, I needed to confirm that all my doctors participated in any plan I joined , i.e. would they be reimbursed by either company? When I called my doctor’s office to do that I was told to call the insurance company. Two phone calls later (one to each company) my physicians’ participation was confirmed. The good news was that I avoided lengthy “holds” on the phone calls since during the open enrollment window (deadline of December 7) both companies had an abundance of marketeers ready to answer my questions. My second phone call to both companies was to confirm that my specific prescription medicines were in their formulary, i.e. their cost would be covered. Some of my medicines were in Tier 1 and some in Tier 2 (different copays for each Tier), and there were slight differences between the companies. The short news here is that none were in Tiers 3 and 4 (the much higher copay Tiers), but two of the drugs would need “pre-authorization” of medical necessity by my physician (actually the same requirement as my current policy).

So far so good, but, of course, one never knows what medications you might need in the future, so the first whiff of being in a gambling game wafted into my mind. When I then delved into the morass of copays, deductibles, and co-insurance percentages (all of which are different kinds of “out-of/pocket” payments by the subscriber, i.e. i n addition to the premium ), I really felt like I was in front of a roulette wheel or at a craps table. I didn’t feel at all like I was playing Black Jack where the odds are so well known that  books have been written about how to “beat” them.

In each plan some physician visits had a $20 co-pay, some had $40 a visit. A Medicare-approved outpatient surgery could have a $150 or a $250 copay. An “inpatient” hospital stay was $150 or $360 a day for the first 5 days (no information available on “observation status” or “ER overnight stay”  which are other kinds of hospital stays). Diagnostic X-ray had a $20 co-pay unless it was for an MRI or CT scan and then it was 20% “co-insurance” which means, I think, I would pay 20% of whatever the MRI charges are (I assume both facility and physician charges are counted). One plan dropped the MRI 20% coinsuranse for a straight $200 copay. Chemotherapy medications and “Other Part B Prescription Drugs” (drugs ordered and administered by a physician ) also had 20% coinsurance payments.

Reeling from this game of variable numbers, which I am not good at (remember I’m just a pediatrician), I then went on to compare some of the “perk” benefits like coverage for eye exams, eyeglasses, hearing exams, hearing aid purchase (from $699 to $999 copay), selected dental, Over-the-Counter allowances, and finally the “wallet benefits” (reimbursements for “qualified health and wellness benefits”). Some were included in one company’s policy and not in the other. There were different copays and different “annual limits” between perks and also between companies. . . . Ahh, “annual limits” ??

So where did I place my bet? I decided it was worth saving $1700 premiums a year to go with a Medicare Advantage Plan with a $0 premium for continued Part A and Part B Medicare coverage while also providing prescription drug coverage and Medicare supplement coverage.

Which of the two private Medicare Advantage HMO plans did I choose? — The one with an annual Out-of-Pocket Limit of $4500 rather than the almost identical . . . I think . . . plan with an Out-of-Pocket limit of $6700. I figured that if I bet wrong on all those deductibles, copays, coinsurances, medication eligibilities, and hospital inpatient days, or if my good health odds really tanked, I would lose $2200 less while trying to save $1700. At least I wouldn’t lose the whole pot. Illness and medical bills contributed to two-thirds of all personal bankruptcies in 2007 (three quarters of those medical debtors had private health insurance).

So, as one saying goes, “Youse pays your money and youse takes your choice.” As another saying goes, this one from one of my medical student buddies when we were a lot younger, “Life insurance? You lose (die), you win ($). You win (live a long life), you lose ($).”

So, did I make the right choice?  I’ll know in a year if I won the bet or the house did.


Vol. 222 December 1, 2019 Annual List of Hazardous Toys

December 1, 2019

World Against Toys Causing Hazards (W.A.T.C.H.) has just published  its 2019 “Top 10”  list of most dangerous toy “nominees” in time for holiday buying. (I’m not sure an actual vote is ever taken, but they still call them “nominees”) . As in the previous 47 years the choking hazards of small parts, the presence of long strings or wires with strangulation potential, and potential eye injuries from flying parts caused several toys to be listed. Here is a summary of some of the more interesting toys . Pictures of the toys and more details are available on the WATCH website.

