Vol. 110 September 15, 2014 Recent Updates From Around the World

September 15, 2014


“Some believe in eating anything, while the weak only eat vegetables.
Those who eat must not despise those who abstain,
and those who abstain must not pass judgement on those who eat.”
Romans 14:2-3

This biblical citation has nothing to do with this week’s contents, but I was so surprised to hear it read in a church service,  and I want to preserve it to use in my defense when my children try to push lima beans, brussels sprouts, and quinoa on to my plate. Plus, I don’t think that it should be only the fundamentalists who quote the bible out of context to support their biases.

My favorite grace, of course, is the Robert Burns grace reproduced here in English (absent the Scottish dialect which really makes it poetic):

Some have meat and cannot eat,
And some would eat, but want it:
But we have meat, and we can eat,
And so let the Lord be “thanket”.

High Dose Flu Vaccine, Hype or Truth?

A study of 32,000 people over 65 years of age during 2011-13 showed that the “high dose” flu vaccine in that age group provided more protection than the standard dose. 1.9% (301) of the standard dose vaccinees got the flu while “only” 1.4% (228) of the high dose vaccinees did. Both vaccines had the same percentage of adverse side effects (9%).

The study’s conclusion was that high dose vaccine is 24% more efficacious, but to me these small numbers hardly justify the high-energy, hyped-up TV ads telling me to “Ask your doctor for the high dose flu vaccine!” AND the authors also remind us that any flu vaccine works best if it matches this year’s flu viruses. That is not always the case. Each year’s flu vaccine is developed from last year’s virus.

Bottom line: get a flu shot, any flu shot.

Too Much Salt Does Kill People, But Not So Much in the U.S.

In a huge, multi-year study funded by the Bill and Melinda Gates Foundation daily salt consumption was determined for 74% of the world’s adult population! The data taken from previously published surveys, 24-hr urine collection reports, and dietary intake studies was fed into a computer (Bill Gates, of course, but the authors added a disclaimer that the “funder had no role in this study or report”). The computer kicked out an average daily salt consumption by age, sex, and year for 187 countries.

The average worldwide salt consumption was about 4 grams per day, twice the amount recommended by the World Health Organization (2 grams per day). 181 of the 187 nations exceeded the WHO recommendation. The computer model went on to estimate that 2 out of 5 premature deaths (under 70 yo.) were attributed to salt consumption above 2 grams a day. The Institute of Medicine has stated that there is little evidence that reducing salt consumption below 2.3 grams a day reduces cardiovascular events. There is even some evidence that a low salt intake (under 1.5 grams a day) can increase your cardiovascular risk!

The good news, for us, is that the  U.S. and Canada have one of the lowest salt consumption rates, but still over the 2 grams threshold. The highest salt consumption associated mortality rates were in Central Asia, Central, and Eastern Europe,  Only Australia and New Zealand had lower CV mortality rates attributed to salt consumption than the U.S. and Canada (again, they beat us!).

Bottom line: If you’re worried about your future cardiovascular events try a 2 gram a day salt diet for a few days. Then very slowly, add a little bit more  salt each day until the food tastes good again.

From the “Duh Department”

Norwegians who have large, complex, or multiple non-cancerous polyps removed from their intestine by colonoscopy have a slightly higher death rate from colon cancer within 10 years than those people with small, single “low-risk” non-cancerous polyps. (3)

People in low income countries have lower risk factors for cardiovascular deaths, but have much higher death rates from heart attacks than middle- and high-income countries (Also true for “deaths from any cause”).(4)

1. NEJM August 14, 2014 vol. 137, no. 7, pg. 635
2. Ibid; pg. 624 and 677 Editorial
3. NEJM August 28, 2014 vol. 371, no. 9, pg.799 and 860 Editorial
4. Ibid; pg. 818

Vol. 104 January 1, 2014 Hubslist’s Blogs of 2013

January 1, 2014


“Happiness is Not a Warm Gun” – Jan 1, 2013
In half of my lifetime our culture has moved from arguing that sometimes it was “better to not wear a seat belt in case there was a car fire” to having my grandchildren remind me that I shouldn’t start the car until MY seat belt is buckled. No ONE law accomplished that, and it happened despite critics and opposition from big time lobbyists. Why can’t we do the same for gun control?

Ten Ways To Improve Your Health – Jan 15, 2013
 This list, “backed by scientific research”, was complied by AARP.
1.  Throw a Party – Social connections help you live longer.
2.  Adopt a Pet – Exercise it (and you) and count it as another social connection.
3.  Choose Dark Chocolate – An ounce a day keeps the doctor away.
4.  Savor Your Coffee –  Three cups a day keeps Alzheimer’s away.
5. Have a glass of wine or beer – “Guinness is Good For You” One glass a day for women, two for men!
6. Have Sex – There is nothing bad about releasing endorphins. It also counts as aerobic exercise.
7. Listen to Your Favorite Music – A song a day keeps the heart pumping away.
8. Take a Nap –  A nap a day keeps the brain hoarder at bay.
9. Go Outdoors – Go look at the greens, don’t just eat them.
10. Use Soap. regular soap – Antibacterial soaps with triclosan aren’t worth the cost and may not be safe.

The MYTH of Antioxidants – Feb. 1, 2013
A 2007 systematic review of 68 clinical trials concluded that antioxidants do not reduce the risk of death. Certain antioxidants were linked to a 5%  INCREASED risk of death. The American Heart Association and the American Diabetes Association now advise “that people should not take antioxidant supplements except to treat a diagnosed vitamin deficiency”. “The literature is providing growing evidence that these supplements – in particular at high doses –  do not necessarily have the beneficial effects that they have been thought to…We’ve become acutely aware of potential downsides.”

