Vol. 71 July 15, 2012 When “Yes” Becomes “No” in Medicine

July 18, 2012

 

“PRIMUM NON NOCERE” – First, do no harm.

This quotation is considered to be the first rule for physicians, but it has a somewhat uncertain origin and a changing definition. The original definition of “harm” became more complicated and variable as medicine accepted the concepts of “risk vs. benefit” and “cost benefit analysis”. Since the values in these concepts are variable, the definition of “harm” has become more variable, more complex, and sometimes more relective of the bias of the definer.

Medicine is both an art and a science, and science, as we know, considers all of its “truths” as tentative. As new data is obtained these truths can change. Here are some recent examples of changes in medical recommendations based on new data AND new elements in“”cost benefit analysis” AND possible bias of the maker of the recommendation.

Men should not be screened for elevated PSA (Prostate Specific Antigen)
The initial excitement about this test for the early (“before symptoms appeared”) diagnosis of prostate cancer has been dissipated by data showing that positive tests (elevated levels of PSA) led to lots of referrals to urologist specialists, lots of biopsies, and lots of invasive surgical and radiation treatment which did NOT result in a reduced death rate or lessened disease burden from prostate cancer. Also, the interventions were associated with a bunch of serious complications.

Prostate cancer is usually an indolent disease. If a man lives long enough it will eventually appear in his body, but will rarely cause death or a heavy disease burden. PSA screening of asymptomatic men who have a normal digital (digital, as in finger) rectal exam and a negative test for occult fecal blood is now considered to cost more (in money, patient inconvenience, and medical complications) than its benefits. The PSA does not identify the less common case of aggressive prostatic cancer at a time that makes earlier treatment more effective.

Women under 50 don’t have to get an annual mammogram.
This 2009 recommendation caused a great deal of controversy because of the long term investments of several “stakeholders” in the mantra “get an annual mammogram to save your life.” But, by 2009, data conclusively showed that in order to save the life of one woman in her 40s from breast cancer, 1,904 women would have to be screened every year for up to 20 years. Because the U.S. Preventive Services Task Force judged that the risks of harm from false positives mammograms, subsequent biopsies, and overly aggressive treatment of indolent lesions that resulted from annual screening outweighed its benefits. Hence, the USPSTF panel’s recommendation that most women ages 40 to 49 need NOT get a routine annual mammogram.

Statins do not prevent fatal heart attacks in healthy people.
Studies in 1999 indicated that lowering cholesterol by taking statins (Lipitor, Zocor, etc.) in people who had had a heart attack reduced subsequent cardiac deaths in those people by 30% and reduced subsequent symptomatic coronary artery disease by 25-60%. This dramatic protective effect of statins in these high-risk patients was extrapolated to people without heart disease or risk factors and by 2008 half of U.S. men between the ages of 65-74 were taking statins. Last year a meta-analysis (a research analysis of a large number of studies) failed to show a reduction of death rates in healthy people taking statins.  “Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life.” (1)  More recent studies documenting the complications and side effects of statin use have also contributed to the change in this recommendation.

Colonoscopy for the prevention of death from colon cancer is no better than, and may be inferior to, flexible sigmoidoscopy.
Not so many years ago your primary physician would perform a screening examination of your lower colon with a flexible sigmoidoscope in his/her office, with just light sedation, no biopsy, and no annoying, rigorous bowel preparation. The reimbursement was modest. Since then, the norm for screening for colon cancer has become a colonoscopy, performed by a gastroenterologist or general surgeon in a hospital or an ambulatory surgical center with sedation heavy enough to warrant the presence of an anthesiologist and associated with an interpretation of the inevitable biopsy by a pathologist. The reimbursement all around is much more substantial.

