April 17th, 2008 by Dr. Val Jones in News
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My friend (and occasional guest blogger here at the Voice of Reason) Dr. Avrum Bluming just co-authored an eye-opening exposé of breast cancer risk factors and how they’re overblown for media purposes. This article was published in the Los Angeles Times today. Here is an excerpt:
We now have a fat file folder of all the studies we could find that have reported an association between some purported risk factor and breast cancer. Of these, the ones that got the most attention were three Women’s Health Initiative reports. In 2002, investigators found an increased relative risk of 26% from using combined estrogen and progesterone; in 2003, it was 24%; and in 2004, the relative risk from using estrogen alone was minus 23% (suggesting it was protective against breast cancer).
To put those findings in perspective, consider these published studies showing the increased relative risk of breast cancer from:
* eating fish: 14%
* eating a quarter of a grapefruit a day: 30%
* gaining more than 33 pounds in pregnancy: 61%
* being a Finnish flight attendant: 87%
* being a Dutch survivor of childhood famine: 201%
* using antibiotics: 207%
* having a diagnostic chest X-ray: 219%
* being an Icelandic flight attendant: 410%
* using an electric blanket: 630% (but only if you are a black woman who used it for more than 10 years but less than six months in a given year).
Why was there no call for Icelandic flight attendants to quit (or transfer to Lufthansa), for black women to use electric blankets for more than six months a year but only for nine years, for labeling antibiotics as carcinogens? Because these findings, which were improbable to begin with, were never replicated. In contrast, the increased relative risk of lung cancer from smoking is consistently between 2,000% and 3,000%. That’s a finding that means something.
Unfortunately, good news doesn’t travel as fast as fear does. In 2006, the Women’s Health Initiative investigators reanalyzed their data and found that the risk of breast cancer among women who had been randomly assigned to take hormone replacement therapy was no longer significant. Women assigned to take a placebo but who had used hormone replacement therapy in the past actually had a lower rate of breast cancer than women who had never taken hormones.
This reassuring but non-scary news did not make headlines…
To read the rest of the fascinating article, click here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 15th, 2008 by Dr. Val Jones in Uncategorized
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My sister’s 1 year old baby had a sudden dilated pupil in only one eye, confirmed by two witnesses and lasting several minutes. I blogged about the event here, and have been quite perplexed ever since. Unequal pupils are fairly rare and don’t have all that many potential causes – some of which are life threatening (shhh).
As with many patient histories, the devil’s in the details. Although I asked my sister if there was any possible way that her baby could have gotten a strange chemical in her eye (and she assured me that nothing of the kind could have happened) my mom outed her to me via phone.
“Oh yes, they had their floors resurfaced the day prior [to the pupillary event,] and the babies were crawling all over that new floor.”
Hmm… so there WAS a potential chemical exposure after all. “Ah hah!” I thought. So I decided to do a Medline search for cases of chemical exposures causing anisocoria (pupils of different sizes). I soon realized that I’d forgotten to constrain my search to human studies, but was most amused by some factoids that I turned up.
My favorite study title was this:
“Anisocoria in the dog provoked by a toxic contact with an ornamental plant.” Surely the ornamentality of the plant is irrelevant to its toxic properties? What sort of provocation could the plant have inspired in this innocent canine? Well, it was a French study – perhaps something was lost in translation.
The runner up is this one:
“Clinical and necropsy findings associated with increased mortality among American alligators of Lake Griffin, Florida.” Apparently, different pupil sizes don’t bode well for alligator longevity, especially in Lake Griffin, Florida. Note to self – if I’m about to be attacked by an alligator, look him straight in the eye to find out if he has a chance of winning.
Honorable mention goes to:
“Liberalized screening for blunt carotid and vertebral artery injuries is justified.” Which tells me that some folks may not even notice or recall a blunt force injury to the neck – so we should be on the lookout and ready to screen people liberally for this concerning and under recognized issue.
Sigh. Did I find anything helpful about floor refinishing chemicals and potential eye effects? Nope. My attention drifted off at around study number 300 (I had gone back 10 years in the literature). Though I have to say that many journal article titles are inherently whimsical. So my dear readers – I open the question to you all: Have you ever heard of a floor finishing chemical causing a pupil to dilate?
Come on, I’m dangling a nice case report out here for you…
(And yes, we’ll keep an eye on the baby for any signs of a more ominous cause, stay tuned).
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 14th, 2008 by Dr. Val Jones in True Stories
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My husband has perfected the art of dry humor. He is very thin and naturally athletic and I tease him a lot because I’m not as thin or naturally athletic (ahem – yeah, I’m jealous). So we have a running joke about him being skinny.
Today I needed to find my sister’s mailing address really quickly, and realized that the only place we had saved it is my husband’s Gmail contacts list. To retrieve them I’d have to use his login and password (which I could guess at, but didn’t really want to do without his permission first). Unfortunately I couldn’t get through to him at work, so I just went ahead and logged in (correctly guessed his password) and retrieved my sister’s address.