The ATF has no ammunition – Feb. 15, 2013
The Tiahrt Amendment, passed by Congress in 2006, permits gun dealers to destroy gun registration applications within 24 hours of completion so as “to avoid any inadvertent errors from being promulgated” . It placed these prohibitions on the ATF;  the federal agency overseeing firearms

prohibited from establishing a registry of gun owners (imagine no one keeping a registry of car owners)
prohibited from requiring gun dealers to maintain inventories of their wares
prohibited from inspecting any gun dealer’s records more than once a year
prohibited from revealing firearms trace data to anyone other than law enforcement personnel (firearm tracing is done for  firearms used in crimes. One study showed that 57% of guns used in crimes in one state were traced to only 1% of gun dealers.)
prohibited from requiring gun dealers to respond to police inquiries.

 So we may not need any more laws or regulations for gun safety. We could just repeal the one “Tiahrt Amendment”, and let the ATF begin to do its job.

Take a Pill – March 1, 2013
“Something like a third of consumers who’ve seen a drug ad have talked to their doctor about it,” says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject.”About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored.”  Our mantra continues:
“Hey, Doc,
Forget the Mediterranean Diet.
I’m an American.
Give me a pill.”

The New Pope – March 15, 2013
The medical question I have not been able to answer despite my extensive, exhaustive research (at least an hour on Google) is:  Which Pope had the ulnar nerve palsy? The classic hand gesture of the “Papal Blessing” or “Papal Benediction”, despite erudite analysis by reverent writers on the religious symbolism of his hand and fingers, is, in fact, the result of a nerve palsy of the hand. Even the Vatican tourist guides know this.popesign1The Italian bishops were surprised that the Bishop of Milan, Angelo Scola, was not elected, and much to their embarrassment they prematurely released a report that he had been. I, too, was disappointed that Angelo Scola did not get elected. We all could have called him Pope Scola.

Pope Francis Bails Out Obamacare – April 1, 2013
In a solemn Easter Mass Pope Francis dramatically offered the help of the Roman Catholic Church in funding universal health care in the U.S. He noted that because the U.S. is the only civilized Western country without universal health care and is currently having financial problems, it is the Christian thing to do. “Since neither disease nor money is restricted by national boundaries, it makes good sense to protect the rest of the world from the health problems of  the beleaguered U.S. ” The Pope’s plan was immediately dubbed, “Francincare” (pronounced  as “Frankincare” with the Italian hard “c”). At the end of the press conference Pope Francis returned briefly, showed the persistent Papal nerve palsy to the gathering, and closed with a benediction in Italian: “Felice Aprile Ingannare Giorno”, in Spanish: “Felize Abril Enganar Dia”, and finally in English: Happy April Fools Day”.

Patient Centered Medicine – April 15, 2013
PARENT:  So, I should breast feed Leonard for a whole year, but could have started solid foods two months ago?  Most of my friends swear that giving food makes their babies sleep longer at night.
PHYSICIAN: Exclusive breast feeding for 6 months has lots of advantages for the infant. There is no evidence that giving solid foods makes the infant sleep longer at night, but there is probably no harm in starting him on cereal now.
PARENT: Any particular kind of cereal?
PHYSICIAN: A 1994 Swedish study showed that introducing wheat before 6 months of age caused a big spike in gluten allergies and celiac disease, but a more recent one there showed that giving wheat to breast-fed babies at 4 months actually decreased the later occurrence of celiac disease and gluten allergy.
PARENT: So, wheat cereal could be either good or bad at his age? This is very confusing.
PHYSICIAN: Science can be confusing. It often changes its mind as new data is gathered.

Lessons Learned from the Development of Polio Vaccines – May 1, 2013
1. Even in science, what you know is important, but WHO you know can be also.
2. Yesterdays “field trial” is today’s mass immunization campaign, and NOBODY tests drugs or vaccines, whether from mice brains or monkey kidneys, on themselves and their family members anymore!
3. The history of testing vaccines and drugs on impaired or incarcerated populations reminds us again of the necessity for “informed consent”.
4. As more academic institutions seek joint contracts with big pharma to replace reduced NIH support of research (MGH and Sanofi, AztraZenenca, etc.) accusations of being a “commercial scientist” seem moot.
5. Some immigrants can be very smart, focussed, and hard-working, and they can contribute immensely to our country’s health and wealth.
6. Science keeps gathering data and testing hypotheses, so we should not be surprised when its recommendations change.

Medical Marijuana – May 15, 2013
1. Marijuana use before the age of 20 does have structural and functional effects on brain development, primarily but not limited to the frontal lobe. (“The frontal lobe, responsible for impulse control, is the last to develop and the first to go.”)
2. After the age of 20 there is little current evidence that MJ causes any permanent effect on brain function or structure.
3. There are  currently no predictors that will identify an occasional user of MJ as one who will become dependent or addicted to MJ (daily use), but the earlier one starts using marijuana (13 yo.) the more likely brain function will be effected.
4. Despite the “trustworthy karma” of medical marijuana, marijuana prescriptions will result in the dispensing of varied, complex, and inconsistent products.
5.Access to marijuana by middle and high school students in 2013 is now so easy according to both students and researchers that medical marijuana dispensaries will provide little increased access to adolescents.

The three drugs of adolescent choice today, tobacco, alcohol, and marijuana, do share a common denominator in that those who use one of the three drugs by age 13, will use one or more of the others before 18 yr. There is NO evidence that one is the “gateway” to another. In fact, one researcher remarked that the concept of a gateway is more of a myth than a reality. He called development of addiction to one or the other substance as a “shared vulnerability”.

