Vol. 193 May 15, 2018 Antibiotics are Beneficial: A Reminder

May 15, 2018

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A disease outbreak anywhere is a risk everywhere.”
-Dr. Tom Frieden, Director U.S. CDC

 

We read a lot about the dangers of using too many antibiotics. The popularity of “organic foods” is due in part to their claim to be from “antibiotic-free” animals and plants. Concern about the increasing antibiotic resistance of germs due to antibiotic overuse is real as is frequently described in scientific journals as well as the general press. Why, then, would the New England Journal of Medicine publish an article describing the benefits of random, mass distribution of an oral antibiotic to nearly 100,000 children who had no symptoms or diagnosis! Maybe because that effort reduced the death rate of children aged 1-5 months by 25%!

As you’ll remember in my last blog,  I was impressed by Bill Gate’s knowledge of the medical literature because during his presentation he cited this antibiotic clinical trial which had been published that very same week. Well, full disclosure, he knew about the study because his foundation funded it! This study is the kind of innovative medical study related to global health that the Bill & Melinda Gates Foundation supports. I think it is worthwhile to review the details of the study, if just to remind us that antibiotics are good, that medical science advances on the shoulders of previous work, and that sometimes simple answers, like putting iodine into salt or fluoride into water, can prevent a whole lot of disease.

Previous studies in sub-Saharan Africa showed that blindness caused by trachoma, an infectious disease, could be reduced markedly through the mass distribution of an oral antibiotic, azithromycin. Other studies suggested that the same antibiotic could prevent other infectious deaths like malaria, infectious diarrhea, and pneumonia. It is known that azithromycin affects the transmission of infectious disease, so that treatment of one person might have benefits on others in the same community. The data in two of these studies of trachoma prevention in Ethiopia suggested that mass distribution of azithromycin “might” reduce childhood deaths. Since death (after the neonatal period) is a relatively rare event, even in these settings, the trial had to be conducted in a large population. Hence the need for a large grant to carry it out.

A single dose of oral azithromycin was given to 97,047 children aged from 1 month to 5 years in three African countries during a twice-yearly census. 93,191 children in different communities of the same countries were given a placebo. Over the two-year study the “treated” children received 4 oral doses of azithromycin, each about 6 months apart. Children were identified by the name of the head of the household and GPS coordinates of their location for subsequent censuses. Approval for the study was obtained from 9 ethics committees in 6 countries (3 in the US, 1 in the UK, and 2 in Africa).

The average reduction of annual death rates of children receiving a single dose of the antibiotic every 6 months was 13.5% . Children aged 1 month to 5 months receiving the antibiotic had a mortality rate reduction of 25%. At the conclusion of the trial all the children in the communities of Niger, which has one of the highest child mortality rates in the world and a mortality rate reduction of 18% for all ages in this study, were offered treatment with azithromycin.

This study is a beautiful example of the testing of a simple hypothesis, generated by the results of previous work, using innovative methods, requiring a large population for validity,  and implemented by a multi-national team of medical scientists with a large grant from a private foundation that resulted in clear benefits for better global health.

I, for one, am happy to trumpet some good news about antibiotics and this example of “medical research for all” at its best.

Reference:
Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa, NEJM 378;17, April 26, 2018

 

 

 

 

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Vol. 184 January 1, 2018 To the Dark Side of EMR

January 2, 2018

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“… a fundamental barrier [to successful EMR implementation] that has not received due attention is the disconnect between health IT developers and users.” (1)

I was a solid advocate of electronic medical records (EMRs). Now I am a skeptic.

Primary care physicians are currently paying a big price, in terms of both time and money for the elusive promises of EMRs. As a quality reviewer of hospital medical records, an experienced office-based pediatrician, and a medical director working with an excellent medical staff, I believed that EMRs would really help us to improve the delivery of quality care. I happily jumped on the “evidenced-based medicine” bandwagon and believed that EMR data would help us. After three years of working with two different EMRs in a primary care practice, I have now “gone over to the dark side.” I have slowly realized that EMR “data” does not equate with “useful information” for primary care providers.

