August 4th, 2009 by DrWes in Better Health Network, Humor
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When looking for the cause of atrial fibrillation during a physical examination, not only can the doctor’s olfactory bulb be helpful, but so can the examination of what gets brought into the exam room.
Patient: “Hey doc, it’s just a Pepsi.”
Doctor: “Really? Can I see?”
Nothing a good knife and a piece of scotch tape can’t manufacture.
Case solved.
-Wes
*This blog post was originally published at Dr. Wes*
July 29th, 2009 by Jonathan Foulds, Ph.D. in Better Health Network, Health Tips
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Last week marked the 10th anniversary of a smoking cessation website called “whyquit.com”. Now those of you who know me, and know that website and its director, Mr John Polito, may wonder why I’m choosing to give it some free publicity. The website is strongly against the use of all pharmacological aids for smoking cessation, and some would argue that it does harm by misinforming smokers about the harms and benefits of these smoking cessation aids. However, although I certainly do agree that the site does misinform about pharmacological aids, it also has a number of positive qualities and presents a different perspective that may appeal to and help some smokers.
The site started 10 years ago primarily to tell the story of a few individuals who were killed very young by smoking caused diseases. The idea was to vividly tell their tragic stories and to inspire others to quit tobacco and so avoid the same. In 2000 Joel Spitzer, an experienced smoking cessation counselor and author joined whyquit and the site took on more of a role of advising smokers how to quit using a very clear philosophy based on the “cold turkey” method.
The site has a large amount of educational material, including free pdf copies of lengthy books by Polito and one by Spitzer. The descriptions of individual cases of tobacco-caused diseases are informative and will inspire some to avoid the same harrowing experience. The site also has a discussion forum called, “Freedom from nicotine.” But once again the fundamentalist opposition to the use of pharmacotherapy aids is evident in the rules for use of “Freedom from nicotine”. The site states that,
“A single-minded program, those applying for posting privileges must have quit all forms of nicotine delivery cold turkey within the past 30 days, without use of any products, pills or procedures, and remained 100% nicotine-free for at least 72 hours. A nicotine-free forum, any nicotine relapse – even one puff, dip or chew – permanently revokes posting privileges.”
This is a rather unusual requirement for people to use a quit smoking discussion site, and it seems rather odd to ban people “permanently” from using the discussion forum, because they had a puff or chewed a piece of nicotine gum.
The site contains a large number of factual inaccuracies, particularly when referring to research on the use of pharmacotherapy for smoking cessation and the evidence on it. There are too many examples to mention, but just to mention a few:
– the site states that nicotine withdrawal lasts 72 hours. Most studies of nicotine withdrawal symptoms find these to be significantly raised after the first week, and typically not returning to normal levels for 3 weeks.
– The site asserts that in “real life” studies nicotine replacement therapy doesn’t work and “cold turkey” always produces a higher quit rate. An example of a study refuting that claim is provided below (West and Zhou, 2007)
– The site asserts that placebo-controlled trials of pharmacological treatments are all severely flawed because participants can sometime guess better than chance (.e.g. because the medicines work so well at treating nicotine withdrawal that participants can tell what the got, so the study is not perfectly “double blind”). On this point the site is somewhat out on a limb as most scientific research bodies regard the randomized placebo-controlled trial as amongst the best ways to find out if a drug treatment works or not.
– The idea that the results are entirely due to participants’ awareness of whether or not they received the drug also doesn’t bare much scrutiny. For example, in dose-response studies or studies where there is also an “active” comparison, participants are less able to identify what treatment they received, but the higher dose typically does better than the lower dose, and both do better than placebo.
– The site is also highly critical of anyone who has been funded in any way by pharmaceutical companies, and implies that such a conflict of interest almost certainly causes those individuals (including myself) to lose all independent judgment. While I agree that researchers should declare their sources of funding and that readers should weigh that information when reading research reports, the idea that the whole field has been bought and sold to the pharmaceutical industry is blatantly false. It is not at all uncommon for researchers receiving pharma funds to publish studies with disappointing results for the pharma company, including reports of potentially serious side effects.
(e.g. Foulds, J., Stapleton, J., Hayward, M., Russell, M.A.H., Feyerabend, C., Fleming, T., and Costello, J. Transdermal nicotine patches with low- intensity support to aid smoking cessation in outpatients in a general hospital: a placebo-controlled trial. Arch Fam Med 1993; 2: 417-423.