Sunscreen SPF Ratings Escalation – June 1, 2013
This year Consumer Reports states that the according to their tests the maximum effective SPF is now 40. Paying for anything above that is wasted money. Two years ago Consumer Reports tests showed that any sunscreen with a SPF (Sun Protection Factor) over 30 gave no more protection than a 30. They also recommended that year-old sunscreen might have lost some of its effectiveness, so new sunscreen should be bought each year. New FDA regulations require the sunscreen to be labeled with a three-year expiration date.

What Massachusetts Docs Think About Medical Marijuana – June 15, 2013  Common threads in the  118 comments posted were:
1. Does marijuana even belong in the purview of physicians? “Just legalize it and let patients decide whether to use it or not”
2. Most physicians who supported its medical use would do so “in certain circumstances”; implying strongly that physician control over use was assumed by supporters.
3. All camps called for more research to move toward a stronger basis of evidence.

Do You Have Obesity or Are You Just Fat?- July 1, 2013
The House of Delegates of the AMA just voted to designate obesity as a disease. This means that you will no longer “be fat”. You will “have obesity” like you “have diabetes”.  The AMA Scientific Council recommended to retain obesity as “a condition”. A spirited debate about the consequences has begun. I suspect that much of the controversy  is about money. Medicalizing a societal condition will cause more money to be spent on surgery and drugs.  “Insurers will pay more.” The upside of that could be more provider reimbursement for prevention and life style counseling by primary care providers, but surgery and big pharma are usually first in line. Two new anti-obesity drugs (Belvig and Qsymia) came on the market this past year. More than one-third of Americans will instantly be labeled as “ill” and therefore eligible for more medical services.

Sunscreens Are Poisonous? – July 15, 2013
The culprit is oxybenzone  and other similar chemicals in chemical sunscreens first described as “endocrine disruptors”, a code word for “estrogen effect” which directly connects it emotionally to breast cancer, particularly by Dr. Oz.   Oxybenzone is such a common ingredient in skin products that a CDC survey of Americans in 2003 detected it in 97% of urine samples. The link to breast cancer in humans has not been proven. One reassuring fact is that hormones, like all chemicals and unlike radiation, have to reach a certain blood or tissue level to have any significant effect.  An average woman would have to apply 1 and 1/2 quarts of sunscreen to 25% of her body (arms, legs, and face) each year for 277 years to attain the levels of oxybenzone that had uterine effects in lab rats!

Too Much Sun in Vermont?! – August 1  , 2013
I am in a hammock in Vermont reading, much to my surprise, that Vermont, the land of a severely short summer, has one of the highest melanoma rates in the country.  About 29 people per 100,000 in Vermont get diagnosed with melanoma as compared to the national average of 19 per 100,000. Bennington County has the HIGHEST rate of melanoma of any county in the nation, 179% above the national average!

Somezhiemer’s – Sept. 1, 2013
News releases and internet blogs this week are full of buzz about a protein that apparently is related to the memory loss of aging; something I call Somezhiemer’s as opposed to Allzhiemer’s (sic).  In this Columbia University School of Medicine study a deficiency of the protein RbAp48 in a specific part of the brain in both older mice and 8 older humans (both postmortem) was correlated with memory loss ; at least the ability of the mice to remember a water maze pathway.
The good news is that one specific biological cause of memory loss has been discovered, as contrasted with speculation about aluminum, cooper, mercury, zinc, and other environmental agents.The bad news is that us older people will probably not, in our lifetime, be able to take a “RbAp48 pill” each morning, so we don’t misplace our car keys, glasses or …. forget to write an August 15 blog.

Fear of Fever – Sept. 15, 2013
Many parents think that a temperature over 98.6 F is a fever. Most pediatricians consider a temperature of 101 F or higher as a fever, except in infants under 3 months where we pay attention to temperatures over 100 F. Any pediatric practice worth its salt has a handout or a website page describing fever as one of nature’s way to fight infection. Fevers are usually caused by common viruses for which antibiotics are no help, and discomfort from them is relieved easily by simple medicines.
We desire zero risk level in our lives, and a fever, no matter how small or how short in duration, indicates that something may be wrong. Speaking of risks, how can we accept that everyone must remove their shoes at the airport because one person had a bomb in a shoe, but we don’t register gun owners and accept the much greater risks of our kids being shot?

 Obamacare Begins – October 1, 2013
Like the Bible, Obamacare is open to interpretation. Your view of it may depend on your political party rather than your religion. Both are vulnerable to quoting out of context in support of opposing viewpoints. Both have overall, encompassing goals which can often be lost, or at least obscured, by minute details of excess verbiage. Both have, and will continue to have, “unintended consequences” (like the Inquisition and the Crusades) that we mere mortals have to deal with.
Everyone certainly agrees that Obamacare is NOT divinely inspired. Congress has clearly rejected the idea of a central authority (like the Pope, or Donald Berwick, MD as “Czar” of CMS). The Bible is no longer chained in the dark in the back of the church.  Obamacare is now out in public, out in the market place. We shall eventually see how well it meets the needs of our citizens for affordable health care.
By the time the Republicans win the presidency Obamacare will have so many beneficiaries (voters) that they won’t dare to kill it, and they’ll have to rename it. I wonder WWJD?

Flu Vaccination – October 16, 2013
The trivalent vaccine is the most readily available (at both your physician’s office or a retail store) and there is no compelling reason to seek out the quadrivalent vaccine. The vaccine’s effectiveness in preventing the flu depends on which flu strain is circulating in your area. Effectiveness may be as high as 80% in young adults, but is almost always lower in the elderly. A high dose vaccine that allegedly delivers four times the usual prod to your immune system is being marketed for the over 65ers , but it is not recommended since there is no independent study of its success.
In Massachusetts last year there were 5 flu deaths in children under 17 yo.  None of the five had been adequately vaccinated. Two of the five had no pre-existing health problems. Nationally there were 146 pediatric deaths from the flu last year compared to 34 the previous year.  40% of those deaths were in children who were otherwise very healthy.  90% of them were unvaccinated.

