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 7th, 2008 by Dr. Val Jones in Expert Interviews
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Celiac disease (also known as celiac sprue) is an autoimmune intestinal disorder that affects millions of Americans, but is often misdiagnosed and misunderstood. I interviewed Revolution Health’s gastroenterologist, Dr. Brian Fennerty, to help set the record straight. I highly recommend that you listen in to the entire conversation here, but I’ve captured the highlights in written form below.
Dr. Val: What is celiac disease?
Celiac disease is a genetically determined sensitivity to gluten, which is a protein component of wheat and other cereal grains. Some people think of it as an allergy to gluten, but it’s not a true allergy because it causes symptoms through a different biological pathway. Allergies respond to anti-histamines (and involve IgE antibodies released by eosinophils and mast cells) whereas gluten sensitivity involves IgA and IgG antibodies (released by different types of cells called lymphocytes) and do not respond to anti-histamine treatments. So the treatment for celiac disease is largely avoidance of gluten containing foods rather than directly treating the immune response.
Dr. Val: Is celiac disease under-recognized by physicians?
About 1-2% of adult Americans actually have a gene for celiac disease. However, many people with the gene don’t have symptoms. And there are others who don’t have the gene who do have celiac disease. This makes celiac disease both common, and commonly misdiagnosed.
Dr. Val: Why do some people with celiac disease have symptoms and others don’t?
That’s the million dollar question. It’s probably due to the relative vigorousness of their immunological response to gluten, and how much of their bowel is involved. Symptoms of celiac disease can range from a severe gluten intolerance in a child who stops eating (due to pain and bloating) and ceases to grow due to malnourishment, to an elderly person who has no intestinal symptoms whatsoever but is found to be iron-deficient on a screening exam – which leads eventually to the diagnosis of celiac disease.
Dr. Val: How do you diagnose celiac disease?
Doctors often misunderstand how best to diagnose this disease, and because of that patients are often misled. Nowadays we screen for celiac disease with a blood test called “tissue trans-glutaminase” (TTG) to determine whether or not this enzyme is present in an abnormal form (which is the case in patients with celiac disease). However the test has an 80% sensitivity, which means that 80% of the people who have celiac disease test positive with the TTG test, but 20% of the people who test positive do NOT have celiac disease. When only 1 or 2% of the population has the disease, a positive test is given so frequently that most people who test positive don’t actually have the disease. A negative test, on the other hand, is more helpful to exclude the diagnosis of celiac disease. So anyone with a positive celiac blood test should assume that they don’t have celiac disease until it has been confirmed with a duodenal biopsy.
Dr. Val: How invasive is a biopsy for celiac disease? Are there risks involved?
The biopsy involves an upper endoscopy (NOT a colonoscopy) so there is no bowel prep requirement so it’s much more comfortable. The biopsy itself is very shallow, so there’s no risk for bleeding. The only risks are those associated with a regular endoscopy. It is a sedated exam, so you may lose time from work, but it’s not painful or as involved as a colonoscopy.
Dr. Val: Could you still miss celiac disease on a biopsy?
It’s possible though quite unlikely. The test is very accurate, but there are some mild cases of celiac disease where the part of the bowel that we biopsy is not involved in the disease process and may not be visible under the microscope. If the disease is still strongly suspected in someone with a negative biopsy, a second biopsy can be done with a longer scope (called an enteroscope) to get a sample of tissue from farther down in the small intestine. A second option would be for the patient to swallow a camera capsule so that we can take photos of the bowel wall to see if there are changes in the lining of the intestine suggestive of celiac disease. A third option is to try a gluten-free diet and see if the patient’s symptoms improve.
Dr. Val: Is there any new research or potential therapies for celiac disease?
Because this is an immunologic disorder (where the intestine’s immune system is reacting abnormally to a normal dietary constituent and causing inflammation) we can try to control the inflammatory response. In the past we tried very potent immunomodulators like chemotherapy, or anti-inflammatories used in other auto-immune diseases like rheumatoid arthritis or Crohn’s disease. However, these are very strong medications with many unwanted side-effects. There are targeted therapies being developed that will help to block the gluten response without exposing the patient to the potent general anti-inflammatory properties of chemotherapy-type agents, but we don’t know yet if this approach will be successful.
Dr. Val: What’s your advice for patients with celiac disease?
I have three pieces of advice that I generally give my patients with celiac disease:
1. Become as informed as possible about your disease. Websites such as the Celiac Sprue Association and NFCA are excellent sources of trustworthy information. At the same time, the Internet is an extremely dangerous place for celiac patients because there are a lot of websites that are not science-based, but driven by marketers who are trying to sell products to patients. So the patient has to learn to filter the information they’re getting off the Internet.
2. Consult with a dietician or nutritionist who understands celiac disease. Not all dieticians are skilled at counseling people with gluten sensitivity, so be sure to find one who has expertise in this area. A good dietician or nutritionist is the most important part of the healthcare team for a patient with celiac disease.
3. Make sure your diagnosis is accurate. There are many tens of thousands of people walking around with a diagnosis of celiac disease who do not have it. If you’ve been diagnosed on the basis of a blood test alone, and your symptoms don’t correlate perfectly with gluten sensitivity, you need to question that diagnosis.
Dr. Val: Do people with celiac disease have higher risks for other gastrointestinal disorders?
