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Weight Loss: Another Scary Option

I came across an interesting weight loss invention this weekend that proposes to allow people to have their cake and eat it too.  Scientists have constructed a kind of plastic intestinal condom to block digestion of food.  Since gastric bypass surgery essentially reduces food absorption while decreasing stomach size, this removable plastic lining could act as a sort of non-invasive alternative to such a permanent procedure.  Sounds intriguing?

Well, before we get our hopes up, it’s always best to check with the gastroenterologists.  I dropped Dr. Brian Fennerty a note to ask him what he thought of this proposed weight loss solution.  His response was enlightening – “The Endobarrier Gastrointestinal Liner is potentially very dangerous as it may block the pancreatic duct and cause pancreatitis, dislodge resulting in bowel obstruction, or ulcerate. There are no comparative trials and as such I would consider it investigational at best.”

Why is blocking the pancreatic duct scary?  The pancreas is a little organ that should get a lot more respect, in my opinion.   It produces enzymes that are secreted into the intestine to break down food – I like to think of the pancreas as a bag that contains acid as strong as Alien blood (those of you who’ve seen the movie will get that reference).  Basically, the pancreas can liquify a steak – so plugging up the exit route for those enzymes is a really bad idea.  You can imagine why pancreatitis is so painful.

And then there’s the risk of the liner getting loose and wadding up in a plastic ball and blocking your bowels, or the risk of the plastic irritating the intestinal lining and causing an ulcer which could bore a hole straight through your gut.

Well, I don’t mean to resort to scare tactics here… but honestly, this procedure has serious risks that one doesn’t really get from the media’s article on the subject, “New Procedure Could Help Millions.”  So be careful out there folks – always check with your doctor before you try something new to lose weight.  I’m afraid that diet and exercise are really the safest options out there.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The Last Straw: My Road To A Revolution

This week’s host of medical grand rounds invited individuals to submit blog posts that feature stories about “sudden change.”  As I meditated on this theme – I realized that one of my patients played a key role in my sudden career change from academic medicine to joining a healthcare revolution.

As chief resident in PM&R, I spent a few days a month at an inner city clinic in the Bronx, helping to treat children with disabilities.  The clinic was dingy, overcrowded, largely windowless, and had waiting lines out the door starting at 8am.  Home health attendants generally accompanied the wheelchair-bound children to the clinic as many of them were orphans living in group home environments.  The kids had conditions ranging from cerebral palsy, to spinal cord injury from gun shot wounds, to severe spina bifida.  They sat together in a tangled waiting room cluttered with wheelchairs, walkers, crutches, and various prosthetics and orthotics.  There were no toys or even a TV for their amusement.  The air conditioning didn’t work well, and a lone clock ticked its way through the day with a bold black and white face.

The home health aides were eager to be called back to the examination rooms so that they could escape the oppressive conditions of the waiting room.  I opened the door to the room and called the name of one young man (we’ll call him Sam) and an aide leapt to her feet, knocking over another patient’s ankle-foot orthosis in the process.  She pushed Sam’s electric wheelchair through a series of obstacles to the exit door and back towards the examining room.

Sam was a teenager with cerebral palsy and moderate cognitive deficits.  His spine was curved into an S shape from the years of being unable to control his muscles, and he displayed the usual prominent teeth with thick gums of a patient who’d been on long-term anti-seizure medications.  He looked up at me with trepidation, perhaps fearing that he’d receive botox injections for his spastic leg muscles during the visit.  His wheelchair was battered and worn, with old food crumbs adhering to the nooks and crannies.

“What brings Sam here today?” I asked the home health aide, knowing that Sam was non-verbal.  She told me that the joystick of his electric wheelchair had been broken for 10 months (the chair only moved to the left – and would spin in circles if the joystick were engaged), and Sam was unable to get around without someone pushing him.  Previous petitions for a joystick part were denied by Medicare because the wheelchair was “too new” to qualify for spare parts according to their rules.  They had come back to the clinic once a month for 10 months to ask a physician to fill out more paperwork to demonstrate the medical necessity of the spare part.  That paperwork had been mailed each month as per instructions (there was no electronic submission process), but there had been no response to the request.  Phone calls resulted in long waits on automated loops, without the ability to speak to a real person.  The missing part was valued at ~$40.