Both procedures reduce the incidence and mortality of colon cancer, but “as reimbursement moves from fee-for-service to bundled payments for episodes of care, there will be a renewed focus on delivering evidence-based interventions in a manner that optimizes resource use.” (2)

Daily low-dose aspirin does not reduce cardiovascular deaths in healthy people.
Use of aspirin to prevent a subsequent heart attack in people who have already had one DOES reduce their death rate from another heart attack. Extrapolation of this widely accepted fact has prompted many  healthy people with no history of heart disease to take low dose aspirin daily. In yet another meta-analysis of over 100,000 people “at risk for” but not having coronary artery disease, daily aspirin did NOT lower the rate of fatal heart attacks. The rate of non-fatal heart attacks was reduced by 20%, but more importantly the use of aspirin INCREASED the rate of non-trivial bleeding (GI bleeding, stroke, hematuria, and nose bleeding) by 31%, ie. the risks of daily aspirin use outweighed its benefits.
SPOILER ALERT: The study recommends that physicians and patients should decide on a case-by-case basis about whether to continue daily aspirin if you are already taking it. My own physician noted that in several of the international studies in this meta-analysis the dose of aspirin was up to 300 mg a day (one adult aspirin) but that in the U.S. the usual recommended aspirin “low” dose is 81 mg. ( a baby aspirin) daily The higher the dose of aspirin the more likely it is to cause bleeding.

DEET insect repellent is safe to use on anyone over the age of two months.
“The American Academy of Pediatrics states that insect repellents with DEET are safe to use on children as young as two months old.” Apply only once a day, but you can use any concentration from 7% to 25%. The higher concentration isn’t any more effective, but its protection lasts longer. DEET protects against tick bites too.

Statistics NEVER lie, … or can they?
Published medical research produces data that meets statistical standards of “significance” which reassures the reader that the findings are “true”. Meta-analysis studies ( a technique of comparing data results from different studies and treating them as if they are all from the same study) are the current epitome of statistical correlations. The interpretation of statistics, however, is not standardized, and epidemiology (the science of statistics applied to large populations) has been called by some cynics as “the art of lying on a grand scale.”  Here’s an example of the potential pitfalls in interpreting statistics:

700,000 physicians “cause” 120,000 accidental deaths per year for a rate of
.171% accidental deaths per physician per year

There are 1,500 accidental gun deaths per year and 80 million (yes, million) U.S. gun owners for a rate of .0000188% accidental gun deaths per gun owner per year.

THEREFORE, statistically, doctors are approximately
9,000 times more dangerous than gun owners.

We withheld the statistics on ….Lawyers !
for fear the shock would cause people to panic and seek medical attention! (3)

References:
1. Arch Int Med June 2010:170:1024
2. NEJM 366;25 June 21, 2012, pg. 2421
3.  thanks to Bob Harrington for picking this pearl off the web
4. Overdiagnosed: Making People Sick in the Pursuit of Health
H. Gilbert Welch, MD, Lisa M. Schwartz, MD, Steven Woloshin, MD
http://www.beacon.org/


Vol. 67 May 15, 2012 Our Health Care System: A Symphony Orchestra or A Herd of Cats?

May 15, 2012

 AMA chief executive James Todd, MD, jokes that leading physicians is like herding cats. Princeton health economist Uwe Reinhardt, PhD, compares it to making eagles fly in formation.  – AMA News, 1993


Two well-known analogies of our health care system came to mind the other night while I attended a concert of our local symphony orchestra.

The “symphony orchestra analogy” originated, or so the story goes, from the tension between a hospital administrator struggling with rising costs and decreasing reimbursement and the hospital’s Board. The Board Chair continually challenged the administrator to increase efficiency and reduce costs. The Board Chair also happened to be on the Board of the local symphony orchestra. One night the hospital administrator attended a concert, and wrote this letter to his Board Chair the next day:

“I enjoyed the concert last night very much, and you are to be congratulated on your effective stewardship of this important asset to our community. However, I couldn’t help but notice that the French horn players only played about 17% of the time. Surely they could be playing other instruments at other times with a little cross training. The two soloists, one alto and one soprano, seemed very underutilized. They only sang during the third movement. It seemed a wasteful use of your most expensive professionals by having them just sitting there gazing at the audience for most of the time. The forty violinists were impressive, but surely you could have gotten along with 35 or even 30. The drummer seemed to be the most efficient and was obviously cross-trained. He played almost all of the time by having a triangle, castanets, and car horn to fall back on when not beating a drum. Finally, couldn’t a less expensive automated device replace the pianist’s page-turner?

I am sure that you could probably cut 10-15% of the orchestra’s budget if you just implemented these logical changes.”

Just re-reading this and substituting “gastroenterologists” for “French horn players”, “cardiac surgeons” for “soloists”, and “primary care physicians” for “violinists” belabors the point.