Paranoia – Nov. 1, 2013
Former Vice President Dick Cheney recently said during a “60 Minute” interview that he had his cardiologist turn off the wireless function in his implanted pacemaker “in case a terrorist tried to send his heart a fatal shock.” Years later, he saw that scenario played out in an “Homeland” episode. We knew that his DC residency was pixellated in the Google satellite view, and we wondered if he was on the NASA phone surveillance list.  But then, we remembered that he had ordered it.
Polls taken in Boston after the Marathon bombings indicate that more people think that “such attacks are likelier, but fewer live in dread of them.”.”In the United States since 9/11 Islamic terrorism has resulted in the deaths of 37 people. During that same period, ten thousand times that many have been killed by guns wielded by their countrymen or themselves.”

Is It a Strep Throat or Just a Virus Cold? – Nov. 15, 2013
A team of Boston research physicians have recently come up with a potential APP for that! These physicians combined two clinical findings that the patient could recognize with real-time data about the occurrence of positive strep tests in the community in the past 14 days to generate a “Home Score” to tell you if you really need a strep throat test.
There may soon be a home kit for that! Other physician researchers in Boston are ready to test a home-based, patient-administered Rapid Strep Test. A positive home-based RST would be enough to initiate treatment and prevent complications.

The Myth of Multi-Tasking – Dec. 1, 2013
“Multitaskers are terrible at every aspect of multitasking…When we talk to multitaskers they seem to think that they’re great at it and seem totally unfazed and totally able to do more and more and more.” Actually, those who did it the least, did it the best. “We are worried that multitasking may be creating people who are unable to think well or clearly.”
Recent work involved study of the erosion of social and emotional development by the increasing use of social media. “We have to get back to that saying, ‘Look at me when I talk to you’”.

Aspergers or Autism – Dec. 15, 2013
Confusion about these syndromes  increased in the 2000’s as screening tools improved and awareness of the syndromes grew.  The authors of the 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) , the bible of insurance company reimbursement, has attempted to simplify and clarify the situation by lumping all the diagnostic names into one billing code, “Autism Spectrum Disorder” (ASD).
The attempt has not succeeded according to its critics and many practicing physicians.
Parents of Asperger children could lose insurance benefits now tied to that diagnosis. Grant-supported educational and enrichment programs for Asperger’s may dry up. Asperger’s has always been a less terrifying diagnosis than autism.  People with Asperger’s, and probably more important, their parents, don’t want to be labeled with the stigmata of “autistic”. Dan Akroyd and Daryl Hannah  self-proclaimed their Asperger’s in 2013.

Vol. 99 October 16, 2013 Flu Vaccine Update

October 16, 2013

hubSeasonal flu vaccine is effective and should be offered to everyone over 6 months old
who does not have a specific medical contraindication. (1)

Remember how excited we got about swine flu?
And then how concerned we became about the swine flu vaccine?
We began calling it H1N1 flu in hopes of reducing some of the stigma attached to its name.
We thought it might cause much more illness and deaths than seasonal flu, H1N2.
It didn’t.
That was in 2009 and 2010.

There is no such flu excitement this time around, but there are a lot more flu vaccines. There are 20 flu vaccine preparations made by 9 different pharmaceutical companies for prices ranging from $9.50 to $32.00.  (The highest priced one is for people with egg allergy.)

The “flu shot” delivers inactivated (or killed) virus, provides protection against three strains of flu (“trivalent”), and most preparations, but not all, are suitable for any one over 3 yo.

The nasal spray, “Flumist”, delivers live virus providing protection against four strains of flu (“quadrivalent”) and gives excellent protection to children over 2 yo. It can not be given to people over 42 yo. This live virus vaccine may cause shedding of the virus from the vaccinee for a few days, but serious illness from such person-to-person transmission has not been reported.

Children from 6 months to 8 years old receiving a flu vaccine for the first time or who have NOT received at least 2 doses since July 2010 need a SECOND vaccine administration at least 4 weeks later.

The trivalent vaccines protect against influenza A (California strain) which is “H1N1-like”, influenza A (Victoria strain) which is “H3N2-like”, and influenza B (Massachusetts strain) which is “2012-like”. Influenza virus strains are named after their site of origin, and, yes, Massachusetts can now proudly claim a place along other locales that gave their name to diseases; like Coxsackie, N.Y. for hand-foot-and mouth disease and Lyme, Connecticut for…you know. The quadrivalent vaccine adds an influenza B (Brisbane strain) which is “2008-like”.

The trivalent vaccine is the most readily available (at both your physician’s office or a retail store) and there is no compelling reason to seek out the quadrivalent vaccine. The vaccine’s effectiveness in preventing the flu depends on which flu strain is circulating in your area. Effectiveness may be as high as 80% in young adults, but is almost always lower in the elderly. A high dose vaccine that allegedly delivers four times the usual prod to your immune system is being marketed for the over 65ers , but it is not recommended since there is no independent study of its success.

In Massachusetts last year there were 5 flu deaths in children under 17 yo.  None of the five had been adequately vaccinated. Two of the five had no pre-existing health problems. Nationally there were 146 pediatric deaths from the flu last year compared to 34 the previous year.  40% of those deaths were in children who were otherwise very healthy.  90% of them were unvaccinated. (2)

So, don’t be flu-ish, get your flu shot …or spritz in the nose.


