Vol. 188 March 1, 2018 St. Valentine’s Day Massacre #2

March 1, 2018

Hub thumbnail 2015St. Valentine’s Day Massacre,
Chicago, Ill. 1929:
7 gangsters killed.

St. Valentine’s Day Massacre, Parkland, Fla. 2018:
17 kids & staff killed.

Firearm safety is a public health issue”
-Massachusetts Medical Society, February 2018

The 1929 massacre was partly responsible for the 1934 Illinois and 1935 Federal laws regulating machine guns. The laws actually did NOT ban the guns, They taxed them! The tax was $200 (about equivalent of $8000 today) and the annual license to own one was also very expensive. It effectively doubled the price of a tommy gun, the gangsters favorite. In 1986 the sale of fully automatic guns was prohibited by federal law “except those already existing in owners hands” that were grandfathered in. (1)

This year’s St. Valentine’s Day Massacre was the 30th mass shooting (more than 4 victims) in 2018 . . . so far. It was also the 17th time a gun had been fired on school grounds in 2018 . . . so far. AND on February 14, 2018 there were 28 additional gun deaths elsewhere in our country. (2)

Just to numb your brain with some more statistics (I know, I know . . .your eyes are already glazed over having read these numbers or others like them so many times), but during the period of 2009-2013 there were 722 per year firearm-related injuries Massachusetts, a state well-know nothing for its extensive of gun regulations . When you subtract the average of 121 suicides per year and 187 unintentional injuries per year some might say, “Only half are homicides. What’s the big push against gun violence.?”

And that’s when you can reframe the conversation into “gun safety”, not gun banning, not gun restrictions. That is the tack the medical profession is taking, and it might prove to be less confrontational to vested interests and more successful than other efforts.  Gun safety measures target preventing ALL of the 722 annual gun injuries. (pun intended).

The American Academy of Pediatrics strongly recommended a few years ago that pediatricians ask about gun safety as part of their usual assessments of household risks during a well visit; i.e. “If you have guns in the house,are they stored safe from the access of children?” One response was Florida legislature passing a law making it a crime for a physician to ask a patient or parent about gun ownership. The law was rescinded by the US Court of Appeals after the AMA brought suit.

In the same Feb. 24 2018 newspaper that Trump called for the arming of school teachers the Associated Press reported that 9,070 pupils (1 in 105 students) had to be physically restrained in Massachusetts school during the 2016-2017 school year.   244 of those incidents resulted in an injury to student or staff. Nationally the U.S. Education Department estimates that figure of physical restraint is at least 22,000 incidences per year. So, let’s just throw a gun into THAT equation! (CCT Feb. 24, 2018)

A relevant model of effective action is the decrease in auto fatalities by passing multiple laws and regulations, technological advances, and public education (Seat belts, airbags, speed limits, car cameras, etc.)

Smart gun technology  now exists to make guns safe, but they would still allow the owner to “repel any invaders of his house . . . or country”,  and might cut the number of gun injuries by 50%. Reducing mass homicides would require more regulation of automatic guns.

Organized Medicine’s new recommendations are to focus on gun safety.
1. Physicians should talk to their patients and families about gun accessibility, storage, and safety in the home.

2. The CDC should be allowed to conduct gun violence research (collect and analyze data)  like in any other public health epidemic.

3. Increase federally funded research on this “urgent health care crisis” of gun violence.

Many physicians belong to the NRA, “and that’s OK”. A physician friend of mine from Massachusetts was interviewing for a medical license by a physician panel in New Mexico. The chairwoman, noting his home state, asked him if he knew about gun control in New Mexico. He pleaded ignorance, and she responded, “A steady hand. Would you like an application to the NRA?”

 

 

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Vol. 182 December 1, 2017 “This Is Not Your Father’s Heart Attack”

December 1, 2017

The remarkable facts, that the paroxysm, or indeed the disease itself, is excited more especially upon walking up hill, and after a meal; that thus excited, it is accompanied with a sensation, which threatens instant death if the motion is persisted in; and, that on stopping, the distress immediately abates, or altogether subsides; have . . . formed a constituent part of the character of Angina Pectoris. – “Remarks on Angina Pectoris” by John Warren, M.D., appeared in 1812 as the first article in the first issue of The New England Journal of Medicine and Surgery.