I have never belonged to the AMA, for me a “too-conservative” medical organization that I considered primarily a bastion of physician resistance to positive change. A definite sign of my conversion from EMR advocate to EMR skeptic is my agreement with a recent AMA statement by the Executive Vice-President and CEO of the AMA:

“Harnessing the power of health data is an enormous and important challenge, and one that should be led by physicians. The solution must be useful for physicians, and it must allow us to spend more time with our patients and deliver better care.”

Of course, there are all kinds of physicians in all kinds of practice settings, and “one size fits all” does not seem to be working for primary care EMR.

Use of EMR in our office is slowing us down, is decreasing the time we spend with patients and their families, is increasing the chances of provider communication gaps or slips, and has increased the frequency of “work arounds” for the delivery of quality care. “Work arounds” is a traditional quality improvement term that describes the methods that workers in any setting develop to skirt the system problems that hinder them from doing their best job. The presence of “work arounds” is one of the cardinal signs of a dysfunctional system. “Work arounds” often serve as the first target of any effort to analyze quality performance.

So why have I “gone over to the dark side”.
EMR has become way too complicated – There are too many screens requiring too many clicks, too many switches from scrolling wheel to cursor pointer, too many inconsistent navigation routes using tiny icons or miniscule, barely-noticed arrows. To see the basic clinical information I need before entering an exam room with our EMR ,  I need to review 2 or 3 computer screens, make 4 or 5 clicks with the mouse, and both scroll and/or drag with a cursor for the information that I use to be able to read quickly on two facing pages in the paper record.

In the quest for the versatility that is necessary to serve thousands of different physicians in hundreds of different settings, the award-winning EMR we use is awkward and time-consuming for us in primary care. It is driven by the need for reimbursement documentation in specialized (expensive) care settings. Workaround? – I read the paper encounter forms completed by my patients and my staff before I start the patient encounter. It is faster, sometimes more reliable (because there is no absent entry), and is more focussed on today’s encounter than those multiple computer screens which are trying so hard not to “miss” any data, no matter how irrelevant to today’s tasks.

EMRs have too many ways to record information from multiple sources – Valuable patient encounter information from nurses, social workers, and medical assistants can be hard to find in the mass of data. It usually requires purposeful clicking on tiny icons or miniscule arrows (again) on multiple screens. Boiler plate checklists tend to make every patient’s chart read the same. Workaround? – I know how to type. The actual, and helpful, differentiation between my patient encounters is almost always found in my “free text” note. But, not all providers in my office know how to or like to type. When I have to track down another provider to find out the information I need, there are now two of us not seeing patients.

Safeguarding patient privacy in an EMR is more complex. Sensitive results or comments are sometomes consciously avoided in the EMR or are deeply buried underneath a number of more clicks, scrolls, and screens. Workaround? – See above about physically tracking down another provider or more likely, that valuable information is not available in the medical record at the time that you need it. The route(s) of clinical information coming in from outside our office like lab results, X-ray readings, and specialists’ consultations are multiple, varied , and often obscure in our EMR. The vigilance required to NOT miss such reports is INCREASED, not decreased, in EMR. Workaround? – I ask the nurse, medical assistant, or front desk staff to track down the information by telephone or fax just like “in the old days.”

Correction of recorded errors like dates, or names, or even diagnosis can be tedious in the EMR.  A simple single line cross-out and rewrite did it in the paper record. The EMR requires multiple cursor clicks and several screens to do the same. The timing of the clicks, or more nearly correct, the sequence of clicks can be important for success. Workaround? – Sometimes I will delete a whole section of generic computer-speak in an EMR section because I can’t easily change one or two lines  (2 screen colors, at least 3 clicks, and a small check box way down at the bottom of the screen are often involvedin making an EMR correction).

