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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Vol. 217 September 1, 2019 Understanding Medical News of Famous People

September 2, 2019

David Andrews, veteran center for the New England Patriots, and Ruth Bader Ginsburg, veteran Supreme Court Justice, have both been in recent newspaper headlines (in different sections of the paper, of course) due to their new medical diagnoses, “clots in the lung” for Andrews and “pancreatic cancer” for RBG. Most articles devote significant space to speculation about their prognoses, i.e. when can Andrews return to play in the NFL and will Ginsburg outlast Trump’s presidency? Why do the answers seem so elusive, and almost always end up with “it depends”?

 

“Clots in the lung” are pieces of blood clots that travel through the blood steam after breaking off from blood clots in the legs (deep vein thrombosis or DVT). In the lungs the clots can clog or drastically slow down the flow of blood through lung vessels and is called pulmonary embolism (PE). PE may often produce no symptoms or cause chest pain, cough, difficulty breathing, and sudden death.

PE is treated with so-called “blood thinners” aiming to reduce the risk of more emboli traveling to the lungs. Neither of the two classes of anti-coagulation drugs actually thin the blood. Both interfere with the multiple steps of coagulation needed to form a clot, thus reducing the chance of more pieces of clot breaking off and traveling to the lungs.

How long is drug treatment necessary? It depends. The shortest duration of 3-6 months is recommended for “provoked” PE, an embolism from a leg or pelvic clot provoked by an injury, surgery, infection, cancer, or other recognizable event. An “unprovoked” PE, one without a recognizable event, is usually treated for longer periods.

It is probable that Andrews’ PE was related to a football injury, a “provoked” PE, so that anti-coagulation treatment will last for at least 3-6 months. Hence he is out for the season, since it would be dangerous for him to play football with an intentionally defective blood clotting mechanism. If his PE was not the result of an injury, then it was “unprovoked” and treatment duration may be even longer.

RBG just completed treatment for her third bout of cancer. She was treated for colon cancer in 1999, “early” pancreatic cancer in 2009, and a cancer in her lung was surgically removed in December of 2018.  This recent treatment consisted of 3 weeks of highly focussed radiation to a small malignant mass in the part of the pancreas (the “head”) that surrounds the bile duct that goes from the liver to the small intestine. A stent was placed in the bile duct presumably because even this highly focussed radiation could cause the duct to swell and obstruct resulting in her becoming jaundiced. Her doctors did not identify the mass as colon, lung, or pancreatic cancer, but reported that it was localized with “no evidence of cancer elsewhere”.

That last bit of news is significant since the prognosis of pancreatic cancer depends on the stage of disease, from 1 to 4. Stage 1, local disease, has a 5 year survival rate of 12-14% while Stage 4, widespread disease, has a 5 year survival rate of 1%. Survival rates are statistics based on the outcomes of hundreds of patients and can not be reliably applied to an individual patient. RBG has especially proved that herself. In a recent interview RBG remarked that “a certain Senator who predicted my early demise after my 2009 diagnosis of pancreatic cancer is now dead himself while I’m still alive.”

Because of the fallacy of applying the mortality statistics of hundreds of patients to an individual, the honest doctor realizes that a prognosis often can not be given accurately. That knowledge is also colored with the emotion of difficulty breaking bad news. One study showed that only about 37% of oncologists were able to give an “honest” prognosis to a cancer patient under treatment. When the doctor did give a prognosis, it was often overly optimistic. 

So, what is the prognosis for Andrews and Ginsburg? It is relatively save to say that Andrews will not play NFL football this season and that Ginsburg, a champion statistic outlier for 86 years, will probably be sitting on the bench when the Supreme Court resumes in October. After that, who knows what will happen. The doctors may guess, but they don’t know either.


Vol. 215 June 15, 2019 Sometimes Even Good News is “Fake” News

June 16, 2019

A lesson in evaluation of a cost-reducing health care program:
a learned, scientific critique of a controversial Medicare reimbursement program.

 

“The Hospital Readmissions Reduction Program (HRRP) was established in 2010 by the Centers for Medicare and Medicaid Services (CMS) with a “goal of reducing ‘preventable’ re-hospitalizations by imposing financial penalties on hospitals with higher-than-expected readmission rates in the 30 days after a hospital discharge”. This was one of several new “Pay For Performance” (PFP) programs aimed at lowering federal health care costs by tying Medicare reimbursement to hospitals, physicians, and even home care agencies to the use of more appropriate (read “lower cost”) medical care delivery settings.