The parallels between the musicians in the orchestra and physicians are more numerous than you might think.

Both are highly trained over many years. Both are said to practice.
Both are highly specialized. (one instrument or one organ system)
Both have to prove their competence. (auditions or licensing and credentialing)
Both are independent professionals that may periodically play together. (a concert or cardiac surgery)
Both get specific instructions for performance ( a musical score or practice guidelines)

What then is the big difference between musicians and physicians? Besides their pay scale (thay difference may be smaller now for primary care physicians), the big one, right off the bat, is that the musicians in an orchestra have a CONDUCTOR to help them play together.

Who can help the health care professionals to play well together? The Federal government? Clearly Congress has said “No”, even to a highly qualified physician “conductor” like Donald Berwick, MD. And, of course, the orchestra conductor is leading music that was written by someone else. (Congress?)

Are we left with just “herding cats?”  The Affordable Care Act calls for the creation of Accountable Care Organizations (ACOs) to improve quality and reduce costs. An ACO may include physicians (cats), hospitals (dogs) and patients (rabbits). Can they work together to work with, and even protect themselves from, the wolves (health insurance companies)? The first 27 ACOs designated by the federal government have been mostly physician-run, only a third of them even involve hospitals, and they cover a very small number of patients. The next round of 90 ACOs to be designated on July 1 will give us a better idea about this attempt to “herd cats” regionally and a better view of any potential impact on our health care system.

In the meantime, the music plays on.

Oops, there I go mixing metaphors.

But that may be “the answer”. Our health care system is just that, a really mixed up metaphor.


Vol. 64 April 1, 2012 Breaking Medical News

April 1, 2012

FDA APPROVES VIAGRATOR

The Food and Drug Administration announced yesterday approval of the new drug, Viagrator, a combination of Viagra and Lipitor. Pfizer has been seeking lost revenues since Lipitor’s patent expired,and the demographics of the users of Viagra and Lipitor are almost identical. Combining the two into one capsule is a slam dunk. Viagrator will still carry a warning about the need to call a doctor if effects last for more than 4 hours, but new information that a double-cheese omelet can reverse it will be added.

Pfizer is searching for an appropriate celebrity to serve as a symbol of both sexual prowess and high cholesterol to promote its new product. Industry sources report that Newt Gingrich is the leading candidate, but doubt that a contract can be signed before November.

MEDICARE TO AWARD “FREQUENT FLYER POINTS”

In Medicare’s quest to become more like Visa with single swipe payments, timely and understandable statements, and better fraud protection Medicare has announced its own frequent flyer reward points program. Each Medicare dollar spent on medical care will earn points for the patient that can be redeemed for other medical services. The rewards menu is quite complicated. For example, 4 MRI’s earn you enough points for a colonoscopy. Points from 6 EKGs can be redeemed for a week’s supply of Inderal or nitroglycerine. The medical device rewards catalog includes a CPAP machine after 8 visits to a pulmonologist. a walker after 2 visits to an orthopedist or 4 visits to a neurologist, and a high-seat toilet after the second hip or knee replacement.

The AMA has come out strongly against the use of Medicare reward points for travel to other countries for surgery, and the American Society of Plastic Surgeons has refused to participate in the rewards program at all. They are still mostly “cash up-front”. Efforts by the Obama administration to use the program as a Medicare cost-cutter by deducting points for inappropriate care (for example, after 4 visits to an ER in 6 months you would LOSE 200 points) have been rejected by Congress so far.

FREE PIZZA FOR BIRTH CONTROL

A new twist to the current controversy about paying for abortion and birth control pills was recently put into the other side of the intercourse equation. An enterprising group of urologists is offering a free pizza if you get a vasectomy in March. The free pizza is touted to help you recover post-operatively as you watch March Madness on the tube. I wonder what you could get for a tubal ligation? … an Easter dinner for 6?

BLUE CROSS TO MANDATE FITNESS CLUB MEMBERSHIP

Some Blue Cross/Blue Shield policyholders recently received a notice that in 2012 the healthcare insurer will reimburse up to $150 for fees in health fitness clubs or structured weight loss programs for its subscribers. The response was so positive that BC/BS’s initial caution quickly turned to such enthusiasm that BC/BS plans to make fitness club membership MANDATORY for its subscribers on July 1,2012.