The EMR has reduced the delegation of accepted clinical tasks. Renewing or initially writing common prescriptions ordered by me is not permitted to be done by the nurse practitioners or nurses on our EMR. Instead of a verbal request to a trusted professional, my time and attention is required on at least three computer screens, up to half a dozen clicks, and my entry of my unique password to do that. True, the prescription is sent electronically to the correct (usually) pharmacy, but the nurse or office staff used to do that quite quickly via fax, and it took less of my time. Work around? – Perhaps patient safety clearly trumps convenience here, so I have not spent much time thinking about a work around for this, but it does continue to disrupt a previously smooth work flow.

My computer keyboard is in one room, and I use three other rooms as exam rooms, To complete a note, look up a growth chart,  check results, answer an unexpected question from a parent, or order a medication I often do a far amount of time-consuming walking back and forth between rooms. Workaround? – Why not just get a tablet?, you ask. Well for some mysterious reasons neither of our EMRs support that functionality in our office. After several frustration attempts we know that the tablet works beautifully at IT headquarters, but  not in our office.

What benefits most from EMR in the office setting?
Reimbursement and research.
Clinically the only useful information to know about an ear infection is whether it is “left” or “right”. Our EMR requires a half dozen more adjectives before the diagnosis is “recorded”. It has no effect on reimbursement now (what we are paid for that office visit) ,as far as I know, and I can only hope that such minutiae won’t affect reimbursement in the future.
There are also half a dozen adjectives required to record the diagnosis of “nose bleed”, and I can only imagine that somewhere out there exists a researcher just waiting to write the definitive article on “recurrent, non-injury, chronic, episodic nosebleed” which happen more often on the “right” than the “left”.

Both these R&R benefits of EMRs are quite removed from improving actual clinical care. That is another reason for my move to “the dark side”, and this current blog that deviates from my founding pledge to NOT publish personal rants.

If you chose to dismiss this particular rant as “just another doctor complaining about his poor lot in life”, you should read a more scholarly short treatise on the same subject: “Accelerating Innovation in Health IT”,  New England Journal O f Medicine, 375:9, September 1, 2016, 815-7 (1).

 


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

 


Vol. 174 July 15, 2017 Dumb Government and Smart Guns

July 15, 2017

Gun violence injuries and deaths in the U.S. is a public health crisis.”   – AMA

Gun violence kills roughly 30,000 Americans each year, about as many people as car accidents. The federal government has been restricted in gathering and analyzing gun violence data since 1996 when a CDC study linked the presence of a gun in the house with an increased risk of homicide. The NRA responded with a successful lobbying effort to pass the restriction that the CDC may not use any money allocated to it for “activities that advocate or promote gun control.” It stripped $2.6 million from the CDC budget for firearm injury research. After the Newton School shooting in 2012 Obama issued an Executive Order (one of his relatively few) commanding the CDC to renew their research into gun violence and requested Congress to allocate $10 million for that. Congress never did, and research never resumed.

The NRA has also successfully limited the federal government’s ability to trace guns involved in crimes, “crime gun-tracing”. Some states have developed data bases of crime-gun tracing to identify sources of and reduce illegal gun trafficking. Massachusetts established crime-gun tracing in 2014, but has not published a meaningful analysis of the data which might lead to some action. The 2017 Massachusetts legislature has inserted into their budget proposal a request that the governor produce such an analytical report.

Doctors, particularly pediatricians, are keenly aware of the dangers of having guns in the  house. 90% of accidental gun injuries to children happen in a home with a gun. The American Academy of Pediatrics has explicitly recommended that pediatricians routinely ask gun-safety questions during health and wellness visits. But in 2011, Florida passed a “Privacy of Firearm Owners” law levying $10,000 fines and loss of medical license to any pediatrician that inquired about the presence of firearms in the house. The law was upheld by a Florida state court in 2014 based on “2nd Amendment infringement”. The law was just struck down this year by a Federal Appeals Court that ruled that “there was no evidence that the law infringed on the Second Amendment.” By the way, the Affordable Care Act (aka Obamacare… remember Obamacare?) specifically prohibits physicians from keeping records on gun ownership. an assurance to any paranoid, conspiracy-theory-believing gun owner that docs were now not in league with big government. (see “Docs vs. Glocks”, Scientific American, August 2015. pg. 10)