I emailed my husband apologizing for hacking into his Gmail account without his permission. This was his response:
“That’s ok. I’m the only skeleton in my closet.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 13th, 2008 by Dr. Val Jones in True Stories
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I received a panicked call from my younger sister today. She is the mother of one-year-old identical twin girls, born slightly prematurely. During her pregnancy she had a problem with twin-twin transfusion syndrome and had to lie on one side for many weeks to ensure that both girls received an adequate blood supply. She delivered by Cesarean section and fortunately both girls have been doing well. That is, until a few hours ago.
My sister described an episode in which her daughter was in the bathtub and suddenly had one of her pupils become very large. It remained dilated for several minutes, which caused her to call her husband in to take a look. He confirmed that the eye was dilated and they decided to call me right away because they’d heard that a dilated pupil might have something to do with concussions or head injuries, though the little girl had not had any recent trauma to her head.
I tried to get a full history from them – they said she was acting “totally normally” – the usual peeing, pooping, eating checks were fine. They said she was sleeping well, not vomiting or lethargic, and that her pupil had now (after several minutes) returned to normal size. They said her fontanel was not bulging, and when I asked them to shine a light in her eyes they both constricted immediately.
My sister asked me, “what could this be?”
Ugh. I’m not a pediatrician, nor an ophthalmologist, but I do know that asymmetric pupils are usually an ominous sign. All I could think of was “space occupying lesion” but I didn’t want to scare my sister unnecessarily. All the other history sounded so reassuring (the child was well, with no apparent behavior changes, the eye had returned to normal, etc.) that I had to say that they should get in touch with the pediatrician on-call.
And here’s where things got confusing. My mother called me by coincidence just after I hung up the phone with my sister. She had been visiting with the babies for a full week, and slept next to their cribs during their vacation. I told my mom about the pupil issue, and she started relaying some potential “symptoms” that she had witnessed over the past week or so. She claimed that the baby had indeed vomited recently, that her behavior was different than her twin (more irritable and emotionally labile) and that her sleep patterns were also disrupted.
Now I was more concerned – was this early hydrocephalus or maybe even brain cancer? Would I be responsible for missing a diagnosis? I was thousands of miles away from the infants and trying to piece together a story from historians with different observations. So I called some pediatrician friends of mine and asked what they made of this. One said – “anisocoria is a concerning symptom in an infant, she needs a CT or MRI to rule out a tumor pressing on her eye nerve. She should go to the ER immediately.” The other said that since there were no other current symptoms, and the eye was back to normal, it should be worked up by an ophthalmologist as an outpatient.
What a bind to be in – I have some witnesses describing very concerning symptoms, others suggesting that everything’s fine except for a fleeting period of pupil size mis-match. I have dear friends suggesting everything from an immediate ER visit with sedation of the child and a head CT or MRI to watchful waiting and distant outpatient follow up. And I have my sister relying on my judgment (as a non-pediatrician) to tell her what to do.
Here’s what I did – I got my sister and her husband on the phone and explained to them that I take their observation of pupillary dilatation very seriously. I explained that this is not a normal event, and should be followed up by an expert to make sure that there’s no underlying cause of the eye symptoms. I also said that the fact that the baby is acting normally and the eye is no longer dilated are reassuring observations. I told them that they should keep a close eye on the infant, and that if they see any hint of recurrence of the pupil problem, or anything out of the ordinary like vomiting, inconsolability, lethargy, swollen fontanel, fever, or strange body movements or seizures, they should go to the ER immediately. In the meantime they should alert the doctor on-call to the situation and discuss everything with their pediatrician during her next available office hours.
I hope that was the right approach. I will not rest easily until the baby has been fully examined by an expert. Being a doctor carries with it a lot of anxiety and personal responsibility – at any time of the day or night your peace of mind can be uprooted by an abnormal finding relayed to you by friend, family, or patient. And if anything goes wrong – or if interventions are not achieved at an optimal speed and accuracy, this question will forever plague you: “Should I have done something differently?”
Who knew that my relaxing Sunday afternoon would be turned upside down by a dilated pupil?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 12th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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I recently wrote about some awkward moments that I’ve had with my patients over the years. However, I think that Shadowfax’s blog post may win the award for most distressing patient encounter.
A hospitalized, elderly man was very ill and had requested to be considered DNR (do not resuscitate). Many years prior he had had a defibrillator implanted so that his heart would be automatically shocked if it went into an abnormal rhythm. His family gathered around him as he died peacefully from old age coupled with infection. The defibrillator, however, correctly recognized an “abnormal heart rhythm” (i.e. a flat line) and continued to shock the deceased man’s heart at regular intervals, causing his chest to twitch in front of his pained family members. The hospital’s defibrillator magnet (the off-switch for the device) had been misplaced, and so physicians were left to call neighboring hospitals and cardiologists to try to shut the machine off.
In the process of trying to locate the magnet, the doctors had to identify the brand of the defibrillator – a Saint Jude device. As it happened, one of the doctors receiving the request for the magnet was Catholic, and recognized the grim irony of the situation.
Saint Jude is the patron saint of lost causes.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