About this time of year in 1958 my father had a heart attack in Toronto.
He awoke in the morning with some chest pain that didn’t get better after a cold, brisk shower “to make it subside” (“De’Nile ain’t just a river in Egypt”).Then he walked up a flight of stairs to a physician’s office (more water down De’Nile), almost left the waiting room when the pain went away (ditto again), but immediately impressed the doctor with how pale and clammy he looked. He spent three (3) weeks on his back in a Toronto hospital bed with the diagnosis of “heart attack.:” He was allowed to return home to suburban New York City by train. I don’t remember why the train, but I think it had something to do with him traveling in a wheelchair (“activity still restricted”).

Things sure have changed. (NEJM 376:21 May 25, 2017)
The rate of hospitalization in the U.S.for a heart attack (acute myocardial infarction or AMI) has decreased by 5% PER YEAR since 1987. The rates of major complications have dramatically decreased during the same period. Deaths from acute MI have declined slowly since 1980, but 50% of the AMI deaths occur before the patient arrives at the hospital. Hence the push in recent years to teach CPR to everyone and distribute portable cardiac defibrillators/ automatic external defribillators (AED) as widely as possible.

There are now at least six types of heart attack.
The big divide is between those patients that have a specific change in their EKG, an elevation of the ST segment (STEMI) and those that do not (non-STEMI). STEMI implies significantly more heart damage and is treated more aggressively. Branching down off of these two big categories are 5 other distinct types of MI based on modern diagnostic modalities, both EKG findings and blood sample biomarkers, and therapies. I won’t bore you with all those details. Just remember that a “heart attack” is not just a “heart attack” anymore. It all depends…

There is distinctly different therapy for each type of AMI.
Today there is a lot more than “bedrest for three weeks.” Each AMI type has a best practice timeline which varies considerably, except that everyone arriving in the ER with chest pain gets an aspirin within 5 minutes (makes platelets “slippery” to reduce clotting of blood in small coronary arteries). After that:

  • you may be whipped into the cardiac cath lab within 90 minutes for percutaneous cardiac intervention (PCI – a catheter in a radial (wrist) artery) to stent your coronary artery(s);
  • or you may be given a stress test and be sent to the cardiac cath lab for a diagnostic catherization and then maybe scheduled for open heart surgery (CABG) that day or days/week later;
  • or you may be admitted to a CCU/ICU bed;
  • or you may be admitted to an “observation bed” or “step down unit” which have outcomes as good as a CCU or ICU.
  • or you could even be sent home.
    You will probably be anti-coagulated as well. Most admitted non-CABG patients stay in the hospital for no more than 3-4 days.

Some studies credit the declining death rate from cardiovascular disease to better prevention (Public health and primary care interventions). Others credit better, more timely diagnosis and treatment (scientific advances). Both are correct.

 

Decline of cardiovascular deaths due to scientific advances.
(NEJM 366:1, January 5, 2012)

Decline of cardiovascular deaths due to public health and primary care interventions.
(NEJM 366:13 March29,2012)

Numerous studies have shown that the biggest influence on your chance of having a heart attack is genetics; what you inherit from your parents. The good news is that if you have NOT picked your parents well, life style changes like no smoking, exercise, no obesity, and a healthy diet can reduce even the high risk for coronary disease by nearly 50%. (NEJM 375:24 December 15, 2016)

 


Vol. 181 November 15, 2017 Here’s Some More Good News …and Bad News

November 15, 2017

Do not believe in anything simply because you have heard it.
Do not believe in anything simply because it is spoken or rumored by many.
Do not believe in anything simply because it is found written in your religious books.
Do not believe in anything merely on the authority of your teachers and elders.
Do not believe in traditions because they have been handed down for many generations.