Foulds, J. and Toone, B. A case of nicotine psychosis? Addiction 1995; 90: 435-437).
The reality is that for years academic researchers have been encouraged by our employers to build bridges with private industry in order to make scientific advances, and do so with their eyes open. Most acknowledge our funding as openly as possible without becoming very tedious (e.g. my funding sources are mentioned on my home page on healthline and also on my program website, rather than on every single blog post). Most of us draw the line at funding from the tobacco companies because they have such a clear and consistent history of distorting science and using primarily for PR purposes, and largely because their ultimate purpose is to sell a product that is extremely harmful to health, rather than products designed to improve health.
However, the point here is not to quibble with every single point or inaccuracy on the site. Rather readers should be aware that in among the inspirational stories and plenty of good advice on this site, there is an almost fundamentalist agenda that its just wrong to use medicines to help you quit smoking. If you agree with that, or are prepared to take it with a pinch of salt, then you may find other aspects of this “single minded program” to be helpful.
Here’s an example of a recent “real world” study finding that smokers using NRT have a higher quit rate
This post, Whyquit.com: Factually Inaccurate, But Doing Some Good Nonetheless, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
July 29th, 2009 by KevinMD in Better Health Network, Opinion
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When it comes to opiate drugs, like morphine, there is a bitter debate between patients who are in chronic pain, and the doctors who are vilified for under or over-prescribing these medications.
But there are some other subtle influences that push doctors to prescribe these drugs, in some cases inappropriately. An ER physician talks about the issue, saying, “when dealing with a patient who is in pain, or appears to be, it can be impossible to sort out when a patient needs opiates for legitimate reasons, and when it is merely feeding a long term addiction. We are trained to provide comfort and relief from suffering to our patients, and we generally will err on the side of treating pain, rather than withholding addictive medications.”
There is also the pressure to provide “patient satisfaction,” and indeed, low scores in this area can place a doctor’s job in jeopardy. Taking a stand against those who inappropriately request opiates will result in low patient satisfaction scores, and “will often times result in arguments, profanity, and calls and letters to administration.”
What’s the answer? Perhaps a little less reliance on these scores, since a good patient satisfaction score is not necessarily correlated with proper medicine.
*This blog post was originally published at KevinMD.com*
July 27th, 2009 by Nancy Brown, Ph.D. in Better Health Network
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Orthorexia is a term coined by Dr. Steven Bratman. “Ortho” simply means straight or correct, while “orexia” refers to appetite. Orthorexia nervosa refers to a nervous obsession with eating proper foods. While anorexia nervosa is an obsession with the quantity, orthorexia is an obsession with the quality of the food consumed.
Given how heavy people seem to be getting in our country, focusing on health should not be a bad thing. However, while it is normal for people to change what they eat to improve their health, treat an illness, or lose weight, orthorectics may take the concern too far. While it is normal for people switching diets to be concerned with what types of food they are eating, this concern should quickly decrease, as the diet becomes normal. Orthorexia, in contrast, is when a person is consumed with what types of food they are allowed to eat and feel badly about their selves if they fail to stick with their regimen.
People suffering with this obsession about what they eat may find themselves:
• Spending more than three hours a day thinking about healthy food.
• Planning tomorrow’s menu today.
• Feeling virtuous about what they eat, but not enjoying it much.
• Continually limiting the number of foods they eat.
• Experiencing a reduced quality of life or social isolation (because their diet makes it difficult for them to eat anywhere but at home).
• Feeling critical of others who do not eat as well they do.
• Skipping foods they once enjoyed to eat the “right’ foods.
• Feeling guilt or self-loathing when they stray from their diet.
• Feeling in “total” control when they eat the correct diet.
Often orthorectics will “punish” themselves by doing a penance of some sort, if this “fall from grace” does occur. While orthorexia nervosa isn’t yet a formal medical condition, many professionals do feel that it does explain an important health phenomenon. If you or someone you know suffers from something that sounds or feels like this description of orthorexia nervosa, you should go visit either a nutritionist or doctor.
References
1) Bratman, Steve. “Health Food Junkie–Orthorexia Nervosa, the New Eating Disorder.” 1997.