NERF Ultra One– “furthest flying NERF dart ever” ; 120 feet – potential eye injuries
YETI – a”cuddle” toy with easily pulled out long hairs that can be ingested or cause ligatures around fingers, toes, and other protuberant organs.
NICKELODEON FROZEN TREAT SLIME – Made with a variety of hazardous chemicals, it has a DO NOT EAT label on the package, but looks like mint chocolate chip, berry smoothies, and soft serve.

 

 

 

 

 

 


ANSTOY ELECTRIC TOY GUN-

(no further comment necessary on this realistic looking submachine gun)

 

POWER RANGERS ELECTRONIC CHEETAH CLAW– “Use the strength of the claw to take on enemies. . . but don’t hit or swing at people.”

WATCH added an additional caution about buying toys online, which they predict to be about 60% of total toys bought this holiday season. An analysis of over 2000 toys on Amazon revealed that 64% did not have the choking hazard warnings that the same toys did on Target.com.

The independent federal Consumer Product Safety Commission logged 257,000 toy-related injuries in 2017. “One child is treated in a U.S. emergency room every 3 minutes for a toy-related injury.” (That child must be really accident-prone and  very tired – drum roll of rim shots!) In the last two years over 1.2 million toy units were recalled after lead paint poisonings, lacerations, or strangulations. However, toys are getting safer. In 2008 the CSPC issued 172 recalls (not units) while there were only 12 recalls in 2019.

The Toy Association, a toy industry trade group that represents most of the toy makers named on the list, dismissed the annual list as misleading. It suggests parents should always purchase toys from reputable stores and online sellers. “By law, all toys sold in the United States must meet 100+ rigorous safety tests and standards,” the organization said in a written statement. That sounds a lot like Dan Ackroyd as the toy salesman pitching a bag of broken glass on a classic SNL Christmas skit. (Ackroyd’s comeback was a pitch to buy an accompanying bag of toy bandaids.)

Additional serious hazards for small children this holiday season are liquid nicotine and marijuana pods for vaping devices.

Delivered in high doses, nicotine can be lethal.  Exposure to liquid nicotine found in e-cigarettes has resulted in thousands of calls to poison control centers in recent years.  Liquid nicotine poisoning can occur in three ways: by ingestion, inhalation, or absorption through the skin or eyes.  For small children, coming into contact with even a small amount of a highly-concentrated liquid nicotine product can be fatal.

The CSPC is responsible for enforcing a key provision of the Child Nicotine Poisoning Prevention Act of 2015 that requires any nicotine provided in a liquid nicotine container sold, offered for sale, manufactured for sale, distributed in commerce, or imported into the United States to be in “special packaging”.  This packaging, in layman’s terms, must be designed to prevent children from accidentally accessing and ingesting liquid nicotine, and must restrict the flow of liquid nicotine under specific conditions.

Though not lethal, yet, concentrated pods of marijuana for vaping devices if ingested by toddlers can cause significant ICU stays for them. The even more concentrated forms of MJ in edible “dabs” (up to 90% THC) can really cause trouble if ingested by toddlers.

 


Vol. 221 November 15, 2019 “Cassandra Speaking of Climate Change “

November 15, 2019

Cassandra: one who speaks a prophecy that no one heeds.

A friend of mine (actually his wife) was cleaning out his collection of many years of books, cowboy boots, framed certificates, and other cherished stuff when he found three 1996 pamphlets published by The Worldwatch Institute, an independent, nonprofit environmental research organization in Washington, DC. founded in 1974 and still going strong.  My friend thought I might be interested in them.  One of them, “Climate of Hope: New Strategies for Stabilizing the World’s Atmosphere” published in June 1996, prompted me to think about what were their predictions and did they come true? That is the subject of today’s blog.