The solutions to gun violence deaths are mostly focussed on mass shootings including either/or/and:
1. eliminate mental illness,
2. eliminate terrorists,
3. eliminate humane treatment (put water boarding video of terrorists on You Tube),
4. eliminate Muslims,
5. eliminate political correctness  (utter the words “Radical Islam Terrorists” which Obama refused to say (sic.) (1)

The truth is that “mass shootings”, though a big part of media attention, are a small part of the  30,000 annual gun death toll. 62% of  gun deaths are due to suicides committed with guns that DO NOT BELONG to the victim (particularly among the young). Criminals steal about 250,000 guns per year. 1.7 million children live in homes with unlocked, loaded firearms. (2)

The NRA consistently raises the spectrum of the need for the home owner to have a means of self-defense, but a gun is 22 times more likely to be used in a criminal assault, an accidental death or injury, a suicide attempt, or a homicide than it is for self-defense. 61% of gun homicides are by people who know each other.(3)

Making a gun as smart as an iPhone is one way to prevent to a large portion of gun injuries and deaths. Previous attempts to develop such a smart gun have been fraught with problems, have been actively boycotted by gun manufacturers, and have been opposed by gun advocates and the NRA. Kai Kloepfer, a 15-year-old high school student in Colorado, in response to the Aurora theater shooting near his home, started a science project in 2015  to design a pistol that will only fire when a sensor in the grip recognizes the fingerprint of the owner. His project won awards, and Kloepfer delayed his entrance to MIT for a year when he got a grant to develop a working model of such a smart gun. By 2017 he successfully built and demonstrated a smart pistol. The gun takes 1 second to unlock, its battery lasts a year, a light indicates the battery status, and a second light indicates it is unlocked and ready to fire. Neither a child nor a thief can fire the gun. The owner may store up to 10 “authorized user” fingerprints (like for a spouse or domestic partner ). The smart gun is smart enough to NOT  connect with the internet, so it can not be hacked or hijacked.

The NRA response has been predictable: “NRA does not oppose new technological developments in firearms; however, we are opposed to government mandates that require the use of expensive, unreliable features, such as grips that would read your fingerprints before the gun will fire.”(2)

Hey, at least the NRA didn’t evoke the 2nd Amendment argument. That is progress!  Technology can deal with “expensive” and “unreliable”. Technology is far faster to upgrade than the Constitution.

References:
1. “A Nation Captive To The Gun”, Garry Wills, Boston Globe 6/15/2016
2. “The Future of Everything”, Wall Street Journal, 2017, Geoffrey Fowler
3. Journal of Trauma and Acute Care Surgery, 1998

 

 


Vol. 155 October 1, 2016 Legalizing Recreational Marijuana?

October 1, 2016

Hub thumbnail 2015Massachusetts voters and 7 other states will be voting November 8 on proposed laws “legalizing, regulating, and taxing Marijuana”. All of these “binding” Questions have been placed on the ballots by “Initiative Petition” (grassroots’ signature campaigns … no pun intended).The proposed Massachusetts law will legalize for anyone 21 or older the possession of 1 ounce of marijuana outside a residence or up to 10 ounces inside a residence, of up to 6 marijuana plants, and of GIVING without payment 1 ounce or less to another person 21 or older. The actual bill fills 11 full pages which reflects not only the controversial issues surrounding the bill, but also the complexities of proposed regulations and taxation.  

Colorado legalized recreational marijuana four years ago, and its experiences (both positive and negative) are currently feeding both sides of the debate of the economic, social, and political consequences.

I will only summarize some of the medical issues (“the News”) with scant remarks about some other issues (”the Editorial”).

Marijuana is a gateway drug: Not really
Physician researchers studying substance abuse ( at least those pediatrician-scientists who present at conferences in Boston) consider nicotine, alcohol, and marijuana as almost equivalent “initial drugs of choice” in adolescents and young adults who become addicted to heroin or opiates. They speak of marijuana “heavy-users” ( more than one joint daily), not marijuana “addicts”, and they represent a small percentage of adolescent MJ users.