1. The Medical Letter, Volume 55, Issue 1425, September 16, 2013
2. Massachusetts Department of Public Health, October 16, 2013

Vol. 89 May 1, 2013 Science, Personalities, and Politics of the Polio Vaccines

May 2, 2013

hub_2Dr. Hilary Koprowski, the creator of the live polio vaccine, died last month at age 96. What? I thought Dr. Albert Sabin developed that vaccine.

At a physicians’ educational meeting last month, Dr. Larry Pickering of the CDC and the University of Georgia recounted the headline-grabbing, fearsome, panic-causing polio epidemic of 1952-53 and gave us some insight into the sometimes dramatic duel between Dr. Sabin (with his oral live virus vaccine) and Dr. Salk (with his injectable killed vaccine) in everyone’s urgent efforts to stop the spread of the disease. I read Dr. Koprowski’s obituary the next week.

Dr. Koprowski was a Polish immigrant, earned his MD at the University of Warsaw, and helped develop a yellow fever vaccine with the Rockefeller Foundation. That success led him to the idea of using the same process to develop an attenuated live virus vaccine for polio. He was working for the Lederele pharmaceutical company in Pearl River, NJ at the time, and so was some times dismissed as a “commercial scientist”. He was described as a loner who was most comfortable in the lab, never sought public attention, but occasionally referred to himself as the “developer of the Sabin polio vaccine” .

Koprowski first tested the safety of the vaccine by having himself and his family sip a grey slurry of the seventh pass of the virus through the brains of Swiss albino mice in 1948 (1). When none of them got polio, he then tested its efficacy by administering it, at the facility’s request, to 20 retarded residents of Letchworth Village, NY  in 1950. All showed excellent development of antibodies against polio. Dr. Koprowski sent a sample of his vaccine to Dr. Albert Sabin.

Dr. Albert Sabin, also a Polish immigrant and a Rockefeller grantee, received his MD from New York University and developed his live virus vaccine from Dr. Koprowski’s sample using monkey kidney tissue at Cincinnati’s Children Hospital. After testing vaccine safety on himself and his family, he gave it to institutionalized children in a Ohio reformatory in 1954. All developed antibodies, and none got polio.

Meanwhile Dr. Jonas Salk, also a graduate of New York University School of Medicine, received a grant from the National Foundation for Infantile Paralysis to study the three types of polio virus at the University of Pittsburgh. The grant allowed Dr. Sabin to finally establish his own lab after several years of difficulty due to the traditional “academic jewish quotas” of the time. When he succeeded in developing a killed-virus vaccine, he successfully tested it in 1953 in 43 children at the D.T. Watson Home for retarded and feeble-minded children in Pittsburgh.

In 1938 Basil O’Conner, CEO of the National Foundation and a former law partner of Franklin D. Roosevelt (the most famous polio victim in the world), had started a fund-raising effort called the March of Dimes which in its first year literally inundated the White House with coins and letters. When Salk’s vaccine proved efficacious in 1953 Basil O’Conner successfully urged the U.S. government to launch a field trial of his grantee’s vaccine. That “field trial” eventually distributed vaccine to 1.8 million children with the help of 20,000 physicians, 64,000 school personnel, and 220,000 other volunteers. (Now THAT’S a “field trial”.) The success of the trial was announced on April 12, 1955 in a Waldorf Astoria Hotel press conference and radio broadcast supported by a $250,000 grant from Eli Lilly and Company, and Salk became a superstar. Salk, himself, valued his privacy, abhorred the resulting publicity, and refused any effort to patent the vaccine.

Basil O’Connor was much more energetic in promoting the use of the Salk vaccine and a fearful public embraced it. An adversarial situation soon developed between Salk and Sabin as each pushed the government in Congressional committee hearings to use their vaccine. Sabin became “openly hostile to Salk” and would provide immediate “specific critiques of his presentations at scientific meetings”. Basil responded in the newspapers by saying in 1955, “Those who would prevent its [Salk vaccine] use must be prepared to be haunted for life by the crippled bodies of little children who could have been saved from paralysis had they been permitted to receive the Salk vaccine.”

The oral live virus vaccine was used to immunize over 100 million Russian children between 1955 and 1961, but it’s first U.S. trial was in 1961 on 180,000 school children in Cincinnati, Ohio. The live virus vaccine reproduces itself in the intestines of those vaccinated and spread of the attenuated virus from those vaccinated can protect others in the community. This was an advantage in endemic, poorly developed countries, but caused the U.S. to stop using the Sabin vaccine for fear of secondary spread.

The polio vaccine we give today is a 1988 refinement of an injectable killed-virus for all 3 types of polio and is 100% protective after three injections in the first year of life and a booster at 6 yrs.

All three physicians went on to develop or lead separate, stellar research organizations bearing their name and  continuing their superb work.

In 2007 Dr. Hilary Koprowski was awarded  the annual Albert B. Sabin Gold Medal given by the Sabin Vaccine Institute.

Relevance today?
1. Even in science, what you know is important, but WHO you know can be also.
2. Yesterdays “field trial” is today’s mass immunization campaign, and NOBODY tests drugs or vaccines, whether from mice brains or monkey kidneys, on themselves and their family members anymore!
3. The history of testing vaccines and drugs on impaired or incarcerated populations reminds us again of the necessity for “informed consent”.
4. As more academic institutions seek joint contracts with big pharma to replace reduced NIH support of research (MGH and Sanofi, AztraZenenca, etc.) accusations of being a “commercial scientist” seem moot.
5. Some immigrants can be very smart, focussed, and hard-working, and they can contribute immensely to our country’s health and wealth.
6. Science keeps gathering data and testing hypotheses, so we should not be surprised when its recommendations change.