Acturarial analysis suggested that members needing walking assistance devices, specially modified automobiles, or wheelchairs be excluded from this requirement. This suggestion was ignored when AARP pointed out that many “thousands and thousands of AARP members” used canes. Legal counsel expressed concern in today’s environment about potential law suits against this “individual mandate”. BC/BS officials dismissed the concern with “Hey, it’s not like we’re mandating that everyone eat broccoli!

NEW APPS TO BE UNVEILED AT SEXTECH-HACKATHON

Now that sexting has become prevalent, what’s next? Well, we are in a capitalistic society that rewards entrepreneurs, so you guessed it, a one-day California conference to develop apps for it. Why not unleash, and even incentivize, the most creative, innovative minds of our society to help us deal with “unmentionables”?

The call is out to….“design an app to solve the challenge of providing honest, real-time, private data from youth and young adults about “unmentionable” activities, like sexual behavior, substance use, sadness, and relationship drama to researchers and program experts who work with youth.”

The reason to do this is that…“the health field has been trying to prevent the most common adolescent and young adult health problems since time began: sexually transmitted diseases, depression, substance abuse and dating violence. By the age of 25, more than 90% of young adults will have experienced more than one of these problems, and for some youth, the consequences will be lifelong (infertility, homelessness, brain injuries, etc.).”

“It’s almost impossible to know what works in terms of prevention efforts, as health researchers rely on survey answers given by youth after the fact with questions such as: How many times did you use a condom for sex in the last six months? Now, really, who remembers?”

“We want to put the best and brightest minds in tech behind the solution. We want an app where young people are enticed and excited to share their Unmentionable data – data about the whos, whats, wheres and whens of their risk behaviors – in the moment or soon after.”

Interested? Too bad, it’s already over. March 31 in San Francisco.

HAPPY APRIL FOOLS DAY…or NOT!


Vol. 56 December 1, 2011 Two Holiday Myths: 1 True, 1 False

December 1, 2011

“IT IS BETTER TO GIVE THAN TO RECEIVE”
-Acts 20:35

“THANKSGIVING TURKEY MAKES ME  SO SLEEPY”
-Everyone in my family

Is it better to give than receive?   Yes, according to moral teaching.

Does it make us FEEL better? Yes, according to the fMRI and biochemical laboratory.

A study of 19 subjects playing a computer game for money while being monitored by a functional MRI device (fMRI) that detects which parts of the brain are activated by specific situations had certain brain areas “light up” with activity when they won money. Those same areas of the brain lit up when they donated part of that game money to charity. Those brain areas are associated with good feelings like love, sex, and accomplishment, and  causes release of the chemical Dopamine, the “messenger of happiness and reward”. A particularly  large donation during this fMRI monitored game activated the area of the brain that releases Oxytocin, an essential chemical of male-female attraction, also called the “the cuddle or love hormone”. (1,2)

” …the mesolimbic reward system is engaged by donations in the same way as when monetary rewards are obtained. Furthermore, medial orbitofrontal–subgenual and lateral orbitofrontal areas, which also play key roles in more primitive mechanisms of social attachment and aversion, specifically mediate decisions to donate or to oppose societal causes. Remarkably, more anterior sectors of the prefrontal cortex are distinctively recruited when altruistic choices prevail over selfish material interests.” (3)
(This will NOT be on your final exam.)

In an even more shocking fMRI study, 20 healthy heterosexual couples showed that women had their reward areas of the brain light up when they were able to hold the hand of their boy friends while he was receiving painful electric shocks.  Presumably the woman was not happy to have her boy friend shocked, but she felt better when she could give him support by holding his hand. If they weren’t holding hands these reward-related brain areas did not light up. (4)

So giving is better than receiving, and can make you FEEL better .

Does eating turkey make you sleepy? No more than eating chicken, pork chops, lamb chops, or salmon.

This myth has developed around Thanksgiving dinner because most of us nap after dinner, and there is tryptophan in turkey. But many other foods have more tryptophan per portion than turkey, and they are not accused of making us drowsy. If we say the amount of tryptophan in 1 gram of turkey meat is a value of 24, egg white is a 100 and soybeans and pumpkins seeds are a 59.  I searched in vain to find out if the white meat and the dark meat differed in tryptophan levels. We, of course, don’t eat as much of those other things as we do of turkey on Thanksgiving day. We also eat lots of carbohydrates, and that is the real enabler of our drowsiness.