Quotes directly from Worldwatch Paper #130 “Climate of Hope” June 1996:

  • “Climate change is likely to be erratic, disruptive, and unpredictable. . . The incidence of floods, droughts, fires and heat outbreaks is expected to increase in some regions.”
  • “Recent changes in global climate trends are almost certainly related to the rapid buildup of greenhouse gases.”
  • “Carbon dioxide is a greenhouse gas, letting in visible light from the sun but trapping heat near the earth’s surface.”
  • “Since carbon dioxide is a virtually inevitable product of fossil-fuel-based energy system, efforts to stabilize the climate will at some point have to require a fundamental revamping of that system. Exactly how to do this and at what cost have been subjects of considerable uncertainty and vehement debate.”

There are several greenhouse gases, including methane (hence the “target” on the backs of farting cows) and chlorofluorocarbons (CFCs, HFCs) which are manmade chemicals that have been largely phased out because of their depletion of the ozone layer. Sulfur gas, also from fossil fuel burning, is not a greenhouse gas but does produce acid rain. Stringent emission standards in the 90’s by most industrialized countries have significantly reduced the amount of sulfates in the atmosphere. Carbon dioxide is the largest greenhouse gas by volume in our atmosphere, and carbon dioxide level measurement have become a standard proxy for predicting world-wide temperature increases.

Prior to the industrial revolution in the 1800’s carbon dioxide levels in the atmosphere hovered just below 300 parts per million (ppm). In 1996 the level was 360 ppm. In order to slow global warming the carbon dioxide level will have to be below 500 ppm. Our world-wide carbon dioxide level is currently 420 ppm. “A 450 ppm target means cutting emissions by more than half by 2050. A level of 500 ppm, which would accelerate global warming, could be reached by 2050 if carbon dioxide emissions are not reduced.” (1996) Because carbon dioxide is a “long-lasting” gas in our atmosphere it’s effect on global temperature is cumulative over decades, so that if we (the world) wanted to return to 1996 levels we (the world) would have to go to zero carbon dioxide emissions, an impossible task.

More words from the 1996 Cassandra:
“We are still a long way from stabilizing the global climate, a far more complex challenge than repairing the ozone layer. Even with quick action, some greenhouse gases will linger in the atmosphere for centuries. Still, close observers note that a climate of hope has crept into negotiations recently. Insurance companies, small island nations, and others with major interests in a stable climate have re-shaped the diplomatic playing field. Finally, the time for serious policymaking may be at hand.”

Remember, these words are from 1996. As Yogi Berra said: “It’s like deja vu all over again.”

Meanwhile, as Stephen Colbert says occasionally,
Cause of the Vaping Lung Injury
In my last blog I reviewed a pathological study of lung tissue in 17 patients with the vaping related lung injury which showed no damages indicative of lipoid or oil-caused pathology. The researchers concluded that vitamin E oil was not the culprit, and that the lung injury was similar to that seen from inhalation of a toxic gas and not the inhalation of oil. They did not know what that “toxic gas” was.  The CDC has just released a study of 29 patients suggesting that the offending agent might actually be inhaled vitamin E acetate because they found that in the injured lungs. They also admitted that other unknown agents might be causing the injury.
Meanwhile, hospitals are reporting an increase (one a week in some places) of a hyperemesis syndrome, (persistent, prolonged vomiting), in heavy users of recreational marijuana. First identified in 2004 it can be difficult to diagnose as several other causes have to be ruled out with x-rays and lab tests, but it is increasing in states that have legalized recreational marijuana.

 

 


Vol. 220 November 1, 2019 Update on Vaping Lung Disease, Medical Marijuana, and CBD.

