February 8th, 2008 by drval in Expert Interviews, News
Tags: Cardiology, Endocrinology, News, Research
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Much to the dismay of scientists, policy makers, and health care administrators, good medical decision making is not always black and white. I understand and sympathize with our desire to distill complex disease management issues into specific, easily measured variables. But unfortunately, the human body is exceedingly complex, and willfully resists reductionist thinking.
The recent ACCORD trial (which was designed to quantify the value of aggressive glucose management in a diabetic population) actually demonstrated a higher mortality rate in the intensive treatment group. What? That’s right, people were more likely to die if they had been randomized to the group that used all means necessary to keep blood sugars in a near normal range.
Now, this does NOT mean that it’s a bad thing for diabetics to keep tight control of their blood sugars, but it MAY mean that if they have to take high doses of multiple drugs to get them to that aggressive goal, the negative drug side effects may collectively outweigh their benefits.
I spoke with Dr. Zachary Bloomgarden, a renowned diabetes expert, to discuss his interpretation of the trial results. Here is a snippet from our interview:
My feeling is that this study shows that there is an art to medicine, and that patients can’t be managed via cookbook methods to treat their disease. If a person can control their blood sugar to an A1c of 6.0 without using too many medications, then that might be a good goal for him or her, but if you have to take high doses of several pills to get to that same goal (and therefore experience all the unfavorable additional side effects from taking them like weight gain, fluid retention, and potential arrhythmias) then it might not be appropriate in that case.
Ultimately, it takes a personalized approach by an experienced physician to determine the best treatment plan for an individual patient. One size doesn’t fit all - that’s part of my
take away from this study. We still
certainly want all people with diabetes to do as well as they can with blood
sugar as well as blood pressure, cholesterol, and the myriad other markers of
control of the disease.
And so my plea is that in our race to ensure “quality care for all” in this country, we take a moment to consider that real quality may not be about getting every patient to the same blood test target, but to get every patient to a primary care physician who can apply evidence based recommendations in a personally relevant way. Cookbook medicine is no substitute for good clinical judgment. Let’s invest in our primary care base, and make it financially viable for them to spend the time necessary to ensure that their patients are on individually appropriate therapeutic plans. I hope our next President will appreciate the critical role of primary care in a healthy medical system.
Addendum: a like-minded fellow blogger weighs in on the study
.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 4th, 2008 by drval in Medblogger Shout Outs, News
Tags: Beauty, Complementary And Alternative Medicine, Dermatology, Hospitals, Infectious Disease
2 Comments »
I learned something interesting today from Dr. Benabio’s Derm Blog: bacteria love to grow in skin cream. He said that it was kind of like cream cheese - leaving it out at room temperature would cause it to go bad pretty quickly, were it not for the usual preservatives. He described an outbreak of a deadly bacterial infection in a hospital ICU - caused by nurses using “all natural” European (preservative-free) skin cream on their patients.
So there you have it folks - deadly bacteria are indeed “all natural.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 31st, 2008 by drval in News
Tags: Cancer, Dermatology, News, Pathology, Skin Cancer, Veterans Affairs
4 Comments »
Tonight (Jan 31, 2008) the CBS evening news will be airing a segment about a tragic case of a young Marine who died of melanoma. According to the news transcript, an unusual mole was diagnosed as a melanoma in 1997, but no follow up was scheduled, and no explanation given to the young man about his diagnosis or treatment plan. Eight years later in Iraq he complained to medical personnel of the mole growing larger and he was told it was a wart which would be treated once he returned to US soil. He slipped through the cracks somehow, and tragically died in 2008 of stage IV melanoma.
One interesting issue raised in the segment is that the Marine was not eligible to to sue for negligence in his case. There is a law, the Feres Doctrine, that denies military personnel the right to sue the government in cases of perceived or real medical malpractice. The rule was established in 1950 after a case was brought to the U.S. Supreme Court (Feres v. United States) in which servicemen who picked up highly radioactive weapons fragments from a crashed airplane were not permitted to recover damages from the government.
While I do understand (in theory) the purpose of this law - if every battle injury allowed soldiers to sue the government, we’d bankrupt our country in the span of a year - it does seem to be over-reaching in this case. The Marine was not injured in battle, but his life was indeed compromised by sloppy medical follow up. In my opinion, the doctor who correctly diagnosed him in 1997 should be held accountable for lack of follow up (if that’s indeed what happened). As for the military personnel who thought the Marine’s advanced melanoma was a wart, that is a tragic misdiagnosis, but hard to say that there was malpractice at play. With limited access to diagnostic pathology services, it is difficult (in the field) to be sure of the diagnosis of a skin lesion. And yes, I can imagine that an advanced melanoma could look wart-like. This is a tragic shame, but since the young man had the melanoma for 8 years prior to the misdiagnosis of the “wart,” in the end I doubt that a correct diagnosis at that point would have changed his terminal outcome.