Tryptophan is metabolized by us into serotonin which is a building block of melatonin, the “sleep promoter”. The “sleep promoter” effect is, of course, on the brain, and tryptophan has a harder time than other amino acids in getting from the blood into the brain. Think of it as a bunch of shoppers on Black Friday trying to get through a store’s front door all at the same time. Tryptophan loses that competition with the amino acid crowd. Carbohydrates enhance insulin production and insulin causes amino acids other than tryptophan to leave the blood and go quickly into muscles. This makes the amino acid crowd at the blood/brain barrier door much smaller and more of the tryptophan successfully gets through. So, turkey meat has some tryptophan, but it is the wine, mashed potatoes, rolls, and that piece of pie at the end that lets it do its work in the brain.

If you doubt this, go ahead and have salmon at your next Thanksgiving dinner and see what happens.

References:
1. Gramza, Joyce. “Tis Bet­ter to Give than Receive.” Sci­en­Cen­tral Video. 10/17/2006 NINDS and NIH. 2/20/2007
2. Ratey, John J. A User’s Guide to the Brain. New York: Vin­tage Books, Copy­right 1994
3. Proceedings of the National Academy of Sciences October 17, 2006 , Jorge Moll et al.
4. Tristen K. Inagaki, Naomi I. Eisenberger. Neural Correlates of Giving Support to a Loved One. Psychosomatic Medicine, 2011


Vol. 48 July 15, 2011 Worry Globally, Act Locally.

July 15, 2011

“What, me worry? ”          –  Alfred E. Neuman 1959

Yesterday I did something about all the worries I have.

What worries?

1.Debt to China – Our stock market had an up-tick today because the China economy improved more than expected this past quarter.
2.Debt ceiling – My children and grandchildren are already in hock up to their eyeballs, and their grandfather doesn’t want his Medicare benefits cut.
3.Medicare fraud – CMS has hired only 41 of 649 needed analysts needed to implement their new anti-fraud computer programs that cost $130 million plus. Why can’t Medicare be like Visa or Capital One. Capital One just announced a 50% increase in their profit this quarter, so I don’t worry about them.
4.Netflix just raised their prices by 60%!
5.My next colonoscopy?  When? Two years, five years, when the gastroenterologist sends me a reminder letter, or never? At least I don’t have to worry about when to get a mammogram!
6.I am over one PSA screening age threshold according to some studies, so I don’t worry about that anymore, … though my internist thinks differently. Maybe I should worry about which study of PSA screening is right for my prostate.
7.Bears! No, no that is Steven Colbert’s worry, not mine.
8.Why does autism seem to be increasing despite our country’s declining immunization rate? They must NOT be related.
9.How come I can’t find the time to do all the things I want to now that I am retired? How did I miss writing my blog for July 1? Did anybody notice? I worry that it may be related to the decreasing energy of increasing age.
10.Global “weirding”, previously known as global warming, now includes droughts, floods, unexpected tornadoes, and severe winters or melting ice depending on your geography and it all makes me worry about my environment.

 This is the worry I did something about.

Yesterday I collected five water samples from Buzzards Bay. I keep my boat on Buzzards Bay.

Samples from the bay have been collected for the past twenty years by over 700 volunteers from the Buzzards Bay Coalition. The samples reveal increasing amounts of nitrogen and phosphorous and other compounds that are earmarks of “pollution”. I felt that volunteering would be a concrete way to contribute to pollution solutions, other than “dilution”.

The sampling was more complex than I thought,and it took the better part of a day. It was 90 degrees with a honking wind out on the bay. There are other steps I take to combat the deterioration of our environmental, but I felt particularly good about this concrete contribution to a local effort. Attending a public hearing about the pros and cons of wind turbines would not have been nearly as satisfying.


Vol. 46 May 30, 2011 For Kids (and their parents) Only

May 27, 2011

“Apparently you can leave your heart in San Francisco, but your foreskin is going home with you.”