References:  1. NY Times, April 21, 2013, pg.18

Vol. 68 June 1, 2012 ECMO or Elmo for your child?

June 1, 2012

Nellie is a girl, a twin born 2 weeks prematurely in our pediatric practice. She weighed a beautiful 4 lbs. 10 oz at birth and was very healthly. At her two-month well baby visit she and her brother were clearly thriving in a loving, attentive family. She got her routine DTaP immunization (Diptheria/Tetanus/Pertussis) then. Thirty seven days later she came back to our office after vomiting three times the night before. Both twins were a bit fussy. We determined that the vomiting actually followed and was associated with several coughing spells. Her exam was normal, her lungs were clear, and she did not appear sick in any way.

The next day she returned to the office with difficulty breathing, had signs of pnemonia in her right lung, and was immediately admitted to our community hospital. Overnight in the hospital she developed pneumonia in the other lung and began to drop the oxygen level in her blood. She was transferred to a children’s hospital because she  now required a ventilator to be able to breathe.  The very next day she suffered almost complete cardiac-respiratory  collapse. Her lungs would not work at all. That is when they put her on the ECMO machine (Extra Corporeal Membrane Oxygenator, aka the “artificial lung”). Like a heart bypass machine the ECMO takes blood from the patient, circulates it through membranes with oxygen, and returns the oxygenated blood to the patient. Without that oxygen,of course, the brain and other vital organs begin to die. Her lungs had failed from an infection with pertussis, whooping cough.

Vaccinations nearly wiped out whooping cough more than 30 years ago, but it has made a vengeful comeback in California, Washington, and other states.

Cases of pertussis declined rapidly in the 1940s. The all-time low was in 1976, with only 75 cases reported in the United States. Since the early 1980s, there has been an increase in reported cases of whooping cough.

Why this resurgence?

Vaccination rates are decreasing as more parents refuse to have their children immunized against a number of preventable diseases.

But, that is not the whole story. Most of the new cases in California are in infants under two months of age, too young to be fully immunized (like Nellie). We also know that even with a full series of three to four pertussis immunizations only 85% of the children develop a level of immunity high enough to protect them. There is also recent speculation that the new pertussis cases are caused by a more virulent, mutant strain of the bacteria that can cause whooping cough even in those receiving our current vaccine. Studies have been launched to test that hypothesis.

One thing is clear. “Herd immunity”, protection of an individual infant by immunizing all the surrounding children in the community, is not enough for pertussis. Some states have refined the herd (community-wide) immunity  concept with a more focussed family-wide immunity concept, “cocooning”. Cocooning seeks to reimmunize for pertussis any adult caretakers of the infant, including the pregnant mother and all other adults surrounding the infant. The objective is too avoid any exposure of the infant to the pertussis germ in the first six months of life, or until the pertussis vaccination series can be completed. The easiest thing for adults to do is to get a Tdap (Tetanus/diptheria/pertussis) instead of their next regular tetanus booster—the Td shot – that is recommended for adults every 10 years.


Currently there are 17 preventable diseases for which we give immunizations in the first two years of life. In 1980 we only had 7 vaccines. Those 7 vaccines contained over 3000 proteins (aka “foreign protein” by anti-vaccine advocates). In 2012 our more purified vaccines, including acellular pertussis vaccine (the “ap” of Tdap) with only 2 proteins, contain a total of  less than 200 proteins in all 17 vaccines.

Ellie was on ECMO for three weeks. Every attempt to remove her from the artificial lung resulted in a dramatic drop in blood oxygen and ECMO treatment was continued. Her kidneys , heart, and lungs were stressed to the failing point. Finally, her lungs began to recover from the pertussis infection. Yesterday they put her twin in the ICU bassinet with her, and her vital signs calmed right down and became even more stable. The two looked like they just “chilled out together” as twins do. Today she will have her breathing tube removed. We antiicpate that she will breathe on her own and continue to improve. We all wonder how her brain fared during all this stress. We shall see.  Some of us wonder what all this intensive care cost?

Make sure you do everything you can so your children to get to know Elmo rather than ECMO.

Let them have their immunizations!

Vol. 66 May 1, 2012 A Medical Business and Marketing Report

May 1, 2012


The price the tooth fairy pays has increased nearly 90% since 1998 to a high of $2.50 in late 2009, but after a 2010 correction in the average price Delta Dental has downgraded its future to “uncertain”. Delta has been tracking how much money kids have been getting for teeth left under pillows for their more than 100,000 subscribers. As illustrated by the graph showing the Dow Jones average and the tooth fairy average price, both took a hit in 2008. (1)


There were more than 9000 whooping cough cases in California in 2010, a level unseen since 1940s. The number of cases in Vermont has gone from 18 to 102 in two years. The number of kindergartener who have been vaccinated against whooping cough (aka pertussis, or the “P” in the DPT vaccine) has dropped from 93% in 2005 to 83% in 2010. In Ashland Oregon the rate of unvaccinated children reached about 30%. Though the link between vaccinations and autism has been shown to be wrong, and it’s author a fraud, the far-fetched rumors on the internet continue to feed the unfounded fears about vaccinations held by many young parents. (2)


A survey of 600 men over the age of 65 who were operated on for prostatic surgery revealed that 27% of those undergoing open-surgery radical prostatectomy still suffered from significant urinary incontinence 14 months after surgery. But, 33% of those undergoing robotic-assisted laparoscopic radical prostatectomy reported urinary incontinence. After the usual caveats about differences between surgeons, the long learning curve for robotic surgery, and the lack of information in the survey about pre-surgical urinary incontinence, the editorial comment casually mentioned that 88% in BOTH groups had “moderate or big problems” with sexual function post-operatively.(3)