Marijuana is addictive: Maybe a little
About 9-10% of users become “dependent”, “need to have daily MJ to feel normal”. Those who start using MJ under the age of 21 are more likely to become dependent. The withdrawal symptoms when heavy users stop after many years are much less than those who stop use of opiates, heroin, alcohol, or even nicotine. No medications are necessary, and any troublesome symptoms usually respond to cognitive behavioral therapy (talking to a therapist). “Addictive behavior” such as crimes to obtain money and violent acts are not usually associated with MJ dependency.

Marijuana is safe: Yes
Lester Grinspoon, MD in his landmark books, “Marijuana Reconsidered” (1971) and “Marihuana (sic): The Forbidden Medicine ” (1991), stated that no one has ever died of a  marijuana overdose, and that statement still stands true.

Marijuana changes your brain: Yes, if under 21 yo.
This reason and the dangers of small children eating large amounts of edible MJ are the reasons the American Academy of Pediatrics opposes the legalization of MJ but NOT its decriminalization.

The Academy also recommends that marijuana be decriminalized, so that penalties for marijuana-related offenses are reduced to lesser criminal charges or civil penalties. Efforts to decriminalize marijuana should take place in conjunction with efforts to prevent marijuana use and promote early treatment of adolescents with marijuana use problems.”

Heavy use  of MJ before the age of 21 can change how the brain functions as revealed by functional MRIs (fMRI).  Heavy MJ use can actually change brain structure in areas associated with impulse control and “executive functions”. Some studies show a lowering of IQ by 8-9 points in heavy users. The long term effects of these structural changes in adolescents are being studied, but everyone seems to agree that MJ use should not be legalized for those under 21 years of age.

Marijuana can impair your driving: Perhaps
Studies do show that MJ can prolong your reaction time and reduce attention span (less so than alcohol – check out this YouTube video), so the opponents of legalization believe that the law will lead to more car accidents. The data on actual accidents, whether fatal or not, is not so clear. There is no standard method to measure “MJ intoxication”. Blood and urine tests measure MJ metabolites which can be present for up to 45-50 days after smoking a single joint (depending on age, weight, and belt size). These tests, since they depend on measuring metabolites, may not even turn positive until 24-48 AFTER a new user smokes a joint. Such tests can identify regular users, but there is no correlation between blood and urine test levels and the actual degree of impairment.  Remember, even the “gold standard” in drunk driving cases, Breathalyzer results, are not permitted to be entered as evidence in court because of variations in calibration and field administration.


The Massachusetts Medical Society opposes  the legalization of recreational marijuana because of 1) “the addictive nature of marijuana”, 2) “the adverse effects on developing brains”, and 3) “the appeal of edibles to youngsters”.

The effect of legalization on youth access to marijuana is a controversial subject that is dismissed by pediatric researchers.

“Adolescents and pre-adolescents already have open access to MJ. Legalizing it won’t change that.”
It is worth remembering that Dr. Grinspoon got interested in the medical effects of marijuana when his son was undergoing chemotherapy, and MJ reduced his nausea greatly. Lester’s wife easily bought that MJ in a Newton schoolyard in the 60s.

That reality that MJ distribution and sales will become a big business is why proponents are pushing its tax revenue upside. Opponents are concerned that “Big Tobacco” or other nefarious organizations will take over the MJ market.

My vote:
I will vote “NO” on Question 4 in Massachusetts proposing the  “Legalization, Regulation, and Taxation of Marijuana” primarily because of its unknown consequences that should become clearer in time (even just a year or two would help). Also, our state’s less than stellar track record in satisfactorily implementing the much smaller program of legalizing medical marijuana ( 59 pages of regulations in 2013 and several public missteps) gives me real pause about how it could all play out.

I think that the recreational use of marijuana will eventually be legalized in Massachusetts, and that there can be some real benefits of such a change.  But, I also think that there is too much that is vague and/or capable of manipulation in this proposed law, even at 11 pages long.


Vol. 153 September 1, 2016 Is Nothing Sacred? No, Not in Medicine.