-Lewis Black on The Daily Show Nov.16, 2010

Age-old Circumcision Debate Heats Up in San Francisco
The 7,000 signatures required to put a question on the ballot in San Francisco have been obtained for a proposal to outlaw male circumcisions. A fine of $1000 or a year in jail would be levied against anyone circumcising a male under 18 years of age. A group called Bay Area Intactivists (check out their website at www.sfmgmbill.org -“mgm” stands for “male genital mutilation”) has been campaigning for the bill for years.

The debate, of course, has been going on for decades (see “The Rape of the Phallus” published in 1965). (1) The Cons have called it “unnecessary surgery”, “a needless expense”, a waste of excellent tissue for grafting if the person gets a serious burn in the future, and “something that diminishes sexual sensitivity for the male”. That last one is a particularly hard one to prove or disprove, or even get public testimony on. The Pros say it reduces the occurrence of penile cancer (a study done in Bowery bums), reduces risk of urinary tract infection in males in the first year of life, reduces HIV infection in African males, and may reduce the spread of HPV (a cause of venereal warts and cervical cancer) to females. Up until this point no one has opposed it as a form of genital mutilation.

Given the religious and cultural traditions of male circumcision (Jews and Muslims consider it a religious event, not a medical one. Australian Aborigines have practiced it probably the longest) and the non-compelling medical evidence of its benefits despite low risks, the American Academy of Pediatrics and the American Medical Association neither recommend nor advise against male circumcision. A reflection of this lack of compelling medical evidence either way is the family of one of my pediatric colleagues. Half of his sons are circumcised, and half are not. None of them are Jewish or Muslim, and they all seem to be doing very well in life, and love.

Screening for Autism in the Pediatric Office
Of 800 toddlers screened for autism in a Utah pediatric office 10 children “had significant signs of autism”. This is close to the CDC estimated occurrence rate of 1 in a 100.(2) 192 (24%) kids had “positive results for autism” on the 23 question paper checklist, MCAT (Modified Checklist for Autism in Toddlers), completed by a parent. Only 47 (25%) of these were deemed “still positive” after a 6 question, structured telephone interview, and they were asked to return for an in-person evaluation. Of the 30 who returned, 10 of them “remained positive for significant signs of autism”.   

The messages here are: 1) ask your pediatrician for the MCAT questionnaire if s/he hasn’t offered it by age 18 months, 2) obviously don’t panic if s/he asks for more information since the MCAT is designed to be very sensitive and has lots of “false positives”, and 3) remember, the sooner that educational and behavioral resources are supplied to the child who shows significant signs of autism, the better the outcome. 

Autism is the biggest unspoken fear of new parents and has replaced fear of SIDS.
At least, that is my impression in my pediatric practice. Sudden Infant Death Syndrome (SIDS) occurrence has dropped dramatically in the U.S. from a level of 1.53 deaths per 1000 live births in 1980 to the current rate of 0.51 per live births. Since the cause (or causes) of SIDS is still unclear, the reason for this great reduction in risk is also unclear. Most people credit the extensive campaign of the American Academy of Pediatrics to get parents to put their infants to sleep on their backs, “Back To Sleep”, started in 1990 on the basis of studies done in Australia. Unfortunately, SIDS remains the leading cause of death for children in the U.S. under 1 year of age, and the American SIDS Institute is striving to reduce the occurrence rate this year to 0.25 per 1000. The Institute of Medicine has found no association between SIDS and vaccinations.

Most kids who avoid certain foods because they are allergic are NOT ALLERGIC TO THAT FOOD.
The “gold standard” for diagnosing a food allergy is an “oral challenge”; you give the food to the child to eat and see if an allergic reaction occurs in a medically controlled setting. 93% of  food oral challenges were NEGATIVE in 44 children who were avoiding 111 foods because of non-threatening allergic reactions (eczema, atopic dermatitis, hivesalso) AND also had positive allergy skin tests or blood tests.  Only 23% of the children who were avoiding peanuts were truly allergic to peanuts. Milk allergy was the most common over-diagnosis with only 13% of the children who were  told that they were milk-allergic based on blood or skin tests actually were. Children who had had life-threatening allergic reactions to food previously were excluded from the study. (3)