After implementation of the HRRP, hospital readmission rates did decrease nationwide for the targeted diagnoses of heart failure, acute myocardial infarction, and pneumonia. So, the federal government ended up reimbursing less money to those hospitals that had higher-then-expected “preventable” patient readmission rates . “Great!”, said some policy makers, “it saved us some money. Let’s expand the program to ALL conditions treated in the hospital.”

“Whoa”, said by a group of research physicians from Harvard and Washington University Medical Schools, both known as liberal academic institutions, ”let’s look at the data.”

  1. The proportion of patients that returned to the hospital within 30 days after discharge actually did NOT change.
    .        .Patients returned to the hospital within 30 days after discharge for care, BUT they weren’t “readmitted”. Instead a significant number of those returning to the hospital were treated for up to 3 days in Observation Beds/Units or overnight in an Emergency Room bed. HRRP did not measure use of Observation Units or overnight stays in the ER. No wonder the “readmission” rates went down.
  2. If a patient dies within 30 days after hospital discharge they obviously can’t be “readmitted”.
    .         .The HRRP statistics did not measure mortality rates. A hospital keeping sicker patients alive by readmitting them for appropriate care rate might have the better outcomes, i.e. a lower death rate, but it would be penalized for having a higher readmission rate. In fact, the financial penalties for higher readmission rates under HRRP are much higher than the penalties for a higher death rate under Hospital Value-Based Purchasing program (HVBP), another federal PFP program.
  3. “Risk adjustment” of patient illness severity is notoriously varied and difficult to standardize.
    .          . “Risk-adjusting” of illness severity, for example, recording the different illness severity between the heart failure patient on two drugs and slightly swollen ankles versus the patient on multiple heart drugs for decompensated heart failure, is very difficult to standardize. Some of the early enthusiasm for HRRP and its reported improvement of risk-adjusted readmission rates may have been the result of improved medical record coding of co-existing conditions. (This is well-known as “gaming the system”, legal and even ethical, sort of like taking advantage of tax code loopholes, but it does nothing to improve the quality of care.)
  4. Social risk factors like patient poverty and poor community resources like lack of public transportation and diminished access to primary care were omitted from risk-adjustment factors.
    .          .Safety-net hospitals (those in poor areas) can be penalized under HRRP as a result of such factors. “The evidence that social risk factors influence readmission rates is incontrovertible.”
  5. HRRP may even have increased the death rates for patients with heart failure.
    .          .Four independent studies showed that the death rates for patients with heart failure INCREASED significantly after implementation of HRRP. The increase was concentrated among the patients who were NOT readmitted, suggesting that the use of ER beds and Observation Units “may adversely affect patients who would benefit from higher-level care.” Two other studies found different results which suggested that HRRP was more beneficIal to patients with acute heart conditions rather than patients with chronic heart failure.The three authors urge several steps to correct what they consider a faulty, positive evaluation of HRRP before jumping into expanding the program to ALL patients admitted to a hospital. This failure to correctly evaluate HRRP “underscores the consequences of implementing national policies after [evaluation that does not include] a control group.”They also urge “policymakers to seek input from frontline clinicians and patients who understand the real-world effects of HRRP. . . . If HRRP is improved it might be transformed from a regressive penalty program to a progressive program that improves patient care.”

    Q.E.D.

    Reference:
    “The Hospital Readmissions Reduction Program—Time for a Reboot”, Drs. Wadhera, Yeh, and Maddox, NEJM 380;24 June 13, 2019.


Vol. 211 April 15, 2019 A Modest Proposal To Eradicate Measles In The U.S.

April 15, 2019

Measles was declared “eradicated” in 2000. Since then we have had unexpected U.S. measles outbreaks in 2014 and presently we are breaking all records for new cases (78 cases just this very week). In 2014 there were 667 cases of measles in Amish country of Ohio. Since January 1, 2019 the U.S. has had 465 cases in 19 states.

For those of us who are used to hearing big numbers every day—size of the national debt, baseball player salaries, number of immigrants pounding on our door, etc.—these numbers don’t sound very compelling. BUT, measles is a preventable disease. One measles vaccine shot protects the recipient 93% of the time. When you add the second shot years later the individual’s protection goes to 97%. 