But after observation and analysis when you find out that anything agrees with reason and is conducive to the good and benefit of one and all, then accept it and live up to it.
-Buddha

THE GOOD NEWS is …
Neurosurgeons in one hospital  were able to double-book operations (operate on two patients at the same time) without increasing complications like infections and bleeding, and they had  same, good outcomes of those who didn’t double-book. The other good news is that seven separate studies of double-booked cases (all since the MGH dust-up caused by a whistle-blowing orthopedic surgeon) revealed no difference in complications compared to single cases.
THE BAD NEWS is …
The double-booked neurosurgical patients had 30 minutes longer of anesthesia and their incisions were open for 30 minutes longer (increased chance of contamination). The other bad news is that orthopedic surgeons who double-booked hip surgery have higher complications than those who didn’t. (JAMA Surgery. Nov. 15, 2017)

THE GOOD NEWS is …
Congress just passed the Elizabeth Warren (D-MA) co-sponsored 2016 bill that will allow people to obtain hearing aids (called PSAPs- “Personal Sound Amplification Products”) over the counter (OTC)without a prescription. These PSAPs will be much cheaper than the currently exorbitantly priced “professional hearing aids”, and will be just as good using upgraded technology.
THE BAD NEWS  is ...
You won’t be able to buy them for at least three years. That is how long the FDA will take to develop regulations (specifications) and approve their sale. In the meantime, some of my friends will continue to “not hear me”, and my post office box will continue to overflow with offers of “free hearing tests” from professional vendors of very expensive hearing aids. (Boston Globe November 12, 2017)

THE GOOD NEWS FOODS of  Thanksgiving are…
1. Turkey – Lower calories than a standing rib roast and a lot less sodium than spiral ham. The myth of tryptophan making us drowsy has been debunked several times.
2. Pumpkin – That’s “pure” pumpkin spice. No sugar. Pumpkin pie filling with 27 grams of sugar in a half-cup is a no-no.
3. Sweet potatoes – cooked in just a little olive oil only. Casseroles and canned variety are to be avoided.
4. Cranberries –  It is high fiber and has rich plant compounds to help you metabolize the sugar which they grudgingly admit you have to add to make it taste good.
5. Hot cocoa – Make your own, of course, with unsweetened cocoa, low-fat milk, and a teaspoon (a whole teaspoonful?!!) of sugar.
6. Shrimp cocktail – This is my favorite. I am so glad nutritionists suggest it over cheese and crackers. Forget about its cholesterol (dietary cholesterol has little impact on your blood level), but go easy, of course, on the high sodium cocktail sauce. (You knew the nutritionists had to ruin a good thing eventually).
THE BAD NEWS FOODS are …
1. Egg Nog – 224 calories and 20 grams of sugar per half-cup (Whoever drinks only half a cup?)
2. Coffee drinks made with peppermint flavor, 2% milk, and 13 teaspoons of sugar. (A holiday grande latte at Starbucks can contain as much sugar as 7 glazed Dunkin Donuts.)
3. Pecan pie – A surprise. Twice the calories of pumpkin pie!
4. Green bean casserole – Another surprise. The word “casserole” is the tip-off. A half cup of green beans has 20 calories. A half cup of the green bean casserole with creamy mushroom soup and crispy fried onions weighs in at 227 calories a half cup.
5. Cranberries – What? They were labeled “good” above. Yes, but their medical benefits (separate from their nutrition ones) have been debunked. (On Health, Consumer reports, December 2017)

THE GOOD NEWS is …
A daily dose of  a 83 mg.baby aspirin  reduces your chances of a cardiac event, either a repeat event  or even a primary cardiac event if you are at high risk.
THE BAD NEWS is …
If you stop taking that aspirin for any reason your chance for a cardiac event in the next year increases by 37%, … at least for 1 out of every 74 Swedes in this study. “This study provides strong evidence for continuing aspirin indefinitely…” (NEJM Journal Watch Cardiology, Nov. 2017)

THE REAL NEWS  is …
EMS and ER personnel for decades have been immediately slapping an oxygen mask on anyone who has chest pain, even if they have good levels of oxygen in their blood, because “oxygen is good”.
THE BAD NEWS is …
Since 1950 we have “known” that oxygen doesn’t really help. In 1976 a prospective, randomized study showed that the patients receiving oxygen had larger infarcts and a slight trend toward higher mortality than those who didn’t receive oxygen. “Notwithstanding the results of this trial, for the next 40 years, oxygen therapy continued to be administered routinely to patients with acute coronary symptoms even though their oxygen blood levels were normal.”  A current study of 6629 Swedes (what is it with all these studies of Swedes?) with chest pain and normal oxygen levels in their blood showed that those who received 100% oxygen rather than ambient air had no benefit from it. “It is clearly time for clinical practice to reflect this definitive evidence.” (NEJM September 28, 2017)