But I wonder if the Feres Doctrine should be modified to allow for more accountability amongst military physicians in caring for diseases and conditions unrelated to military service? Although I am not pro-lawsuit, it does seem unfair that this Marine was denied the opportunity to pursue justice in his case. What do you think? Check out the segment with Katie Couric tonight and let’s discuss.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 25th, 2008 by drval in News
Tags: Infectious Disease, News, Research, Vaccines
1 Comment »
I spent a year working in a vaccine research laboratory at the Mayo Clinic. My project involved analyzing the DNA of military personnel who had died of the measles in the early 20th century. Strangely enough, the military saved small pieces of their flesh embedded in paraffin wax (and frozen) for future study. I guess that “future study” was my research project.
I must admit that I felt a little bit creepy as I cut tiny slivers of tissue out of the waxy fossils. I wondered about the lives of the tissue’s original owners. Who were these soldiers? Did their families still think of them? Did they leave wives and children behind?
Well, as it turned out, most of the tissue samples had a little piece of DNA in common and it was pretty exciting to discover what may have been a genetic susceptibility to this particular virus. Figuring out why some people survive the measles while others are overcome and die from it can be the turning point in understanding how to protect future generations from its ravages.
Today I read about some new research linking susceptibility to the influenza virus to certain family lineages. This makes perfect sense, since our body’s ability to defend itself against disease is largely based on our genetic code. However, we’re only just beginning to unwrap the subtle role of each piece of DNA code in our immune function. The complex interactions of microscopic proteins and chemicals in our bodies is much more difficult to interpret and predict than we can even fathom. Nonetheless, it’s really exciting that we’re inching closer to being able to protect ourselves from scary viruses. We’ve won a few battles, but haven’t yet won the war.
And on another front, some researchers are working on modifying the ebola virus so as to render it harmless to humans. I’m not sure I’d want to sign up for THAT research project, frankly. I have a lot of respect for those who work in labs with such risky pathogens - but let’s just say I wouldn’t want to invite those folks out for a beer.
Let’s keep an eye on scientific discoveries in the field of virology. With the bird flu and other threats looming on the horizon, our lives may one day depend on it!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 23rd, 2008 by drval in News
Tags: Illicit Drugs, Pathology, Pharmaceuticals
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I was shocked and saddened to hear of the sudden and unexpected death of actor Heath Ledger. As fate would have it, I had watched his movie, “Candy” on the weekend prior to his death. Candy is the sad story of a young Australian couple who get involved in the drug culture, begin shooting heroin, and end up as junkies, prostituting themselves to afford their habits.
While the cause of Heath’s death is not yet known, a drug overdose is suspected and autopsy results will not be available for up to two weeks. A coworker asked me why the results would take so long, and what’s involved in an autopsy. I found a good article on the subject and will excerpt it here:
- Before the actual autopsy, as much information as possible is gathered about the person who died and the events that led to the death. Other information may be gathered by investigating the area where the person died, and studying the circumstances surrounding the death.
- Procedures done during the autopsy may vary depending on the circumstances surrounding the death, whether the medical examiner or coroner is involved, and what specific issues are being evaluated during the autopsy.
- The autopsy begins with a careful examination of the external part of the body. Photographs may be taken of the entire body and of specific body parts. X-rays may be taken to evaluate skeletal or other abnormalities, confirm injuries, locate bullets or other objects, or to help establish identity. The body is weighed and measured. Clothing and valuables are identified and recorded. The location and description of identifying marks, such as scars, tattoos, birthmarks, and other significant findings (injuries, wounds, bruises, cuts), are recorded on a body diagram.
- A complete internal examination includes removal of and dissection of the chest, abdominal, and pelvic organs and the brain. The examination of the trunk requires an incision from the chest to the abdomen. The removal of the brain requires an incision over the top of the head. The body organs are examined before removal, then removed and examined in detail.
- In some cases, organs may be placed in a preservative called formalin for days to weeks prior to dissection. This is particularly important in the examination of the brain for certain types of diseases or injuries. Tissue samples are taken from some or all of the organs for examination under a microscope.
- Completion of the autopsy may require examination of tissues under a microscope, further investigation of the circumstances of death, or specialized tests (such as genetic or toxicology tests). The tests performed may vary based on the findings at the autopsy dissection, the circumstances of death, the questions asked about the death, and the condition of the tissues and body fluids obtained at autopsy. A written report describes the autopsy findings. This report may address the cause of death and may help answer any questions from the deceased person’s doctor and family.