September 1, 2016

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It can be frustrating and unsettling when after years of telling us that something is good…or bad for you, doctors then tell us that the opposite is true! “Redefining the truth” is the essence of science, particularly the science of medicine. The medical mantra is: Keep studying, keep collecting data, keep analyzing, and if the “truth” changes, report it!
Here are some more revisions of the truth as examples.

Baby Dolls and Teen Pregnancies
Giving high school students a baby doll to take of care for several weeks is touted as a deterrent to teen-age pregnancies. The sophisticated doll is programmed to cry, make demands, go to sleep (or not), etc. just like a real baby. Students are instructed to care for it 24/7 as if it were a real baby. The expectation is that such a “reality-check” would make teen agers more aware of the burdens of caring for an infant and that would convince them to use effective birth control.

A recent report in the British Medical Journal documented that the average teen age pregnancy rate in those who cared for a doll stayed the same or even INCREASED in some schools. The article speculates that the positive, loving experience that some teens had and the extra attention they received while caring for the doll caused this. The company that makes the dolls quickly switched its marketing pitch from “reducing teen pregnancy” to “teaching quality infant care”.

Get the Lead Out”
The high level of lead in the water in Flint, Michigan in 2015 immediately raised an alarming concern about “poisoned children”.  A blood lead level of 5 micrograms per deciliter is considered “a threshold for official action as a “precautionary principle” according to public health experts.   5% of the kids in Flint had blood lead levels of 5-10 micrograms per deciliter.  The increase from 2.4% having a level over 5 in 2013 to 4.9% of kids tested in 2015 raised the public health alarm.

It is well known that the body can excrete lead. If the input of lead (ingested in food, water, or dirt or breathed in from car exhausts) exceeds the excretion rate and the blood lead level reaches 40-69 micrograms per deciliter then outpatient treatment is recommended, even though the person is asymptomatic. Blood levels above 70 can cause symptoms and are treated by hospitalization. None of the Flint children had lead levels over 40.

Lead performs no essential function in our bodies and chronically high levels can cause neurological damage, so it is incumbent of public health officials (and politicians) to prevent prolonged exposure, but these children have NOT been damaged. They will, I am sure, be monitored and studied for years to come to see if there is any subtle effect of these low lead levels. Because that’s what medical science does.

Lowering Blood Pressure in Intermediate-Risk Persons Without Heart Disease with Two Drugs Did Not Decrease the Rates of Major Cardio-vascular Events

NEJM 374:21 May 26, 2016,pg. 2009-2019

Lowering Cholesterol in Intermediate-Risk Persons Without Heart Disease and Normal Lipid Levels With One Drug Decreased the Risk of a Major Cardio-Vascular Event from 4.7% to 3.6% (a 25% reduction)

same NEJM issue pg. 2012-2031

Lowering Blood Pressure AND Cholesterol in the same study as above with Three Drugs Decreased the Risk of Some Major Cardio-vascular Events from 5.0% to 3.6% (a 30% reduction)

same NEJM issue pg. 2032-2043

Like Fox Radio, “We report the news. You decide.”

“Get the Fat Out…But Which Fat?”
The British Medical Journal published an article in April written by a team of scientists at NIH headed by Christopher Ramsden, called the “Indiana Jones of biology” because he specializes in excavating old studies, particularly those that go against our “mainstream government-sanctioned health advice”. He unearthed a 1968 five-year, tightly controlled study of over nine thousand participants randomly assigned to either a vegetable oil based diet or a standard animal fat diet.

The study documents that eating vegetable fats instead of animal fats did NOT, repeat did NOT, reduce the risk of heart disease or death. Substituting a vegetable oil diet ( about half of the saturated fat of the standard diet) did lower the average blood cholesterol by 14%, BUT the risk of death INcreased 22% for every 30 points the cholesterol fell! 

Dr. Robert Franz of the Mayo Clinic, the son of the organizer of the 1968 study, speculates that his father’s team was disappointed that they could find no benefit of the vegetable oil diet, and so didn’t publish it widely. An accompanying editorial in the BMJ concluded that “ the benefits of choosing polyunsaturated fat over saturated fat seem a little less certain than we thought.”