 Measles, the most infectious disease we know, can cause debilitating encephalitis (brain swelling), pneumonia, and, very rarely in the U.S., death in both infants and adults. Madagascar is not so lucky. Because of its poverty Madagascar has a vaccination rate of only 58% despite the population’s desire for vaccination. They had 1200 deaths in the115,000 who got measles last year. Europe had 41,000 measles cases in 2018. A community vaccination rate of 90-95% is necessary for effective “herd immunity” in which the vaccinated keep the un-vaccinated safe just be reducing their chances of exposure.

You are not likely to be exposed to a case of Madagascar measles, but if you happen to be in the Williamsburg section of Brooklyn, or Rockland County, NY, or  Portland, Washington, or near Sacremento, California, you may be exposed. These four hot spots of current measles outbreak apparently share an unintended consequence of easy-access global travel.  Unvaccinated Orthodox Jews returning from the September annual Hasidic Pilgrimage from Israel to Uman, Ukraine unexpectedly brought measles back to their unvaccinated, ultra-orthodox Jewish U.S. communities.

There is no aversion to vaccination in the Bible, the Quran, or even Sanskrit texts. It is speculated that these communities have low measles vaccination rates because of “anxiety about science”, “concern about risks of new technology”, and, especially in Soviet emigres, “distrust of the government”. 

In 1896 a Jewish man in Britain refused vaccination contending that it was against his religion. The prosecutor, also Jewish, asked the opinion of the Chief Rabbi of Britain who answered, “Hogwash.” The London court agreed.

Anti-vaxxers don’t respond to facts, They reject scientific data. They are apparently immune to dreaded stories about sick, dying children but appear to believe dreaded stories of assumed vaccine reactions. The mayor of New York City has declared a public health emergency and wants to fine any Williamsburg orthodox Jew who refuse the measles vaccine $1000. He has threatened to even close non-compliant Yeshivas. Rockland County tried to bar unvaccinated persons from public places including . . . gasp, . . . malls! A judge with a cooler head put that on hold.

After reading about the British 1896 court case a modest proposal just sprang out of my head: We should sue an anti-vaxxer, the parent of an unvaccinated child, for civil damages!

It has been recently and repeatedly affirmed that 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. 

So, all we have to do is wait until an unvaccinated child with measles exposes a vaccinated child. Since we know that the measles vaccine is not truly 100%  effective, the vaccinated child has a small chance (probably 3% – 7%) of getting measles. If the vaccinated child now with measles develops the more common complication of pneumonia, or the rare one of encephalitis, or the even rarer one of death, his or her parents could sue the unvaccinated child’s parents for all present and future medical bills, loss of school days, future loss of income due to brain damage, loss of companionship, and other compelling emotional stresses dear to personal injury lawyers. If encephalitis were the complication, the huge jury award would be enough to get the attention of even the most adamant anti-vaxxers. They would learn that their stance is not just a risk to society; it could be a large monetary risk to them personally.

References:
1. “A Modest Proposal”, Jonathan Swift, 1729 


Vol. 207 February 1, 2019 Things That Threaten

February 1, 2019

With our President and our own intelligence agencies currently in public disagreement about our greatest threats (Southern border migrants {Tweets} VS China, Russia, and North Korea {“Worldwide Threat Assessment”} ), it seems an appropriate time to list again some of the things that might threaten us from a medical point of view.  I last did this on February 1, 2010.

Repeats from 2010:

Watching TV – increase chance of a cardiac death by 18%, increase chance of obesity in children by 5%. 

Tanning Booths – Increase chance of malignant melanoma by 75%; 20 minutes in the booth equals 5 hours in the sun.

Cell phone use in cars – Increase risk of accident by 400%

Toys – 13,663 head injuries in children from toys seen in an ER in 2005; 251,000 toy injuries seen in ERs in 2018; 41% (102,910) were injuries of face or head.

Sleep apnea in truck drivers – Sleep apnea increases the chance of a driving accident by about 100%; 17% of truck drivers have sleep apnea

Brain cancer from cell phones– no evidence for it in 2010; “maybe” in 2019; very heavy users over 10 years in Sweden had an increased incidence of acoustic neuroma (non-cancerous growth on hearing nerve).

Contaminated herbal supplements – more studies continue to find supplements with incorrectly labeled ingredients and/or unlabeled contaminants. Most of these supplements are for sexual enhancements, body building, or weight loss.  