Between 1993 and 2006 over 4000 in the U.S. were affected in 121 infectious outbreaks from raw (unpasteurized) milk or cheese. Two-thirds of those affected were children who had more hospitalizations for these illnesses than adults. Most of these outbreaks occurred in states where the sale of raw milk and milk products is legal. (4) “Advocates of raw milk hold that pasteurization kills enzymes that make food digestible and bacteria that contribute to a healthy immune system….it tends to be richer and sweeter, and, sometimes, to retain a whiff of the farm – known to connoisseurs as ‘cow butt’.” But, raw milk is profitable. The largest raw milk diary in the world, with 430 cows in Southern California, produces 2400 gallons of milk a day which retail at $16 a gallon.(5)


A four-year study of over 34,000 adults interviewed about 18 variables revealed that the “most satisfied” patients had a 12% higher hospital admission rate, had 9% more drug prescriptions, and a death rate 26% higher than the “least satisfied” patients. The correlation between higher mortality and more patient satisfaction seems to contradict the adage that “more is always better.” (6)


In response to an on-line petition with 6000 signatures Starbucks has announced it will stop using cochineal dye to color its strawberry and raspberry products. Cochineal dye is widely used in the food industry and is extracted from a tiny beetle. The petition against the bug-based dye was started by a South Carolina woman who “wanted to inform customers that the chain’s strawberry drinks weren’t vegan-friendly.” (Now THAT’S an “angry vegan”) (7)


Partners Health Care is building a new rehab hospital across the harbor from Boston on the edge of the Charlestown Navy Yard. The architects assume the building will have a 80 year life span, and that with global warming the worst storm within 80 years might cause floods up to 5.5 feet above previous flood levels. “Looking at long-term risks, benefits, and costs the Spaulding Hospital design team decided it would be a prudent investment to put the hospital generators on the roof… And 61% of Americans don’t think global warming will pose a serious threat to them or their way of life in their lifetime.” (8)


In February the US Food and Drug Administration began requiring that drugs that lower cholesterol, statins like Lipitor and Zocor, carry a new warning that cognitive side effects such as memory loss and confusion can occur while taking statins. About 10% of statin takers already suffer from muscle ache side effects from the drug. People take statins to prevent heart disease, of course, but a 2011 Cochrane review of 14 trials of statins found that 1000 patients need to be treated for a whole year to prevent one death. (9)


Having sex does not help you lose weight. Twenty minutes of running burns about 261 calories, swimming about 182 calories, jogging about 159 calories, while twenty minutes of vigorous sexual activity for a 150-pounder burns a paltry 35 calories. It may be aerobic, but it won’t make you lighter. (10)


Nine medical specialty groups have developed a list of 45 “routine” tests  and procedures they consider unnecessary, a waste of money, and can expose patients to some risks. The list includes annual electrocardiograms for healthy people, CT scans for low back pain, chest X-rays before surgery, giving antibiotics in the first week of a cold, brain MRIs for headaches in healthy patients, and CT scans or antibiotic treatment for sinusitis . The physicians involved in the groups project (“Choose Wisely”) think that patients do play a role by asking for tests or procedures they have heard or read about, but don’t need. The groups also think that the list may help reduce the amount of “defensive medicine”, performing tests out of fear of malpractice if something is missed. (11)


A recent Avoiding Avoidable Care Conference reported that the $10 Billion a year is paid to medically injured patients (and their lawyers, of course), and that another $46 Billion is spent on “doing more than we should because we want to reduce the threat of litigation”. The total of $56 Billion represents about 8 days or only 0.02% of our annual health care spending. “It is not clear to me that [medical malpractice reform] is really going to be the thing that changes the cost curve.”said Amitabh Chandra, an economist and Professor of Public Policy at Harvard. (12)


Pitchers elbow” in Little League pitchers used to be attributed to their throwing the curveball, and its use was severely curtailed for the youngsters, but it is now making a comeback as new studies indicate that it is total number of pitches thrown rather than the type of pitch that causes the inflammatory condition. As is common in predicting future values, the range of maximum pitches allowed per week to avoid the development of “pitchers elbow” is from 150 to 300 depending on the source. Some orthopedic surgeons still feel that the curveball should remain banned from Little League play. Dr. Lyle Micheli, director of Sports Medicine at Children’s Hospital in Boston, recommends that young pitchers learn how to throw the knuckleball instead. (13)

1. Boston Globe, April 24, 2012, G 13, Rachel Zarrell
2. Boston Globe,  April 22, 2012, editorial page
3. N Engl J Med 2012 Mar 15;366 and Journal Watch General Medicine April 1, 2012;vol.32,7,p.54
4. Emerg Inf Dis 2012 March; 18:385 and Journal Watch General Medicine April 1, 2012;vol.32,7,p.56
5. New Yorker Magazine, April 30, 2012, p.32, Dana Goodyear
6. Arch Int Med 2012 Mar 12;172 and Journal Watch General Medicine, April 1, 2012;vol. 32, p.59
7. Cape Cod Times, April 20, 2012, C5
8. Boston Globe, April 20, 2012 Opinion, Joan Wickersham, A 11
9. Boston Globe, April 16, 2012, G 12, Deborah Kotz
10. Consumer Reports on Health, May 2012, p. 12, “Tip of the Month”
11. Boston Globe, April 4, 2012, B 11, Liz Kowalczyak
12. Boston Globe, April 20, 2012, B 6, Chelsea Conaboy, “White Coat Notes”
13. Boston Globe, April 1, 2012, C 2, Kevin Paul Dupont, “On Second Thought”


Vol. 59 January 15, 2012 “Good” Things That Aren’t So Good.