November 1, 2019

“We thought vaping was safe, and it wasn’t. . . it isn’t.”
-Charlie Baker, Massachusetts Governor, justifying his state-wide 3 month ban of vaping

 

What Causes Vaping Associated Lung Disease?
The plot thickens as to the cause of the nation-wide epidemic of vaping-associated lung injuries, including deaths. Our immediate “conventional wisdom” was that it was probably related to inhalation of the vitamin E oil  used to cut the black market THC. (You may have read it here first) Oil inhalation associated injury is now doubted after examination of lung biopsy tissue and/or autopsy specimens from 17 patients. Pathologists from the Mayo Clinic in Scottsdale, Arizona found no evidence of inhaled oil or the expected microscopic hallmarks of lipoid pneumonia in the lungs of patients with the lung injury after vaping. What they did find was evidence suggesting a chemical “burn” or reaction to a toxic gas. There was no sign of an immune response (like an allergic reaction) that would have suggested that only certain individuals could develop the lung injury disease. The researchers did not speculate as to what could have caused the injury, except they are clear that it doesn’t appear that vitamin E oil is the culprit. It puts us back to considering all possibilities: something added to black market vaping material (both THC and nicotine vapers have been injured or killed), noxious gas produced by the device itself, or a combination of the two. This lung injury epidemic began in August 2019 despite several previous years of vaping use, so “something has changed”.  Stay tuned, and don’t vape.

Are There Any Benefits of Medical Marijuana?
Despite the many claims of the benefits of medical marijuana for a variety of conditions, current scientific evidence supports benefits in only three situations: 1. reduce nausea and vomiting after receiving chemotherapy, 2. subjective decrease of spasticity symptoms in multiple sclerosis, and 3. improve chronic pain in adults. The benefit seen in a very rare form of childhood epilepsy is due to CBD alone, not THC. The old idea of benefit in glaucoma treatment was disproven a while back (remember folks? you may have first read it here). A current controlled study of the benefits of medical marijuana is underway at MGH and one of its researchers gave a interim report of their early findings at a conference I attended last week.

The researchers are attempting to do a randomized study of the benefits of medical marijuana in patients 18-55 yo.already holding a medical marijuana card (obtained from a marijuana-use certifying physician for $300 for a single visit). Neither of the researchers, and, in fact, not one of all the MGH physicians are marijuana-use certifying physicians. Since these patients view the marijuana as a treatment for their condition it is unethical to randomize some into a control group who would receive none. Since the clinic can not handle all comers at once they assigned about a third of the patients to a 3 month waiting list for their medical marijuana card. Tests and questions of both the waiting list patients (“control group”) and the patients receiving medical marijuana immediately (“treatment group”) should reveal reveal any benefits or harms from medical marijuana use. A previous study showed that obtaining a medical marijuana card caused holders to double the number of days per month that they used marijuana for their symptoms (from 7 1/2  to 15 days per month).

Since the researchers (along with everyone else) don’t really know what exactly is in the products purchased at a marijuana dispensary, they test for 11 different cannabis metabolites (including CBD) in the patient’s urine each visit. Preliminary data on 84 patients reveals minimal decrease of pain, little improvement in sleep, and virtually no effect on anxiety or depression. Despite the fact that patients were told by the sellers that there was CBD in the purchased product (a “marketing plus” since CBD is touted to reduce adverse effects of THC), one third of the patients had NO detectable CBD in their urine!

Spoiler alert: Today’s cannabis is not your father’s kind of cannabis. Joints at Woodstock had about 1-2% THC. Today the average joint has 6-12% THC. A new edible form of cannabis oil or syrup, called a “dab”, can be 60-90% THC. So “a little dab could really do you.”

What About CBD?
We know even less about the medical benefits of CBD despite the many advertising claims, wide spread ease of purchase, and Gronk’s testimonial endorsement. Cannabis contains over 200 cannabinoids. CBD is one and THC is another. Stay tuned. (Remember, you may have first read it here.)


Vol. 219 October 1, 2019 Vitamin D Supplement; Take It or Leave It?