So it makes sense that autopsy results take as long as they do. A thorough investigation requires everything from documenting items from the scene of the death, to a careful analysis of blood toxins, to preserving tissues in formalin before viewing them under a microscope. All of the clues must be carefully weighed (Is there any evidence of a heart attack? Was there a blot clot in the lungs? Was there a brain hemorrhage?) to get the full picture and to be sure of the exact cause of death. All things considered, it’s amazing that the pathologists can render an opinion so quickly.
My heart goes out to Heath’s family as they await closure on the cause of his death.
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See also:
Mira Kirshenbaum discusses depression, suicide, and a healthy way to handle stressful life circumstances
.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 16th, 2008 by drval in News
Tags: Disabilities, News, Pharmaceuticals, Physical Medicine And Rehabilitation, Psychiatry, Research
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We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
- The US Declaration of Independence, July 4, 1776
When I was in college I spent my summers working with mentally and physically disabled adults in group homes and camps. Many of the patients had IQs<75, which presented a unique communication challenge. Emotional outbursts were not uncommon as the adults used the only form of communication that seemed to draw attention to an immediate need. I spent a lot of my time trying to predict needs before frustrations bloomed, and after getting to know the peculiarities of each individual, I could generally keep the group in a fairly content state.
Most of the adults were on a long list of medications - some were for epilepsy, others were for heart defects, but many were antipsychotics and sedatives. At the time I didn’t realize exactly what each medicine was for, and wondered why these relatively young men and women needed so many pills.
In retrospect I believe that many of the medicines were a misguided attempt to control behavior. It’s analogous to giving someone, with their hand in a bucket of very hot water, a pain medicine instead of removing their hand from the bucket. And now new research in the Lancet suggests that antipsychotic medications (such as haldol or risperdal) do little or nothing to control aggressive behavior in the mentally disabled (though not psychotic) population.
So why have we been giving mentally disabled individuals antipsychotics for decades? Sadly, we thought that these pills would provide a quick and easy way to conform their behavior to our sensibilities, without having to get to know the reasons for their frustrations. And of course, these people weren’t intellectually sophisticated enough to question the utility of this approach or to decline the use of such medications.
I find it terribly sad that it has taken us this long to realize that giving anti-psychotics to mentally impaired people is not in their best interest. Surely more evidence would have been gathered prior to subjecting “normal” adults to such treatments. In this imperfect world, it does seem that those without a voice are less often heard. It is our responsibility as healthcare professionals to look after their interests and not take the easy way out. Mentally disabled individuals have the right to express themselves, and to be free of unproven and unnecessary drug treatments. Life, liberty, and the pursuit of happiness. Our own Declaration of Independence argues as much.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 3rd, 2008 by drval in News
Tags: News, Psychiatry, Relationships, Weight Loss
4 Comments »
A colleague of mine asked me what I thought about the recent New York Times article correlating household clutter with weight gain. It’s an interesting connection, so I thought I’d blog about it.
I think that clutter is probably a reflection of person’s emotional state, personality type, and upbringing. Some people seem to be more orderly by nature, others don’t focus on neatness as much. Some of us were trained to make our bed every morning, a few had a parent or nanny to do that. And still others have been “whipped into shape” by their spouse. Overall I think most of us prefer some degree of order over chaos, and given the choice would like to keep a fairly orderly home.
Now, what’s interesting to me is the emotional component in all this. We each have a certain level of baseline neatness, and we stray from that when we feel anxious, depressed, or exhausted. Think about what your house looks like now - is it at your natural baseline of orderliness? If not, are you more anxious, depressed, or tired than usual? I bet there’s a connection.
Many people gain weight when they’re anxious, depressed, or sleep deprived. So in a way, household messiness can be a marker for emotional distress. And it’s the emotional distress that fuels the weight problems. When a person is ready to lose weight, they’re probably motivated because they’ve managed to rise above their emotional concerns to achieve their goal.
So my point is this: take a look at your home to get a sense for how you’re doing emotionally. Are you anxious or depressed about something? Are you having relationship problems? Are you having difficulty sleeping?
Revolution Health has expert-led groups available to help you understand your emotions and how they influence your behavior. I think you will really benefit from getting into a discussion group and sharing your stories with others like you.
Here are some examples of groups that you can join right now (click to join):
Relationship Help - Mira Kirshenbaum, Counselor
Sleep Better - Steve Poceta, MD, Neurologist
Take Charge of Your Life - Ned Hallowell, MD, Psychiatrist
Lose Weight - Val Jones, MD, Rehabilitation Medicine
A Fit Family- Stacy Stryer, MD, Pediatrician
De-stress - Brad Jacobs, MD, Internal Medicine
Quit Smoking - Joe Scherger, MD, Family Medicine
Walk Your Way Thin - Jim Hill, PhD, Psychology
Maintain Your Weight - Chris Newport, Personal Trainer
Eat Right- Sandra Foschi, Nutritionist and Physical Therapist
Why not join a group? They may really help you to look and feel your very best this New Year. Not too many websites will offer this for free as Revolution Health does.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 27th, 2007 by drval in News
Tags: Hospitals, News
2 Comments »
A hat tip to KevinMD’s guest blogger, JoshMD for this great link. The British Medical Journal offers a short historical analysis of 7 common medical myths, sometimes perpetuated by physicians themselves:
- People should drink at least eight glasses of water a day
- We use only 10% of our brains
- Hair and fingernails continue to grow after death
- Shaving hair causes it to grow back faster, darker, or coarser
- Reading in dim light ruins your eyesight
- Eating turkey makes people especially drowsy
- Mobile phones create considerable electromagnetic interference in hospitals.