Vaping of nicotine products – “Unknown risks” noted in August 1, 2009; Still unknown over the long term, but of more concern because of the alarming explosion of use by junior high students and 21% of twelfth-graders.( an increase of 1.3 million teens just since 2017) (NEJM 2018 Dec 17)

New threats:

Gun Violence – I am surprised that this wasn’t in my 2010 list since it seems like we have been talking about this threat for years, but it was before the Sandy Hook and Stoneman Douglas school massacres . Wikipedia has a handy list of 122 world-wide school massacres by country, dates, number killed, etc. Do you remember what the auto industry said in the past regarding proposed laws requiring seat belts? – “Cars don’t kill people; people kill people.” I don’t either. Someone must have made that up to make a point. Check my two previous blogs (2015 and 2018) for the comparison of “the frog sitting in the gradually heating up water” with our pace of achieving gun safety. (“By Degrees”, Markerelli.com)

Climate Change – Extreme weather events and raging wildfires in California have caused some to label climate change as a “Health Emergency”. Accompanying an article describing the stress on emergency medical care resources and the significant contribution to air pollution caused by the California wildfires, a lead editorial in the New England Journal of Medicine stated: “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.”  

Large Gathering in Any Public Place – During a break in the interminable Boston TV coverage of the Patriots prior to Super Bowl LIII one channel showed a segment on the security planned for the Mercedes Benz Stadium in Atlanta. It was impressive; ten miles of fencing, prohibition of drones, helicopter fly-overs, fully-armed policemen, and more-fully-armed soldiers (always shown walking in pairs). Nothing new to us since September 11th. Just another reminder, but now at least we realize it is not actually foreign “terrorists” that have caused the most havoc in our country.

Enough about threats. Any good news?

Salt-free diet not necessary for heart failure patients- A review of 9 studies showed “a paucity of evidence supporting low-sodium diets for patients with heart failure”. The recommended first step is to “… retreat from an unbridled and potentially harmful insistence on rigorous sodium restriction” in these patients. (JAMA Internal Med 2018 Dec; 178)

Vitamin D supplements of no benefit to preventing cancer or cardiovascular disease –A study of 25,800 participants over 50 years old followed for 5 years showed that daily 2000 IU of Vitamin D “did not keep the doctor away” compared to placebo. This is good news for people spending money on vitamin D supplements for this purpose. (NEJM January 3, 2019:380;1)

Omega-3 Fatty Acids (“fish oil”) of no benefit in preventing cardiovascular disease – Ditto  (JAMA Cardiology March 2018; 3)

Stand-up desks at work reduces sitting times – See “Watching TV” above, but unfortunately there are no studies that standing does anything but improve psychological well being of the worker with some work-related benefits.  When arising from the sitting position, the authors recommended doing some physical activity. Standing alone is not any healthier. (BMJ 2018 Oct10:363)


Vol. 203 November 15, 2018 Recent Updates

November 15, 2018

Hub thumbnail 2015

Unsafe Toys for Christmas 2018
World Against Toys Causing Harm or W.A.T.C.H. has just released its 5th annual list of “worst toys for the holiday season” picked for their potential cause of choking, eye injury, or other safety hazard. In 2016 there were 240,000 toy-related injuries. During 2014 to 2016 there were 35 toy-related deaths. The top ten worst toys this year include:

  • Nickelodeon Nella Princess Sleeptime Pet Pillow – choking and suffocation (“DO NOT USE IN CRIB”)
  • Nerf Praxis Blaster- “rapid fire” projectiles could cause eye injuries
  • Marvel Black Panther Slash Claw – “it can actually slash”
  • Power Range Ninja Superstar Blade – “plastic chain saw that can actually cut”
  • Cabbage Patch Dance Time Doll – choking (Is nothing sacred?!)
  • Stomp Ultra Rocket – “fires up to 200 ft. in the air if not stopped by an eye”

Lower Your Prostate Cancer Risk by Riding a Bicycle
Men who did long-term vigorous exercise like biking, swimming, or running had a 25-30% less chance of developing advanced or lethal prostatic cancer. Exercise even lowered the risk for those men who have a specific genetic subtype of prostatic cancer seen in half of the deaths. “The influence of insulin, growth factors, and other metabolic factors” is thought to be the link between exercise and the lower risk according to this Harvard School of Public Health study of 49,000 healthy men between 1986 and 2012.