Caffeine can reduce sleep time in children, just like in “real people”.
A study of 228 children from age 5 to 12 years showed that increased caffeine consumption during the day slightly reduced their total sleep time at night. Not surprising, but what was interesting to me was that the average cola beverage consumed per day was 12 oz. for 5-7 year olds and 24 oz. for 8-12 year olds. Reassuringly, the average sleep duration for 5-7 year olds was 9.5 hours and  8.7 hours for the 8-12 year olds. (4)

But what about getting the child to actually go to sleep?
A study of over 500 New Zealand healthy 7 year olds  showed that on average they took about 26 minutes to fall asleep. The range of this “sleep latency” was 13 to 42 minutes. The 10% of these children whose parents had identified as “having difficulty falling asleep” had a much longer average sleep latency of 41 minutes. Increased physical activity during the day and sleeping longer during the night were associated with shorter sleep latencies. Each hour of sedentary time during the day added about 3 minutes to the duration of sleep latency. There was NO association between duration of TV exposure and length of sleep latency. (5)

Are those adolescents really asleep?
An estimated 75% of teens own cellphones. Since 54% of the teens use their phones for texting and about 25% log on to social media sites more than 10 times a day, cell phone use “under the covers” at night might be contributing to teen sleep deprivation(6) . An amazing  86% of 14 year olds take their cell phones to bed (7). Reminds me of the “old days” of reading magazines under the covers at night with a flashlight (note to younger readers: a flashlight is a silent tubular device without a screen that requires batteries).

References:

1. JAMA vol.193, 1965 pg. 123
2. Pediatrics 2011 May 127:866
3. J Pediatric 2011 Apr;158:578
4. J Pediatric 2011 Mar 158:508
5. Arch Dis Child 2009 Sep: 94:686
6. Pediatrics 2011 Apr; 127:800
7. Robin D’Antona, EdD, BU School of Medicine Developmental and Behavioral Pediatrics Conference, Mar 25, 2011


Vol.45 May 15, 2011 Surprising Medical Fun Facts

May 15, 2011

“Scientists constantly change their minds.
Science is not about immutable laws but provisional
explanationsthat get revised when a better one comes along.
Scientists’ readiness to change their beliefs to align with data
is a source of great strength, not weakness.”
– Daniel Willingham, Prof. of Psychology, Univ. of Virginia
in Scientific American May 2011


Does cranberry juice prevent bladder infections?
NO,
 according to a study of 155 healthy college women in Michigan (the state that produces the most cranberries) who drank two glasses a day of cranberry juice for 6 months after having a bladder infection. The cranberry juice swillers had a recurrence rate of 19% which was lower than the expected recurrence rate of 30%, BUT the control group that drank two glasses a day of a cranberry-like placebo also had a lower than expected recurrence rate at 15%. (1) The study was done to find out if proanthocyanidin, the suspected preventative ingredient in cranberry juice, really worked. The problem is that “tiny little berry that continues to defy science” contains over 200 active substances and several organic acids.Proanthocyanide apparently is not THE one.


Walk fast and carry a big stick .
A study of 35,000 community-dwelling adults with a mean age of 74 showed that life expectancy increased about 12% for each 4 inches per second faster one could walk. A threshold for “higher risk of early mortality” is suggested as “being unable to walk 20 feet in 10 seconds”. (2) In a separate study of 2900 community-dwelling Australian men, 40% of those who were 70-74 years old  reported being sexually active.  43% of those reported having sex less than desired. (3)

The umpires refused to be tested.
Dr. Daniel Laby, a Harvard Professor of Ophthalmology and eye doctor to the Red Sox, reports that the average baseball player’s vision is 20-12. That means they can see at 20 feet what we can’t see until its 12 feet away. The normal standard is 20-20, of course, and the very best a human eye can see is 20-8. He states that seeing the seams on the moving ball is one of the key factors in successful hitting. Dr. Laby offered Major League Baseball the same service for the umpires.  MLB did not respond. (4)

Are they sleeping on the job?
31% of employed Americans take a nap every day, but 39% of UNemployed Americans do too. (5)

Is drinking during pregnancy bad for the baby?
Children born to light drinkers (1-2 drinks a week) were less likely than children born to abstainers to have behavioral problems at 5 years of age and more likely to have higher vocabulary and picture similarity scores. (6)

What about drinking if you are diabetic?
According to “Healthy Eating for Type 2 Diabetes” published by Harvard Medical School, drinking alcohol reduces the risk of diabetes by up to 43%.  It also states that drinking coffee reduces the risk of diabetes by 42%. It does NOT endorse the newly popular Red Bull and vodka cocktails. (7) It does go on to say that losing 10% of your weight is really the best way to reduce your risk of diabetes.