2) Billings, Tom. “Clarifying Orthorexia: Obsession with Dietary Purity as an Eating Disorder.” 1997
3) Davis, Jeanie. “Orthorexia: Good Diets Gone Bad.” November, 2000.
4) Fugh-Berman, Adriane. “Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession with Healthful Eating–A Book Review.” May 2001.
5) Dennis, Tamie. “Booster Shots.” Los Angeles Times, 7/09
Photo credit: Meg and Rahul
This post, The Newest Eating Disorder: Orthorexia Nervosa, was originally published on
Healthine.com by Nancy Brown, Ph.D..
July 13th, 2009 by Nicholas Genes, M.D., Ph.D. in Better Health Network
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I enjoyed NYC Dr. Kent Sepkowitz’s column in Slate the other day — Paging Dr. Feelgood — where he recaps the careers of some celebrity docs and tries to imagine the pathway to enabling addicts. Key part:
In a strange way, I actually stand in awe of these guys. I have taken care of a few celebs in my career, and for me it was an awful experience. If you f*ck it up, you’re toast. Once I took care of a very important person, a person you have heard of and are very interested in, someone you would be shocked to know had the problem—asthma—that I treated him for. Well, almost treated him for. His complaints and his recollection of near death last time he had the identical symptoms so unnerved me that I asked a colleague to assume his care.
But the Dr. Feelgood experiences no such hesitancy… Perhaps it all starts innocently—a rich, famous guy with a tiny problem walks into the office. He can’t sleep at night. He’s so friendly, sincere, not stuck up like some celebs. Then he comes back a week later because of a sore ankle, wanting a little codeine and bearing an autographed photo or a CD. Other patients notice and figure you must be a pretty good doctor if Mr. Showbiz is coming in….
I once wrote about that concern over VIP complaints, in a medscape column. And, like the author, the only thing that impresses me about these celebrity docs is their creativity — Sepkowitz describes how the first Dr. Feelgood used solubilized placenta. And, while the risks of propofol dosing are drummed into our heads in training, it never occurred to me a doctor-to-the-stars might use propofol outside the hospital on an unmonitored patient.
While it didn’t surprise me that propofol has been considered in
palliative care and even implicated in a murder, it turns out propofol (diprivan) abuse and dependency is not unheard of and, as this review by Roussin shows, some IRB actually permitted trials:
Normal healthy volunteers (n = 12) were exposed in a blind fashion to acute bolus injections of 0.6 mg/kg of propofol and to a similar volume of soy-based lipid emulsion (similar to the vehicule of propofol) twice. After these sampling sessions, they were asked to choose which drug they preferred to be injected with. Propofol was chosen by 50% of the subjects, and seemed to have been based on the pleasant subjective effects. In contrast, the choice of placebo (Intralipid®) seemed to have been based on either non-intense subjective effects during the propofol sampling session (increased dizziness, confusion) or residual effects (fatigue) after the sessions. These results suggest that, in some healthy volunteers, propofol functioned as a reward.
…From a psychopharmacologists’ standpoint, propofol shares properties in common with many drugs that are abused. In particular, the onset of the effects of propofol are rapid and this drug makes people ‘feel good’ and feel relaxed [45]. The mood-altering effects of subanaesthetic doses of propofol delivered via an infusion or by an acute bolus injection have been assessed in human healthy volunteers [44,52]. Subjects reported feeling high, lightheaded, spaced out and sedated….
I read up on propofol use a lot a year ago, in preparation for a talk on procedural sedation. At that point I think its only foray into pop culture’s collective consciousness was a poem by Karl Kirchwey called “Propofol” that ran a year ago in the New Yorker. It began:
Moly, mandragora, milk of oblivion:
I said to Doctor Day, “You bring on night.”
“But then,” he said, “I bring day back again,”
and smiled; except his smile was thin and slight.
Now everyone’s talking about propofol. The ASA is using this opportunity to reintroduce talk of restricting propofol to their specialty alone (despite abundant and mounting evidence that it’s used safely in ED procedural sedation). Reporters are wondering why propofol administration is not as closely logged as, say, opiates.
All this activity suggests it soon will be. And while keeping this drug out of the hands of abusers and enablers is a worthy goal of regulation, I hope those who’ve demonstrated a safe track record are not prohibited from using this unique medication.
*This blog post was originally published at Blogborygmi*