October 1, 2019

Ever since the French sailors, weakened by scurvy, lost control of the seas to the British navy which was scurvy-free by vitamin C in the lime juice added to their daily ration of grog (hence the name “Limeys”), vitamins have been a subject of great interest and, even now, a lot of mystery. Everyone agrees that a little bit of them is essential for good health, but even two-time Nobel Prize winner Linus Pauling couldn’t convince all of us that a lot of vitamin C  could cure a cold. (1)

Vitamin D is currently the most popular vitamin to study because of some past research suggesting that vitamin D protects us from heart disease, particularly the elderly. A 2012 survey reported that about 20% of respondents were taking vitamin D supplements (multivitamin supplements were not included).  Supplemental vitamin D AND supplemental calcium have long been touted for preventing loss of bone density, or osteoporosis, especially in post-menopausal women. 

It is clear that Vitamin D deficiency can cause growth retardation and bone disease, particularly in the first years of life. It is a bit unclear as to how much of vitamin D we need. The American Academy of Pediatrics recommends vitamin D supplements of 400 units a day for breast-fed babies. Recommendations for minimum doses in other than infants range from 400 units to 2000 units a day. It is said to be almost impossible to be “vitamin deficient” on a normal diet nowadays, but certain very restricted vegan diets can cause some problems in rare cases.  Also, studies of Northern urban  children (less sun exposure) revealed “low” Vitamin D blood levels which stirred up a lot of discussion about its significance and about “what level was normal”. Too much of most vitamins can’t really hurt you too much. Most “excess” of vitamins ingested ( the amount over the minimum required to prevent a deficiency disease)  just ends up in the toilet via your urine.

A recent systematic review of a large number of peer-reviewed research studies on the use of supplemental Vitamin D to reduce the risk of cardiovascular disease was recently published. (2) This meta-analysis (our trade name for such huge reviews) of 21 randomized clinical trials with over 83,000 participants (mean age, 65) followed for 1 to 12 years showed that using a variety of Vitamin D supplements did NOT lower the risk for myocardial infarction, stroke, cardiovascular-related deaths, or all-cause deaths. This is “the best evidence to date that fails to support use of vitamin D supplementation for lowering cardiovascular risk.” (3)

Of course, the results of that meta analysis was muddied just a bit by another meta analysis of 52 clinical trials with over 75,000 participants (mean age, 74) with 1 year follow-up which showed that Vitamin D supplements was associated with 4 per 1000 persons fewer deaths from cancer in a small sub-group of participants. (4)  To further confuse the issue, it was noted that this small but significant difference occurred in only those people taking the D³ form of oral Vitamin D, not those taking the D² form. But, this review also revealed no cardiovascular benefits.

What about effects of vitamin D supplements on bone-density? If the recommended daily dose of vitamin D is from 400 to 2000 units, what if we took twice that? About 3% of U.S. adults take over 4000 units of vitamin D daily. A Canadian randomized study of 311 adults with pre-study normal vitamin D blood levels took either 400, 4000, or 10,000 units per day of supplemental vitamin D for three years.  Bone density actually DECREASED in those taking the higher doses. Also, the vitamin D blood levels in those taking the 400 units (recommended minimum) did not increase above normal. “The findings point to no benefit for bone integrity—and even harm—with high dose vitamin D supplementation in patients with adequate vitamin D blood levels.” (5) 

In today’s blog I offer evidence-based skepticism about the benefits of both vitamin C and vitamin D supplements. In my last blog I cautioned against vitamin E . . .at least the inhaled form. Is there a vitamin F supplement to continue my progression? Yes, there is! Vitamin F is an outdated term for omega-3 and omega-6 fatty acids,  but I think I’ll let that subject “sleep with the fishes” for the moment.

References
1. “Vitamin C and The Common Cold”, Linus Pauling, 1970 and 1976.
2. JAMA Cardiology 2019 Aug; 4:765
3. NEJM Journal Watch cardiology,vol.39, Oct. 2019)
4. NEJM 2019;380:33
5. JAMA 2019Aug27;322:736

 


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