Fishing is more dangerous than being a fireman or policeman.
The U.S. Department of Labor 2009 statistics of fatal occupational injuries per 100,000 full-time workers showed a rate of 200 for “fishers and related fishing workers” and a rate of 13.1 for police and 4.4 for firemen. Non-fatal injuries or illnesses per 10,000 civilian workers that resulted in lost days of work averaged about 117. The police rate of 676 and the firemen’s rate of 512 were soundly topped by the bus driver’s rate of 892. (8)

What’s the cure for the common cold?
Echinacea ain’t it. (9)  Zinc might be. Use of zinc lozenges within the first 24 hours of symptoms reduced the duration of cold symptoms from 7 to 4 days and reduced coughing from 5 to 2 days. (10) BUT, different zinc remedies contain different dosages and different forms of zinc, and too much zinc by nasal inhaler can blunt your taste sense. 200 mg or more of Vitamin C daily will reduce cold symptoms in smokers or seniors, but it won’t prevent colds. (11)

My two favorite cold cures are:
The British cure – Take a cold shower, immediately go outside while still wet, and run around the house without any clothes on. You will probably get pneumonia and “any damn fool doctor can cure pneumonia.”
The Scottish cure – You need a four poster bed, a hat, and a bottle of scotch. Put the hat on the Southeast  corner post of the bed, sit on the bed, and sip scotch until you see two hats. Even if you are not cured, you won’t care.

Another cause of autism?
Researchers in California studied more than 300 preschool children with autism and found that their mothers were much more likely to live near a freeway, and just freeways not other major roads, when pregnant than 260 preschool children without autism. (12) The California real estate market has been hit hard enough without implicating every house within 300 meters of a freeway.

You’re not still worried about bad effects from H1N1 flu shots are you?
A study of nearly 90 MILLION doses of H1N1 vaccine given in China in 2009-2010 were associated with 11 cases of Guillain-Barre Syndrome (GBS, ascending nerve paralysis). That is a rate of 0.1 per million doses which is lower than the normally occurring or “background rate” in China. (13)

Kids getting dirty may reduce later asthma and eczema.
Two studies in Europe showed that kids living on farms developed less asthma and had less eczema than kids living in a city. The kids on the farms were exposed to more bacteria and fungus and to many more types of those two “germs” than the city kids, and that exposure could explain the difference in the asthma rates. (14)

Unintended consequences of the “hot stuff”.
In a study of a 2008 epidemic of food-borne illnesses involving 1500 people in 14 states, 30 out of 35 restaurants (86%) of the associated restaurants were Mexican restaurants. Common ingredients included jalapeno peppers, serrano peppers, and raw tomatoes. Believe it or not, the CDC researchers were able to trace back the peppers through Texas distributors  to just two farms in Mexico. (15)

Some cars are greener than people.
Researchers in physiology at the University of Milan, Italy found that four men jogging produced MORE carbon dioxide emissions than a hybrid car driving them the same distance. (16)

References:
1. Clin Infect Dis 2011 Jan 1; 52:23
2.JAMA 2011  Jan 5;305:50
3. Jour Watch Gen Med vol. 31 Feb. 1, 2011 p. 26
4. Boston Globe Jan. 22, 2010
5.Harpers Index September 2009 p. 13
6. J Epidemiol Community Health 2010 Oct 5
7. AARP Bulletin Nov. 2009 p.14
8. http://www.marketwatch.com, Ruth Mantell, Feb 2011
9. Ann Intern Med 2010 Dec 21;153:769
10. Jour Inf Dis March 2008, Meenu Singh, MD
11. Consumer Reports on Health March 2011 p.4
12. Environ Health Perspect 2010 Dec 13
13. NEJM 364;7 Feb 17, 2011
14. NEJM 364;8 Feb 24, 2011
15. NEJM 364;10 Mar. 10,2011
16. Scientific American May 2011 p.18



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