Many Nutritional Supplements Include Contaminants
Half of U.S, adults take some sort of nutritional supplements spending about $30 billion annually, and the FDA is prohibited by law to evaluate supplements for safety or efficacy PRIOR to marketing. The FDA can issue post-marketing warnings about adulterants. One study from 2007 to 2016 identified 776 supplements, mostly for sexual enhancements, weight loss, or muscle building, with either adverse events or consumer complaints,. Of the 28 products that had received two or more “FDA warnings” 19 continued to be sold. In another study of 21 supplements with “FDA warnings” because of one or more unapproved stimulants, 12 were still available in 2007 and 9 of the 12 still contained the same stimulants. Q.E.D.; FDA warnings have little effect in protecting consumers from potentially harmful effects of contaminants in nutritional supplements.

Does Drinking More Water Reduce Bladder Infections in Women?
Yes, if they had 3 or more bladder infections in the previous year and are drinking LESS than the recommended 1500 ml. (4 water bottles) a day. If they doubled the amount of water to 3000 ml. (8 water bottles) a day the reoccurrence of a bladder infection is reduced from 3.2 a year to 1.7 a year (at least in Bulgarian women). If they were already drinking over the 1500 ml. minimum a day increasing the amount had no effect on recurrence. [All the U.S. women I know, at least in Barnstable county, take a bottle of water with them when they’re just going to the post office.]

One-half of Obese Adolescents Started Being Overweight When 3 – 5 Years Old (at least in 50,000 healthy German children)
Most of the children who were obese at age 6 were obese as adolescents. Rates of obesity were higher in children with overweight or obese mothers. “It is an ominous sign that the number of American children with the most recalcitrant forms of obesity has increased progressively during the past 10 years.” This study suggests that physicians should start nutritional counseling if exaggerated weight gain occurs after age 2! (NEJM October 4, 2018)

Do Not Use Infant Walkers
Despite the fact that the American Academy of Pediatrics has long called for infant walkers to be banned in the U.S. as they are in Canada, infant walkers are still sold here. An average of 9,000 infants a year under 15 months of age are treated in our ERs with head or neck injuries when infant walkers go down household stairs with an infant in them. The AAP says that “there is no advantage of the walker to the infant and parents should not use them.”

A Chilling Aftermath of Our Latest Gun Violence
A friend of mine has a brother who worships at that Pittsburgh synagogue. He was not there for the October massacre, but sat Shemira (literally a bodyguard) for a member who was. After Shemira the brother called my friend to say that he had bought a gun and obtained a carry permit. My friend was incredulous, and asked him, “When are YOU going to carry a gun?” His brother’s answer, “Only when I pray”.

A Prayer for Our Times
The mid-term elections are over, but the political hyperbole and acrimony, especially from the President to the press, is not. On Veterans’ Day we sang “America the Beautiful” in church, and I was struck by the relevance of the unappreciated second verse:

“America! America! mend thine every flaw,
Confirm thy soul in self-control, thy liberty in law.”

Have a Happy Thanksgiving.


Vol. 201 October 15, 2018 Medical Facts and Fantasies?

October 15, 2018

Hub thumbnail 2015A baby aspirin a day does not necessarily keep the doctor away.
Daily low dose (81 mg. or a baby tablet) aspirin protects you from having your SECOND heart attack, not your first one. Another recent study confirmed that aspirin gives no such protection to someone who has a normal heart history. A baby aspirin is of NO benefit for primary cardiovascular disease prevention. (Despite these repeated studies many of us continue on our merry way of taking a daily baby aspirin in hopes of preventing “the big one.” )

Ritalin is apparently better than nothing . . . and lots of other things.
ADHD (Attention-Deficit-Hyperactivity-Disorder) in school children is not helped much by non-drug therapy. A 2011 review of 54 studies showed little lasting effectiveness of neurofeedback, child behavioral training, parent training, cognitive behavioral (“talk”) therapy, dietary changes, or herbal and Omega fatty acid supplements when compared to the usual psychostimulant drugs like Ritalin. (This lack of evidence of any benefits from non-drug treatment of this common condition is disappointing. The reviewers themselves call for additional studies.)