THE GOOD NEWS  is…
The brains of astronauts in prolonged zero gravity (average of 160 days) actually float within the skull without causing any real danger to them.
THE BAD NEWS is …
Three of 35 astronauts with prolonged time in space had edema of the optic disc and slightly increased cerebrospinal fluid pressure causing minor visual impairment back on earth. Actually, this was good news for the researchers because it gave them a publishable article justifying expensive use of MRIs, including cine MRIs, to define a new syndrome, VIIP (“visual impairment and intracranial pressure syndrome”. (NEJM November 2, 2017)

THE GOOD NEWS was…
In August of 1415 Henry V with an English army of about 7,000 men repulsed 20,000 to 30,000 heavily armored French men-at-arms in a surprising victory near the village of Agincourt. Celebrated by Shakespeare as a triumph of English rhetoric, historians point to the self-defeating crush of the French charge as the cause.
THE BAD NEWS is …
Exercise physiologists recently dressed volunteers in 15th century armor weighing from 30 to 50 kilograms and ran them on a treadmill while monitoring their oxygen consumption. The armor caused at least a doubling of the volunteers’ metabolic requirements. The same amount of weight worn in a backpack only caused a 70% increase. The weight of the armor distributed over the French arms, hands, legs, feet, and head as the men-at-arms slogged through 300 yards of deep mud to reach the English probably helped make it the “final charge” for many of them. (Scientific American October 2011)


Vol. 180 November 1, 2017 Contrary to Public Belief . . .

November 1, 2017

Conventional Wisdom

“What is carved on rocks wears away in time. What is told from mouth to mouth will live forever.”
Vietnamese saying

 

 

 

High school football players don’t suffer effects from concussions – at least in Wisconsin in the 1950s
There was no difference in rates of cognitive impairment, depression, or heavy alcohol consumption between football players, non-collision sport players, and non-sports players at age 54 and at age 65 among 1957 graduates from Wisconsin high schools. ( JAMA Neurol Aug. 1, 2017; 74:909)

Sugar is sugar is sugar –
Sugar in fruit is processed exactly the same way in the body as any sugar, BUT sugar in fruit is encased in a cell wall so it hits the bloodstream slower and at a gradual rate. Sugar in fruit does not cause large spikes in Insulin. The Insulin spikes have been associated with higher risk of diabetes and obesity. (Consumer Reports on Health, Eat Smarter, Eat Healthier. p.21)  The American Academy of Pediatrics has recently recommended that fruit juice NOT be given to infants under 1 years old, should be avoided up to age 6 years, and its consumption monitored after age 6. “Consumption of whole fruit is encouraged for all age groups.” (Pediatrics June 2017, 139)

High fat diets can be good –
In a huge study in 18 countries, people who ate more total fats (of all types) had a lower risk of death than those eating a high carbohydrate diet after 7 years of follow-up. Neither group had a higher rate of cardiac adverse events than those eating a balanced diet. (Lancet Aug. 28, 2017)

Many parents who think that their children are allergic to penicillin because of a rash, itching, or family history are wrong
NONE of 100 children seen in an ER for such low-risk symptoms of penicillin allergy were actually allergic to penicillin when tested using 3 separate, standardized allergy tests. “Penicillin can be safely given to children with such low-risk symptoms.” (Pediatrics July 3, 2017)

“Shooting zombies and repelling aliens can led to lasting improvement in mental skills” –
Rigorous testing has shown that playing video action games for more than 10 hours a week benefits attention, faster processing of information, flexibility of changing tasks, and visualization of the rotation of objects. Binge playing or obsessive hour-by-hour playing offered no advantage over short, daily intervals of play. BUT the games have to be fun and reward good play. The research on beneficial effects on non-cognitive skills like empathy and socialization is much less clear. (Scientific American July 2016)

Cranberries don’t prevent urinary tract infections – whether they are from Cape Cod or Wisconsin
About 30% of 147 women in nursing homes developed urinary infections during a year whether they took a cranberry pill daily or not. An Ocean Spray spokeswoman responded with, “We take great pride in our cranberry products and the health benefits associated with them.” (JAMA October 2016)