I examined Sam and found that he had a large ulcer on his sacrum.  The home health aid explained that Sam had been spending most of his awake time in a loaner wheelchair without the customized cushioning that his body needs to keep the pressure off his thin skin.  She said that she had tried to put the electric wheelchair cushion on the manual chair, but it kept slipping off and was unsafe.  Sam’s skin had been in perfect condition until the joystick malfunction.  I asked if he’d been having fevers.  The aide responded that he had, but she just figured it was because of the summer heat.

Sam was transferred from the clinic to the hospital for IV antibiotics, wound debridement, and a plastic surgery flap to cover the gaping ulcer hole.  His ulcer was infected and had given him blood poisoning (sepsis).  While in the hospital he contracted pneumonia since he had difficulty clearing his secretions.  He had to go to the ICU for a period of time due to respiratory failure.  Sam’s home health aide didn’t visit him in the hospital, and since he was an orphan who was unable to speak, the hospital staff had to rely on his paper medical chart from the group home for his medical history.  Unfortunately, his paper record was difficult to read (due to poor handwriting) and the hospital clerk never transferred his allergy profile into the hospital EMR.  Sam was violently allergic to a certain antibiotic (which he was given for his pneumonia), and he developed Stevens-Johnson Syndrome and eventually died of a combination of anaphylaxis, sepsis, and respiratory failure.

When I heard about Sam’s tragic fate, it occurred to me that the entire system had let him down.  Bureaucratic red tape had prevented him from getting his wheelchair part, poor care at his group home had resulted in a severe ulcer, unreliable transfer of information at the hospital resulted in a life-threatening allergic reaction, and a lack of continuity of care ensured his fate.  Sam had no voice and no advocate.  He died frightened and alone, a life valued at <$40 in a downward spiral of SNAFUs beginning with denial of a wheelchair part that would give him mobility and freedom in a world where he had little to look forward to.

Sam’s story was the last straw in my long list of frustrations with the healthcare system.  I began looking for a way to contribute to some large scale improvements – and felt that IT and enhanced information sharing would be the foundation of any true revolution in healthcare.  And so when I learned about Revolution Health’s mission and vision, I eagerly joined the team.  This is a 20 year project – creating the online medical home for America, with complete and secure interoperability between hospitals, health plans, healthcare professionals, and patients.  But we’re committed to it, we’re building the foundation for it now, and we know that if successful – people like Sam will have a new chance at life.  I can only hope that my “sudden change” will have long lasting effects on those who desperately need a change in healthcare.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

You Should Report Adverse Drug and Supplement Reactions

How do we know when a drug, supplement, or herbal remedy causes harm?  Most people assume that clinical trials provide the only mechanism for determining adverse outcomes but actually, consumers can report concerns directly to the FDA as well.

Did you know that the FDA accepts reports from consumers and healthcare professionals alike on their website, MedWatch Online Reporting?

Herbs, supplements, and “natural” medicines are bioactive substances that many people use to treat diseases and conditions.  They are not regulated for safety and efficacy, and are only now being scrutinized for accuracy of their contents.  Since we’re behind the ball on rigorously testing supplements (though it’s great that NCCAM is evaluating as many of them as their resources allow), it’s important for consumers of herbs and supplements to report adverse outcomes (like allergic reactions, harmful side effects, etc.) to the FDA.  How else will your fellow consumers find out about these unwanted side effects?

MedWatch also welcomes reports about adverse outcomes from prescription and OTC medications, medical devices, or cosmetic products.  I think this is an underutilized resource and could greatly improve public safety if we all pitched in and reported concerning events when they happen.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Bone Cells Might Influence Weight Gain and Diabetes

I rarely get too excited about mouse studies, but this one is pretty amazing.  Researchers at my alma mater have discovered that osteoblasts (cells that create bone) secrete a certain protein that affects the health of the pancreas.  The protein (osteocalcin) stimulates the pancreas to create more insulin-secreting beta cells.  When people don’t secrete enough insulin, the result is often type 2 diabetes.  So a healthy pancreas with a good insulin secreting capacity is critical to regulating blood sugar.