January 16, 2012

Oft expectation fails, and most oft where most it promises;
and oft it hits where hope is coldest; and despair most sits.
~William Shakespeare


Screening asymptomatic men for PSA (prostate specific antigen) does more harm than good.

Ten years of screening healthy men for PSA (prostate specific antigen) as a marker for prostatic cancer has not reduced the death rate from cancer of the prostate (still very low).  This single blood test has resulted in a lot of money and time spent for diagnostic tests (biopsies and their complications which “are not trivial”),  physician office visits, and aggressive therapy which have been of little benefit to patients.. Even when a biopsy confirms the presence of prostate cancer in a  high-PSA patient, there is very little evidence that there is any benefit in treating the patient that has a normal physical exam (digital rectal examination) and normal prostatic volume by ultrasound. While still controversial, recommendations from the U.S. Preventative Service Task Force include “just wait and see” if there is a bump in your annual PSA. If you as a patient can’t tolerate that, it is probably better to ask your physician to skip the blood test.

Screening for lung cancer with an annual chest x-ray doesn’t help either.

A thirteen year study of 155,000 people showed no difference in mortality rates between those who got annual chest x-rays and those who did not. In fact, 95% of the people with “positive findings” on x-ray did NOT have lung cancer. Low-dose CAT scanning of the lung may be a better screening tool, but the jury is still out on that.

What about the screening blood test (CA 125) for often-silent and frequently lethal ovarian cancer?

In a twelve and a half-year study of 68,000 U.S. women screened for ovarian cancer with a CA 125 blood level and vaginal ultrasound the women who were screened did no better in terms of earlier diagnosis, reduction in mortality, or increased longevity after diagnosis than those who were not screened. Serial measurement of CA 125  can be helpful in monitoring tumor activity in patients already diagnosed and treated for ovarian cancer, but it is of no benefit as a screening tool for ovarian cancer. Large scale clinical trials outside the U.S. are currently seeking confirmation or refuting of this viewpoint.

The vaccine against shingles (herpes zoster) is about 50% effective.

A large observational study of people who received the zoster vaccine confirmed that in the “real world”, as in the laboratory, about one-half of vaccine recipients were protected from developing the condition. In the natural course of shingles without the vaccine about 6% of people who have had shingles in the past have a recurrence within 8 years. Presumably the vaccination of someone who has had shingles in the past could reduce the recurrence rate by half to 3%.  As with all medical statistics, of course, if you get shingles it is 100% for you.

If you get a mammogram every year for 10 years the chances of having a “false positive” finding is 50%.

During ten years of study of 160,000 women receiving either annual or biennial mammograms about half of the women during the 10 year period had at least one false positive finding; a non-cancerous abnormality that led to additional imaging without a biopsy. The probability that a false positive finding during the 10 years of annual testing led to a biopsy was about 7%.

Lowering cholesterol levels in the elderly can increase their mortality rate.

A 14-year study of nearly 6000 men with an average age of 69 showed that those with higher cholesterol had LESS non-cardiovascular and less cancer-associated deaths. There was NO association between a higher cholesterol and increased cardiovascular death rates in those men between 55 and 84 years of age.  In those over 85 years old a HIGHER cholesterol level was associated with a LOWER death rate from cardiovascular disease. This means that cholesterol lowering medications (statins) are unnecessary for elderly with low coronary risk factors. So, if you or a family members are over 70 and have high cholesterol, just live with it and don’t take statins. You may live longer.

MRIs give lots of false positives in people with non-specific low back or shoulder pain.

A 1994 study of 98 normal people without back pain showed that 2/3 of them had significant and “potentially serious” findings suggesting back pain on their MRIs. But, they had no pain or other back symptoms. A more recent study of 31 professional baseball pitchers revealed that 90% had abnormal cartilage by MRI in their pitching shoulder; findings considered indications for surgery. But, none of the pitchers had shoulder symptoms, and all were in excellent health.

Lyme blood tests are misleading a lot of the time.

Guidelines for diagnosing Lyme disease by laboratory test requires a positive test of the same blood sample using two different techniques, one an “enzyme assay” (ELISA) and one an “immune blot”. The laboratory diagnosis of Lyme disease requires a positive test with both techniques. A Dutch study of 89 patients with suspected Lyme, syphilis, or mycoplasma pneumonia revealed a significant amount of cross reactivity (falsely positive Lyme test in those that had syphilis or mycoplasma pneumonia). Many samples from suspected Lyme patients had a positive ELISA test with only one of the eight commercial labs providing the test. Some tested negative on ELISA but had positive immune blot tests, and visa versa. Only 16 of the 89 had positive ELISA tests with all 8 laboratories.  This inconsistency of results confirms the opinion of infectious disease clinicians that the diagnosis of Lyme disease is a clinical judgement, not a laboratory one. Reassuringly, all healthy people tested in this study had negative Lyme test results.

1. Three PAS viewpoints, NEJM Nov. 24, 2011 and Year in Review 2011, Journal Watch Gen Med, pg.4 Jan 1, 2012.
2. Chest X-rays for lung cancer, NEJM Aug. 4, 2011 and JAMA Nov. 2, 2011 and Year in Review, Jour Watch Gen Med, pg.5 Jan. 1, 2012.
3. CA 125 in Ovarian Cancer, JAMA June 8, 2011.
4. Shingles vaccine, JAMA Jan 12, 2011 and Mayo Clin Proc February 2011
5. Mammogram false positives, Ann Int Med 2009; 151:716
6. High Cholesterol, J Am Geriatric Soc, Oct 2011
7. MRIs false positives, Wired, January 2012, pg.108
8. Lyme tests, Eur J Clin Microbiol Inf Dis, Aug 2011

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