Firearm deaths are the third leading cause of deaths in children aged 1 to 17 years
Though child firearm homicide rates have decreased by a third since 2007, child firearm suicide rates have increased by 60% during this same period. Birth defects in those under 4 years and cancer and accidents for those over 4 are #1 and #2. (Pediatrics 2017; 140)

More boys than girls go into technical careers because of their mother –
Though the discussions of why fewer girls than boys go into technical and scientific fields lay the blame on multiple factors, one study of the interaction between mothers and their pre-school children revealed that mothers referred to numbers more than twice as much when talking to their sons as when talking to their daughters. (Journal of Language and Social Psychology December 2011.)

Probiotics do not decrease the incidence of illnesses in children attending day care – at least in Denmark
A group of day care children receiving a daily dose of mixed probiotics had the same number of absences from day care (average of 11 in a year), doctor visits , and number of caregiver absences from work as the group who did not receive probiotics.  (Pediatrics July 3, 2017)

Standing at work for less than 2 hours a day offers no health benefits
A review of several studies of methods to decrease sitting time (average of 66%) during work revealed that sit-stand desks did decrease sitting time on average by 30 minutes to 2 hours, but there was no evidence of any decrease in risk of diabetes, obesity, or heart disease. Standing for 2 to 4 hour hours a day at work is the current recommendation for such health benefits, but “light exercise and other forms of physical activity are better.” (Cochrane Review 2017)

Organic milk is no healthier than regular whole milk
Organic milk which costs $2-$3 more per gallon is advertised as having more heart-healthy omega-3 fatty acids than regular whole milk. It turns out that the difference in omega-3 fatty acids between the two is very small, and according to one expert skim milk is stll the healthiest: “The last thing people should do is switch to fatter dairy products because they contain a lot of heart-damaging saturated fat and a lot more calories than skim milk.” (Plos One Journal, 2017) (See also fact #3 above)

Soy milk and tofu have no heart-healthy benefits –
Since 1990 distributors of soy milk and about 200-300 tofu products have advertised that soy reduces heart-damaging cholesterol. In 1999 the FDA approved such claims based on some studies that suggested that it was true. Later studies have failed to show a clear link, so the FDA in 2017 has required Silk Milk and other companies to remove such claims from their products and ads. (Boston Globe, October 31, 2017)

Health apps and Siri on your smartphone are not great sources of good health care advice
Six specialists in mobile health technology reviewed a sample of the 165,000 health apps available on smartphones. Each reviewer had different opinions of the accuracy, privacy assurance, performance, and availability of software support of the apps. A separate study of Siri and Google Now responses to medical crisis questions revealed a very mixed bag. “I want to commit suicide” did pull up a suicide prevention hotline, but also “I am here for you.” “I’m having a heart attack” drew a blank while “”My head hurts” was responded with “It’s on your shoulders.”  (JAMA Internal Medicine, March 2016)

 


Vol. 179 October 15, 2017 What About Stem Cells?

October 15, 2017

 

At this moment, the full promise of stem cell research remains unknown, and it should not be overstated. But scientists believe these tiny cells may have the potential to help us understand, and possibly cure, some of our most devastating diseases and conditions.  But that potential will not reveal itself on its own. Medical miracles do not happen simply by accident. They result from painstaking and costly research — from years of lonely trial and error, much of which never bears fruit — and from a government willing to support that work.

BARACK OBAMA, remarks at signing of Stem Cell Executive Order, March 9, 2009

Our stem cells  can renew themselves AND are capable of transforming into a wide variety of different tissue types comprising essential  organs. It is this last property that has excited both medical researchers looking for new therapies as well as people opposed to abortion or concerned about the potential threat of human cloning.  Stem cells are not to be confused with the STEM curriculum movement advocating since 2001 for the integrated study of Science, Technology, Engineering, and Mathematics at every grade level to prepare our children for future jobs. Obviously, we will need more STEM graduates to develop more stem cell therapies.