To find out why each of these commonly held beliefs are either untrue or unsubstantiated, check out the original journal article. It’s a lot of fun.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 11th, 2007 by drval in News
Tags: Infectious Disease, News
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I was troubled by an article that I read in the Washington Post today. Apparently a common cold virus (adenovirus) has mutated unexpectedly into a killer strain (with a death rate as high as 23% for those infected in Oregon). The CDC has been carefully tracking this virus over the past year, and has noted outbreaks in Oregon, Washington State, Texas, and New York. Genetic studies of this virus suggest that it is similar to adenovirus 14, first described in Holland in 1955, but has very recently mutated into a more virulent form.
The interesting (and frightening) thing about this virus is that it’s so strong that it can kill young, otherwise healthy people, rather than the usual “at risk” populations of the very young and the very old. There’s no way to know if this virus will spark an epidemic, or whether it will die down and disappear for now.
Those who have had the virus, and lived to tell about it, say that it came on like a usual cold but then instead of getting better at the usual 4-7 day point, their symptoms got worse, and high fevers, cough, and difficulty breathing ensued. Some folks have even required mechanical ventilation in the ICU setting to help them breathe.
This virus reminds me that we are very vulnerable to unexpected attacks from infectious diseases. All the while we docs had our eyes on bird flu and SARS, this little cold virus mutated into a killer. If you have a high fever with difficulty breathing, please see your doctor right away. Let’s hope this epidemic threat dissipates before it can gain a real foothold.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 6th, 2007 by drval in News
Tags: Cancer, News, Pediatrics, Plastic
4 Comments »
There is new concern about babies being exposed to a certain plastic chemical found in the lining of formula cans. I have had my eye on this developing story since I first became aware of the potential harms of a commonly used plastic product, bisphenol A (BPA). In fact, I blogged about this almost a year ago - as I was worried about preliminary studies that showed a connection between low level exposure to BPA and fertility, mental and behavioral disorders, and brain structure. My colleague Dr. Mike Glode also has his eye on this story as it pertains to prostate cancer. Revolution Health expert Dr. Joe Scherger was also on the news several months ago, describing his concerns about BPA. Here is a snippet from my earlier blog post:
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Polycarbonate plastic products contain a synthetic estrogen monomer called bisphenol A (BPA). This monomer was first discovered in 1891, and has since been used in hard plastics (such as water bottles, baby bottles, Brita containers, and the linings of canned foods). Globally, BPA is produced in the amount of >6.4 billion pounds/year. The CDC estimates that 95% of urine samples (collected from people living in the United States) contain measurable BPA levels.
In a review article published in NIH’s prestigious Environmental Health Perspectives journal, evidence from 115 in vivo studies of the effects of BPA is analyzed with surprising conclusions.
[In rats,] rate of growth and sexual maturation, hormone levels in blood, reproductive organ function, fertility, immune function, enzyme activity, brain structure, brain chemistry, and behavior are all affected by exposure to low doses of BPA. Many of these effects are due to exposure during early development (gestation and/or lactation), but effects due to postweaning-through adult exposure have also been reported… The literature we reviewed shows that the rate of leaching from commonly used BPA-containing products (the lining of tin cans and polycarbonate food and beverage containers) is high enough to result in adverse effects in laboratory animals… A case control study reporting that ovarian disease in Japanese women is related to blood levels of BPA provides a first confirmation of this prediction in adult humans. Almost one-half of the low dose BPA studies have been published in just the last 2 years.
Is this concerning? Yes. What can we do? BPA is so ubiquitous that it would be hard to completely avoid exposure. Luckily the NIH is sponsoring many new studies to review the safety of BPA, and if it is found to be as harmful to humans in low doses as it seems to be in other mammals, they will take steps to enact laws to minimize exposure. Unfortunately it may take as many as 10 years to collect conclusive evidence as to the safety or harm of BPA exposure.
Until then, reducing exposure to this chemical may be a good idea - you can do this by using BPA free baby bottles, powdered formula instead of canned formula, avoiding drinking out of hard, clear plastic containers, and reducing the use of canned goods - especially for babies. Let’s keep our eye on this evolving story.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