The researchers also discovered that mice who were bred to have no osteocalcin gene had abnormal amounts of fat in their bodies.  So this means that bones may have something to do with energy metabolism and weight gain.

Of course it’s too early to speculate on the implications of all this (what’s true for mice is not necessarily true for humans – but I’m going to anyway).  Since bone cells (osteoblasts) are sensitive to gravity, and increase their activity with weight bearing, this could explain why exercise (especially weight lifting) is important in weight loss.  The new ACSM guidelines recommend weight training as part of a healthy exercise regimen, and the underlying mechanism for this may be that bone cells rev up metabolism and insulin secreting capacity in response to weight lifting.

So, if you want to lose weight – make sure you stimulate those bone cells with some good weight bearing exercises.  They may just help to reduce your risk of type 2 diabetes as well!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

"Black Market Milk:" People Are Seeking Out Raw Milk Against Medical Advice

The New York Times exposed an interesting counter-culture phenomenon today: drinking raw milk.  Grocery store milk has been heated and packaged in a nearly sterile fashion so that no harmful bacteria are in it.  Farmers collect raw milk from cows, then pasteurize (a heat treatment) and homogenize (blend the creamy part with the skim part) it before packaging the milk for human consumption.  This process has virtually eliminated milk borne illness in this country, including the transmission of Tuberculosis, Salmonella, E. coli, and Listeria.

So why are people fascinated with raw milk and seeking out farmers who will sell them milk prior to heat treatment?  Raw milk does taste slightly different (I think it’s a little bit more “gamey”) and there’s no doubt that the creamy layer that floats on the top is delicious.  In New York City raw milk has a black market, cult following.  Should you jump on the bandwagon?

As my regular readers know, I grew up on an organic dairy farm, and had the pleasure of handling cows up close and personal for at least a decade.  In fact, their sweet-smelling grass breath, and not so sweet-smelling cow patties are etched permanently in my mind.  Cows are curious, somewhat dim witted, and generally oblivious to the terrain upon which they tread.
Cows will stand in manure for hours without a moment’s regret, should you present them with fresh hay to eat or some nice shortfeed.  They drop patties on the ground, in their troughs, and occasionally on one other.  Their flicking tails often get caked with manure as they swish flies away and they scratch their udders with dirty hooves as well.

This is why when it comes time to milk them, farmers need to wipe their udders carefully with a disinfectant scrub before applying the milk machine.  Mastitis (or infection of the udder teets) is not uncommon, and is a reason for ceasing to milk a cow until the infection has cleared.

And so, the cleanliness of raw milk depends upon whether or not the farmer removes all the excrement carefully, scrubs the teets well, and remembers not to milk the cows with mastitits.  It also matters whether or not the cows are harboring certain strains of bacteria – which often don’t harm the cow, but cause very serious problems for humans.

Did I drink raw milk as a kid?  Occasionally, yes.  Were my parents super-careful about the cleanliness of the milk?  Yes.  Did I ever get sick from raw milk?  No.  Would I give raw milk to my kids?  No.

I appreciate that gourmands want to experience the flavor of raw foods, but for me, the risks are simply not worth it when it comes to milk.  There is no appreciable nutritional benefit to drinking raw milk (in fact, store bought milk is fortified with Vitamin D, which is critical for healthy bones), and it caries a small risk of serious infection.  If adults want to take that risk, they may do so – but I would strongly encourage them not to put their kids at risk.  I agree with the FDA’s ban on interstate sales of unpasteurized milk, and would not want to see raw milk available widely for general consumption.  Of course, to get around this ban, some companies are selling raw milk and cheese under the label “pet food.”

It’s a crazy country we live in – anti-bacterial hand wipes, soaps, gels, plastics and an insatiable appetite for raw milk.  As a doctor, I throw up my hands.  What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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