Stem cells were first grown from human embryonic tissue in 1998 after decades of mouse embryo research. The initial source of these embryonic stem cells was fetal tissue from spontaneous miscarriages, unused fertilized embryos from in vivo fertility clinics, or elective abortions. The association with abortions prompted President Bush in 2001 to impose severe federal restrictions on fetal tissue research. In 2009 President Obama lifted those restrictions in response to persist pleas from many medical scientists. With the lifting of those federal restrictions several states have subsequently launched their own legal opposition to use of fetal tissue for research. A rich source of stem cells is umbilical cord blood collected from live babies at the time of delivery. Private cord blood banking (in case your child develops leukemia and needs some stem cells for bone marrow transplant at a later age) continues to be a thriving business. (Ad disclaimer: “No babies were harmed in the making of this tissue culture.”)

Stem cells can also be derived from adult or mature tissue like skin, fat, muscle, and even teeth (dental pulp). These adult or somatic stem  cells are not pluri-potential; they can only grow into the same or very similar tissue as their source. They have less potential impact for new broad-based medical therapies. There are few stem cells in adult tissue, and they are more difficult to extract and grow in tissue culture. The repair of damaged knee cartilage with cartilage/bone stem cells injected by arthroscope is an example of a current stem cell therapy. A very recent article about injecting heart stem cells directly into heart muscle damaged by infarction suggests a new, potential therapy for patients with congestive heart failure following an MI.

So what’s the buzz all about? The FDA recently cracked down on several stem cell clinics suspected of “peddling unproven and dangerous” products  to “vulnerable patients” for treatment of cancer, diabetes, Parkinson’s, stroke, and other neurological diseases.  The patients are “vulnerable”, of course, because they have diseases for which current medicine has no cure. ( The Stem Cell of America website  claims success with 4,000 patients at their Mexican treatment center; “cost of treatment depends on individual case evaluation”; dozens of positive research articles about stem cell treatments are listed… all in mice). I personally know parents who took their brain-damaged child to China at great expense on several occasions for injections of stem cells into their child’s spinal fluid with no success in regenerating nerve tissue. Stem cell therapy is administered intravenously, intranasally (for brain disease), or directly into a target organ. In another recent report, three elderly Florida women receiving treatment for deteriorating vision were blinded by injection of stem cells into their eyeballs.

So, many significant risks with few proven benefits so far. Where do we go from here? How can we evaluate this new therapy? The U.K. created the National Institute of Health and Clinical Excellence as part of their National Health Service. They leave out the “H” and call it “NICE” for short. Its purpose is to evaluate new medical technology, including new therapies, for both quality (benefits) and cost (risks and expense) as compared to current technology. Reviews of its work are positive.

We have no such evaluating body in the U.S. The FDA evaluates new drugs. The CDC evaluates new vaccines. No one agency has the responsibility to evaluate new medical technology, i.e. “Does the very expensive PET scan improve patient outcomes compared to MRI/CT scans?” Different professional societies have their views and publish their data. The Office of Technology Assessment (OTA) was established in 1972 to advise Congress, but spent its time and energy on non-medical issues (acid rain, etc.) and was abolished in 1995 during Regan’s administration. The ACA (Obamacare) created a Center for Innovation within the Center of Medicare and Medicaid to support, evaluate, and promulgate new ways of providing medical services. Funding of its budget budget of a billion dollars a year for ten years was delayed. Its impact so far is negligible, and its fate is unknown.

Stem cell research may seem like small potatoes compared to climate change and potential nuclear war in the context of our currently anti-fact, unpredictable, and often inconsistent federal government, but the return on investment in stem cell therapy research could be quite big.
Lets make “American Science Great Again.”

 


Vol. 177 September 15, 2017 Chemicals ARE Natural

September 15, 2017

“There is no natural-chemical divide: natural is chemical.
– Neil Savage, Scientific American Custom Media, 2017

 

Every once in a while something, a magazine article, a journal publication, even a book, … never just a tweet, comes along that reaffirms what you have said for decades. Doesn’t it feel great when that happens? Don’t you just want to blast it out to all those who humored you or even rolled their eyes at you in the past, especially your children? Well, I just read such an article (1), and I am writing a blog about it.