There’s An App For It – Among things that your smartphone can do are:

  • Record and transmit a electrocardiogram of your heart rate and rhythm.
  • Ask questions to determine whether you are slipping into a depression, and send a text message to your therapist.
  • Have a trained counselor call you within an hour of you opening up a bluetooth equipped HIV self-test kit to interpret the results for you.
  • Adjust the volume and sound characteristics of the hearing aid in your ear.
  • Operate an automatic pill dispenser filled with your daily medications.
  • Give you a “text neck”. The 60 degree angle of your neck as you text puts about 60 pounds of strain on your spine. (That’s the equivalent of 4 bowling balls).
  • Measure, record, and transmit your blood pressure or blood glucose level.
  • Give you an inaccurate pulse oximetry reading if using a non-FDA approved monitoring app. (In fact, the FDA faced with the existence of about 400,000 health and wellness apps has decided to review 20 apps a year that are directly related to gathering and transmitting clinical data. – FitBits are not included in that category)

Got your flu shot yet?
This year the CDC is recommending the quadrivalent flu vaccine for everyone over 6 months old who does not have a medical contraindication. No particular vaccine brand is recommended over the others. People with egg allergies can safely receive any of the vaccines. ( The Bill and Melinda Gates Foundation is pouring money into research efforts to reduce the potential effects of one of their greatest fear, another flu pandemic.)

Parents know best.
Children sleep better if fed earlier in life. Official pediatric policy used be to start solids at 6 months. Many parents think that starting at 3 months causes longer sleep periods and less sleep problems. A study of 1300 breast-fed infants in England and Wales showed that the parents are right. Duh! (Pediatricians used to recommend starting certain solid foods at even a later age because of potential food allergies. That is no longer true.)

The “other shoe” on probiotics.
The current wisdom that “probiotics are harmless and can benefit everyone” is not necessarily true. The exploding volume of research on our “microbiome” (the bacteria in our intestines) reveals that the bacterial mix in our intestines is unique to each individual (like a fingerprint) and is “good” for us in its natural state. Probiotics can change that mix, and one study shows that some of us have guts that are not only “resistant” to probiotics, but that alteration of our natural mix by probiotics could delay recovery from some illnesses.

Why your visit to your doctor’s office isn’t the same as the “old days”.
It is estimated that a typical primary care physician needs 22 hours a day to address all of the preventive, acute, and chronic needs of an average patient panel of 2,500 patients. This includes all of the insurance-prescribed, electronically embedded (in the electronic medical record – EMR) quality measures tied to the reimbursement of the physician. (This is one reason we patients are filling out more questionnaires, clicking on more boxes on a screen, and spending more time with nurse practitioners and physician assistants when we go to the doctor’s office. “The doc can’t do it all any more.”)

Watch out. More un-immunized children are on their way to school.
A 2017 CDC telephone survey indicates that about 100,000 children in the U.S. born in 2015 and 2016 have not received vaccination against the 14 disease for which shots are recommended. This is an increase from a similar study of children born in 2011.

Too fat? Just take a pill. . . A new kind of pill.
A capsule with a long thin plastic tube is swallowed by the patient. Once in the stomach air is pushed down the thin plastic tube, the capsule expands into a balloon filling 1/3 of the stomach, the patient has sensation of having a full stomach, and the thin tube breaks off and is withdrawn. In about three months the stomach balloon disintegrates, deflates, and is passed out in the stool. It has been approved in Europe and is being tested in the U.S. hoping for FDA approval in 2020. Another start-up company is hoping that their capsule filled with gel that expands in the stomach juices and accomplishes the same thing will also be approved. ( The gel-filled capsule is a bit of deja vu for me. As a chubby pre-teen trying to lose weight, I remember taking a tablespoon of “weight-loss powder” a half-hour before a meal, waiting to let it expand in my stomach, and feeling less hungry  so I ate less. I forget its name, but I do clearly remember the time I was in a particular hurry, ate too soon after the dose, and promptly emptied my over-filling stomach onto my shoes.)

A timely tip for women.
With all the surprise disclosures of “good men” exhibiting past sexual harassment acts and even sexual assaults, how can a woman feel confident that the man she is with is not the aggressive type? A recent study suggests you can just look at his hands. The shorter the index finger is compared to the ring finger, the more aggressive the man may be. This is from a study of 300 Canadian men and women. No correlation of personality to finger lengths was found in women. Researchers associate this finding with “the amount of testosterone that babies are exposed to in utero”. ( Or could it be related to being born North of the 49th parallel?! )


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