Yes. Celiac disease is associated with diabetes, so people with celiac disease should be screened for diabetes. Some people believe that patients with celiac disease are at higher risk for irritable bowel syndrome, though it’s unclear if that’s because of overlapping symptoms and not an actual increase in IBS. Patients with celiac disease are at higher risk for iron and calcium deficiencies (due to absorption problems in the intestinal lining) which can lead to anemia and osteoporosis. There is also a higher risk of small bowel lymphoma, which is a very rare form of cancer. A celiac patient’s risk (like anyone’s risk) of breast cancer or prostate cancer, of course, are far higher than the very small (but increased) risk of intestinal lymphoma.
So there you have it folks, all you ever needed to know about celiac disease. I’m going to be participating Washington DC’s Gluten Free Cooking Spree this Friday, April 11th. I’m teamed up with the chef from Cafe Atlantico to create a gluten free meal that’s going to be out-of-this world delicious. If you’re local, I hope I see you there!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 3rd, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Well, I know that blog post title probably got your attention. I’m referring, of course, to the unusual career path of Paul Levy, CEO of Harvard’s Beth Israel Deaconess Medical Center in Boston. Paul has done wonderful things over the past several years as CEO, including using his blog to promote outcomes transparency (by making his hospital’s infection rates public) and being accessible to all his staff via Facebook.
I had the chance to speak with Paul at Dr. Anonymous’ Blog Talk Radio show tonight. You should listen to the podcast to learn more about the world of hospital administration, Paul’s life journey, and what constitutes quality care in medicine. Here are some choice quotes from the call:
“I’m from New York, actually, which is something you don’t say very often when you live in Boston. I have to explain that I really didn’t want to be born in New York but my mother was there and I felt it would be appropriate to be near her during the time of childbirth… And I want to make it absolutely clear that I root for the Red Sox…
Well, personally I have a checkered past. I had no idea I was going to do this [hospital administration.] My background is in the energy field and telecommunications. I used to regulate the utilities in Massachusetts, then the state energy department in Little Rock, Arkansas, and then I ended up running the water and sewer system in the greater Boston area. I guess running a sewer system is good training for running a hospital…
There had been a merger of Beth Israel and Deaconess in the mid 1990s. The merger failed and the place was about to go out of business. I thought it was worth saving, so I persuaded them to hire me. It’s not the usual path. I hope that not too many other hospitals that are failing would want to hire the guy who runs the sewer system.”
So there you have it, folks. Sometimes the best CEOs may be found in unusual places… Kudos to Paul Levy for spearheading a major hospital turn around, and kudos to the Harvard system for recognizing leadership excellence in an unexpected corner of the world. Listen to the podcast to find out more about this fascinating story.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 2nd, 2008 by Dr. Val Jones in True Stories
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I’m at a medical conference in Houston this week (picking up some CME credits) and between lectures I’ve had some interesting conversations with my peers. Here’s my favorite story:
A patient underwent a total hip replacement surgery, had a normal post-operative course, was transferred for inpatient rehabilitation, progressed well and was discharged home. Several months later the patient decided to sue the hospital, claiming that he was sent home with a dislocated hip. The hospital couldn’t prove that the patient’s hip was not dislocated at the time of discharge because no x-ray was taken on that day. Of course, the only reason an x-ray would have been taken was if there were a strong suspicion of a fracture or dislocation (x-rays are not normally repeated on the day of discharge).
The hospital was found liable and will settle out of court for an undisclosed (but very large) amount.
My guess is that this case will cause:
1. The hospital to take unnecessary x-rays of all total hip patients on the day of discharge from now to eternity.
2. More dishonest patients to file frivolous law suits.
3. The local med/mal attorney population to spread the word about a new source of income.
4. Further cutbacks in the hospital’s charitable care due to funding deficits.
5. Someone with a hip replacement to buy a new Ferrari.
Sigh.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 1st, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Welcome to Grand Rounds Volume 4, Number 28, part 2. This is the most esteemed medblog carnival on the Internet, founded by Nicholas Genes, MD, PhD on September 28, 2004. Grand Rounds is meant to embody the spirit of good science and humanism in medicine, as it is a weekly collection of the very best blog posts from critically acclaimed, international health care professionals.
This noble undertaking has been carefully advanced by high-minded hosts, who happily put aside their life’s work, their families, yes, even the needs of their beloved pets, in order to provide readers with a cogent analysis of the week’s most important medical facts and opinions. I didn’t think I’d see the day when this great public service would fall into the hands of the lackadaisical. But alas, that day has come – and wouldn’t you know that it would be an Emergency Medicine physician who let us all down?
GruntDoc, a pillar of the medical blogosphere establishment, cannot be bothered to fulfill his hosting role this week, and has asked yours truly to finish his work for him. How typical of an EM physician! Get things started and then hand them off to another doctor to complete. (Witness his shameful apathy for yourself at Grand Rounds, Part 1).
Well, it’s one thing to be summarily passed the Grand Rounds baton, and it’s another altogether to be left with the dregs of the submissions. I am agog and aghast at the low-brow nature of this week’s offerings. Here is but a small sample:
The common leech as a celebrity blood-detoxification system (by Dr. Ramona Bates at Suture for a Living).
The surgical value of flatus (by Bongi at Other Things Amanzi).
In search of the perfect gluteal contour (by My Med Jokes).
In search of your lost tampon (by Dr. Jan Gurley of Gurley Doc).
I find this whole exercise utterly deflating – and unworthy of the high calling of Grand Rounds. But because I myself am long-suffering and reliable, I will not shirk my responsibilities, but rather ask a peer with lower standards (whose sensibilities will surely not be offended by flatus) to continue this week’s carnival. Please go to David Williams’ blog for the rest of this collection of health content of questionable value.
-Posted April 1, 2008-This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