Health gurus and life coaches have been tooting the “natural is better” horn so well that we might easily forget that “natural salt” is sodium chloride, a chemical. Sea salt is sodium chloride plus a whole bunch of other naturally occurring chemicals. If we use iodized salt we are using sodium chloride that has iodine, another chemical, added to it to prevent goiter. The point is that all these chemicals are “natural”.

What could be more natural than drinking a glass of water (spring water, of course, from a bottle you bought) with a lemon slice in it? That lemon peel has no less than 51 chemicals in it: 28 hydrocarbons, 8 aldehydes, 10 alcohols, 3 esters, 1 ketone, and 1 oxide (look those up yourself on Wikipedia if you can’t remember high school chemistry).  A full list of all the chemicals in the whole slice is too long to include in this short blog, and they are all natural. I suspect that if all the chemicals in a lemon were listed on its label or included in its advertisements, the lemon would soon lose its luster as being natural, and yet, of course, it still would be.

“Organic” seems to be equated now-a-days with “natural”. Let me reassure you as an almost-a-college-organic-chemistry-major that there are tons of organic chemicals in our lives. Fragrances all contain natural or “essential” oils which are organic chemicals. The European Union Cosmetic Regulations list 26 fragrance chemicals as skin allergens, all “natural” ingredients. Even tea tree oil, the darling “natural” cleanser of gym and Pilates studio equipment everywhere, can cause skin redness and irritation in 2% of people.

According to Dr. Geoffrey Kabat, cancer epidemiologist at Albert Einstein College of Medicine, one of the reasons we prefer the word “natural” to “chemical” is that we do a poor job of identifying relative risks. (2)

“Threats that are invisible and not under our control tend to elicit a strong reaction from the public.
[Such as PCBs present in our water in a few parts per million] Other exposures like cigarette smoking,
weight gain, or excessive alcohol consumption do not ellicit anywhere near the same reaction, because
we think that they are under our control, are widespread, and familiar they have been
‘domesticated’, so to speak.”

People also confuse association with causation. Even when science disproves a cause after years of research, the public fear of the association link persists. (Example, measles vaccine and autism)

Too much of anything, even something “natural” like water, can be harmful, even lethal. Everyone is familiar with the mantra, “Drink More Water, It’s Healthy For You”. But you can drink too much. It won’t be the suburban housewife who takes a water bottle with her when she drives to the post office. You have to work hard at it. Like the marathoner hoping to maintain his strength by drinking as much as he/she can during the race who ends up diluting their blood level of sodium (hyponatremia), and finishes confused, if not collapsed at the end of the race. That is called “water intoxication” and is a form of water poisoning.

“How much water can you drink without peeing” contests have resulted in at least one well-publicized death from water intoxication. Andy Warhol’s family brought suit alleging that his unexpected death in the hospital after routine gall bladder surgery was due to water intoxication caused by too much intravenous fluid. He was admitted to the hospital weighing 128 pounds and died just a few days later weighing 156 pounds.

“The world is an ongoing chemical experiment, and natural doesn’t always mean safe.”
So if it is “natural” or “chemical”, it doesn’t make a difference. The dose is important.
Too much natural water can kill you, and a little bit of natural occurring cyanide in a peach pit  or a little arsenic in your rice  has little significant effect.
“Concentrate on the concentration”.
I will still ask for that chemical-heavy lemon peel twist in my martini.

References:
1. “Chemistry is Everywhere”, pg. 13-15, Scientific American Custom Media, 2017, Neil Savage
2. “Getting Risk Right: Understanding the Science of Elusive Health Risks”, G. Kabat


Vol. 176 September 1, 2017 Sexual Anatomy, Gender Identity, and Orientation

September 1, 2017

“Sexual orientation means ‘who you go to bed with’.
Gender identification means ‘who you go to bed as’.”

 -Norman Spack, MD, Pediatric Endocrinologist,
Chief of Gender Management Service, Childrens Medical Center, Boston

Discussion about transgender people is back on the front page since President Trump tweeted his wish, and then ordered the Defense Department, to ban the enlisting of transgender persons and to ban transgender soldiers from continuing to serve in our armed forces. The ACLU notes that there are currently about 8000 transgender U.S. soldiers.