Again like Fox Radio:  “We report the news. You decide.”

“Worried About Peanut Allergy in Your Family?
Avoid Peanuts! No, NO, Eat Them as Early as You Can!”
The experts use to say “no solid foods to infants before age 4 to 6 months.”
Experts now say “do not delay solid foods beyond 4 to 6 months.”

In the past 10 years childhood peanut allergy has doubled from 1.4% to 3% (still small).
The experts use to say that “if you’re worried about peanut allergy in your child do not give peanut food until age 3 years”.
Experts now say “give the infant peanut food as early as 4 months of age.”

A 2015 study in the New England Journal of Medicine showed that consumption of peanut food at 4 months of age reduced the development of a peanut allergy (documented by skin-prick tests) by 70% – 86%!!

“We should no longer recommend avoidance of allergenic foods in infants.”


Vol. 152 August 1, 2016 It’s Not the Screen Time, It’s the Content.

August 1, 2016

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“Playing rapid action video games benefits the mental skills of processing information, switching between tasks, and visualizing the rotation of an object.”
                 Scientific American, July 2016


What?!
“Shooting zombies and repelling aliens can lead to lasting improvement in some mental skills.” (1)

Bavelier while a graduate student in the 1990s developed a computerized psychological test of the ability to see an individual shape in a busy visual scene. He tested it first on himself, expected to get an “average score”,  and  got a perfect score. He next tested Green, his mentor who also unexpectedly got a perfect score. They figured something was wrong with the computer program, but they could not identify a bug. After a number of Green’s non-psychological buddies also scored perfect results they spent some time in looking for the reason. The only common denominator among the group was that each had spent more than 10 hours a week playing the video game Team Fortress Classic. That discovery launched them, and others, into 15 years of investigations into the cognitive effects of playing fast-paced “shooter” video games.

According to various studies video game playing can boost a variety of cognitive skills:

  • improve focus on visual details (like reading fine print in a contract or on a prescription bottle)
  • heighten awareness of visual contrast (help drive in a thick fog)
  • enhance mental rotation of objects (get that odd-shaped couch through the door)
  • improve audio and visual multitasking (read a menu while conversing with a dinner partner)
  • improve reaction time to unexpected events by 10%
  • increase the number of correct decisions made under pressure
  • improve specific attention in fast changing visual fields (better control of attention)

One study found that laparoscopic surgeons who were also game players could complete surgery faster with the same precision or quality as non-gamers . I remember many years ago learning that the Israeli Army realized that video game players made the best tank commanders.

Obsessive game playing (“binging”) is NOT needed to boost the brain, and the American Academy of Pediatrics has made recommendations for preventing excessive use of all media by children.   Short, daily intervals of play on fast-action games can reap cognitive benefits. Many so-called “brain games” marketed for improving cognitive skills do not live up to their claims. According to these researchers fast-action video games can because:
1. they are fun,
2. they have careful pacing and levels of play (reduces frustrations of early failures),
3.they require increasing attentional control as the game proceeds,
4. they consistently challenge the player,
5. they provide the successful gamer rewards on different time scales (promotes planning for short and long-term objectives).

The content of the game is very important. Violent, aggressive action games can adversely influence children’s attitudes and behavior. Games involving action sports, real-time strategy (like StarCraft), 3-D puzzles (like Portal 2),or “Prosocial” games that involve cooperation rather than competition are listed as examples of “brain-boosters” by these researchers.

They did not include their opinion of Minecraft , an open-ended, creative game that has captured the imagination of millions of children. This fast-paced, multi-level, 3-D building block game is too hard for this adult to understand or follow. One grandchild agrees and has started an instructional website “Minecraft4Momz” . Take a look on YouTube.

References:
1. The Brain-Boosting Power of Video Games, Sci Am; July 2016, D. Bavelier, Prof. of Psychology, University of Rochester and C.S. Green, Asst. Prof. of Psychology, University of Wisconsin


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