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

October 15, 2018

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

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

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

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

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

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

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

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

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

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

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

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Vol. 118 January 15, 2015 It Ain’t Just Vaccines That People Decline

January 15, 2015

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Half of U.S. patients don’t take their medicines as prescribed by their physicians.(1,2)

We use to call such patients “non-compliant.” As “patient-centered care” became the mantra for contemporary medicine that “passive, judgmental” term of “non-compliant” was banished and replaced by “non-adherent”, a presumably less derogatory term implying a partnership of patient and physician. (3)

A cardiologist, struck by the number of her patients that did not comply with adhere to their heart medicine prescriptions, asked 20 of them who had survived a heart attack why they didn’t adhere to medications that had proven benefits of secondary prevention of a next event, an event that could cause death. (4) Their comments (listed first below)  were surprisingly similar to feelings expressed to me by parents who decline immunizations for their children (typed in bold italics ).

1. Risk Aversion
“Why take medicine that could wreak havoc on your body.”
In people with negative emotional reactions even a small risk of side-effects seemed to overpower any positive feeling about the proven benefits of a drug. Their perception of risk is greater than their perception of benefit. They are “far more sensitive to possibility than to probability”.(5)
Despite numerous studies showing that there is no probability of an association between measles vaccination and childhood autism some parents still feel that there is always the possibility. Arguing relative probabilities of vaccine side effects versus disease effects with them is not productive.

2.Naturalism
“Medications are chemicals and should not be in your body on a regular basis”.
Vitamins, herbs, and other health supplements of all kinds are often turned to because they are not “chemicals”.
“I don’t want to have any foreign proteins injected into my child”. Natural immunity, of course, depends on our body recognizing and reacting to foreign proteins so that symptoms resolve and our next exposure to the same foreign protein doesn’t make us sick again. “It is the additive proteins that we don’t want” is often the next statement from the parents. Pointing out that there are 315 “foreign proteins” in today’s vaccines  rather than the thousand’s in the vaccines before the 90’s does not reassure them.

3.Denial
“Men don’t like taking medicine because to do so they are admitting that they are not strong. Most people like to think that they are strong and mighty. …Their very sense of well-being after surviving a heart attack and quickly resuming healthy lives may convince them that medications are not necessary.”
Some parents feel that their unimmunized children are safe from disease because the rest of the children are immunized, the “herd immunity protection” argument. Pointing out that herd immunity is effective only when the community reaches the currently unachievable high percentage of immunity (a 94% threshold in measles and whopping cough) has no effect. You would think that the possibility of measles in their unimmunized child in a partially immunized community would override the small probability of side effects from the vaccine. It doesn’t with some parents.

4. Avoidance of Sick Identity
“Has having a heart attack become too easy?” People can spend more time being sick from flu than having a therapeutic cardiac cath within 90 minutes of arriving at the ER and walking out of the hospital 24 hours later.
Has the absence of children dying or being crippled by measles, polio, diphtheria, or croup dulled our ability to imagine our children in such a sick state? Sporadic epidemics of whooping-cough and croup in certain states have been successful in raising immunization rates a bit. If there were an Ebola vaccine, I wonder how the vaccination  non- adherent parents would have juggled that possibility/probability calculation for their children.

5. Difficulty Visualizing Benefits
“The benefits of cardiac medications may be imperceptible and the absence of perceived benefit is a well-documented reason for non-adherence”. Adherence to anti-platelet medications (“blood thinners”) is higher than other cardiac meds perhaps because the patient can easily visualize the “thinned” blood flowing smoothly through an unclogged pipe. That the medication is actually “doing something” is reaffirmed by the prolonged bleeding from a razor nick.
Maybe we pediatricians should develop an app and FitBit that could non-invasively measure antibody levels and send an alert to the child (via his/her own smart phone, of course): “Your antibodies against [insert tetanus, diphtheria, or whatever disease name here] have been declining for years and are now at a level that no longer protects you. Go immediately to your nearest [insert sponsoring drug/ convenience/department store name here] and get vaccinated.”

6. Avoiding Dependency
“Relying on cardiac medications is another form of addiction. I brought on this heart attack by my life style and it is my responsibility to avoid another by changing my life style.” Taking medications may be viewed as a loss of control, as “following orders” , as “being told what to do”.
This rejection of authority rings true in my experience with some parents who decline immunization for their children. It also may explain why pockets of unimmunized children who are not in poor families are sometimes clustered within tree-hugging, organic food eating, aging-hippy communities. Frustrating as this rejection of authority is to the physician, repeatedly battering the head and shoulders of these parents with all the scientific facts proving that vaccinating their child is safer than having them contract the disease is counter-productive.

The discussion with parents who decline immunizations for their children is hardly ever a rational one. Some beliefs and feelings seem impervious to facts. Certainly a parent’s personal knowledge of some child, usually a cousin or a nephew/niece, who had a vaccination and then had a seizure or who “has never been the same since” is a real conversation stopper. That personal experience can generate such deep feelings that I no longer even try to talk them out of that hole. We don’t experience that same depth of feelings if an older adult we know survives a heart attack only to die of a second one months or years later. We often feel, not knowing all the details, that “C’est la vie”.

References:
1. NEJM 2005;353:487-97 Adherence to Medication
2. J Gen Intern Med 2008;23:115-21 Secondary Prevention After MI
3. Ann Pharmacotherapy 2004;38:161-2 Adherence or Compliance?
4. NEJM 2014;372;2:184-7 Beyond Belief
5. Psych Bull 2001;127:267-86 Risk as Feelings


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