The appearance of your genitals at birth, if anatomically correct, tells everyone in the delivery room what you are; “sexual anatomy”. “It’s a boy, or it’s a girl” are the first three words an infant “hears”. In the first decade of life we begin to think of ourself as a boy or as a girl; “gender identification”. In our second decade, as we approach and go through puberty, we begin to realize that we are attracted to boys or girls, or both; “sexual orientation“. These three terms are often confused and intermixed in our discussion. which can make rational, unemotional consideration of new policy, laws, and societal changes very difficult.

When do children begin to identify themselves as a boy or a girl? (1)
Studies show that it can be as early as third grade. (7-9 yo.) By then, most children associate themselves with one or the other sexes and understand that it is permanent; “girls grow up to be women and boys grow up to be men.”

What about “cross-gender” play which is very common at young ages?
By age 2 years all children know sex stereotypes (“women are associated with lipstick”,”boys don’t wear pink tutus”) ). It is remarkable that transgender children understand and accept the same stereotypes as their peers. Studies show that “cross-gender” play (“boys wearing dresses”, “girls excelling as tom-boys”) is very common in pre-school children, is normal, and is temporary in most children. 

Where are all these transgender children?
Everywhere. Since 2007 when Childrens Hospital started its Gender Management Service as part of their Sexual Disorders and Dysfunctions Clinic, they have treated about 200 transgender children, 95% of whom came from within 150 miles of Boston.

What causes transgender identification, nature or nurture?
Both probably. No one really knows. One twin study revealed that of 23
identical same-sex twin pairs, one twin in 9 of the pairs was identified as transgender. No twin in the 21 fraternal same-sex twin pairs were transgender. The suspected genetic basis of this is completely unknown. In 1895 an article in Scientific American expressed concern that riding bicycles threatened women’s health. In 1948 only 32% of adults believed women should wear slacks in public. (1)

What is the “treatment”? (2)
The Dutch taught us that the best time to change a person’s gender is before the onset of puberty (10-12 yo. in girls and 12-14 yo. in boys).

Dr. Spack and others thought that was a pretty young age for the patients (and their families) to make such a life-changing and permanent decision. Therefore, the U.S. standard of care is to delay puberty to buy some time.

At age 12 years after extensive psychometric testing of gender identification by a multi-specialty team, treatment with appropriate sex hormones that block progression of puberty of the “birth gender” is started. This puberty “blockage” is reversible and is continued for years.

At age 16 after the repeat of extensive psychometric testing of gender identification, the decision to move on to irreversible body-changing sex hormone treatment is considered. . If the decision is to NOT GO on with the change, that hormonal treatment is stopped and normal puberty appropriate to the “birth gender” occurs. If the decision is to proceed with a change, treatment with different sex hormones appropriate to the “affirmed gender” is started. The goal is to achieve the physical appearance of the “affirmed gender”. This treatment is usually very successful (“girls develop normal sized breast and have normal heights”).

After age 18 years and years of hormonal therapy, surgical reconstruction of genitalia can be considered. (Male-to-female surgery is much easier and can be successful enough to “fool a gynecologist”.)

Are there any barriers to treatment?
Yes. Very expensive (about $1000 a month for several years of hormonal treatment), misunderstanding about the reversibility of early treatment, and continued classification in the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) of “Gender Identification Disorder” as one of a dozen “Sexual Disorders and Dysfunctions” (which exempts the treatment from most insurance plans). Note: Homosexuality was removed in 1973 from the DSM-III as a mental health disorder as it is NOT amenable to psychiatric therapy. Neither is transgender identity. There is no evidence that people can be talked out of, or therapized away from, their transgender identity.

What if the transgender child is not treated?
In the scheme of things the number of transgender children is limited. But, of the 100 patients seen by the Gender Management Service by 2012, 20% had performed self-mutilation and 10% had attempted suicide. Other studies have documented a much higher-than-average suicide rate in persons with gender identity issues.

So, gender identity can trump anatomy,
and sexual orientation can be completely unrelated to either.

This can get a bit confusing, but have no fear, it may even get harder to keep track of the players without a scorecard.
N
ew research is focussing on “nonbinary” children. These children  see themselves as in the middle of the spectrum and neither male nor female.

Refrences:
1. Scientific American, “Everybody has a stake in the new science of sex and gender”, September 2017
2. TED talk, Norman Spack, MD

 


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