October 9th, 2007 by Dr. Val Jones in News
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I was intrigued by a news story all over the wires today and yesterday – that blood transfusions may do more harm than good. Over 4.5 million Americans receive blood transfusions for one reason or another each year in the US. Two new studies have been published in the Proceedings of the National Academy of Sciences, suggesting that blood can get “stale” much sooner than we think. Although we’ve known for a while that blood transfusions should be given only when critically needed, this news is interesting in that it may explain why blood transfusions are not a panacea.
Blood contains nitric oxide – a gas that is used as a signaling molecule in humans. It can trigger the relaxation of blood vessel walls, which is important in getting blood flow and oxygen to areas of the body that need it. Nitric oxide exists in small amounts in the bloodstream, but it can evaporate rapidly once outside the body (such as in a transfusion bag). So the question is: how critical is it to have nitric oxide dissolved in the blood given via transfusion?
The Red Cross keeps blood for up to 42 days after it is donated (though nitric oxide depletion may occur within hours) and will continue to do so until it is clearly shown that the expiration dates should be shortened. Further research is underway to test whether or not infusing nitric oxide back into blood is a viable option to improve its ability to oxygenate the recipient. It’s not easy to do this, since nitric oxide is a very tricky gas that can become a free radical or an acid in the presence of certain oxygen species. So the exact proportion of nitric oxide is critical – a little does just the right thing, but too much can be harmful or even fatal – which is probably why we haven’t tested this in humans yet, only dogs.
Still, many have high hopes for adding nitric oxide to the blood supply – Dr. Jonathan Stamler of Duke University appears to have applied for more than 50 nitric oxide associated patents and, not surprisingly, is taking the lead on various research studies, including the two new ones mentioned in my first paragraph.
My personal take on this? Blood transfusions are a serious treatment that can save lives, but should not be given willy nilly to “boost” people’s hematocrits. I’ve witnessed physicians giving their patients an extra unit of blood “just to perk them up a bit” prior to discharge from the hospital. That behavior is not safe or appropriate. So before you undergo a blood transfusion, make sure you really need one. Until we figure out how to replace nitric oxide safely in the blood supply, the life-saving potential benefits of a transfusion must outweigh the risks of stroke and heart attack from nitric oxide-depleted blood.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 27th, 2007 by Dr. Val Jones in Health Tips, News
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Heart disease is the number one killer of Americans, and high cholesterol levels are a primary contributor to heart disease. But the cholesterol story is a bit complicated – some of it is damaging to blood vessels (Low Density Lipoproteins or LDL is considered “bad” cholesterol) and some of it is restorative (High Density Lipoproteins or HDL is “good” cholesterol). Most medications are aimed at lowering the “bad” cholesterol, and this strategy has been very helpful in reducing heart disease and atherosclerosis. But what about raising the good cholesterol as part of a heart healthy strategy?
A new study in the New England Journal of Medicine suggests that having low levels of HDL can put people at risk for heart disease and heart attacks, even if the LDL is well controlled. This is the first study to show that low LDL does not erase heart disease risk if the individual’s HDL is also low. In fact, each increase of 1 mg in HDL cholesterol is associated with a decrease of 2 to 3% in the risk of future coronary heart disease. So lowering LDL with statins (if lifestyle measures fail) is only half the battle for those who also have low HDL.So how do you increase your HDL levels?The most effective medicine for raising HDL is a type of Vitamin B called niacin. Taken in the quantities required to have an effect on HDL, though, there are usually unpleasant side effects: flushing (redness or warmth of the face), itching, stomach upset, mild dizziness, and headache.
Perhaps the best way to increase HDL is to lose weight and exercise regularly.? In fact, the list of HDL-raising “to do’s” reads like a healthy living manual:
1. Avoid trans fats
2. Drink alcohol in moderation
3. Add fiber to your diet
4. Use monounsaturated fats like olive oil where possible
5. Stop smoking
6. Lose weight
7. Engage in regular aerobic exercise
So next time you see your doctor, make sure you review your cholesterol levels, and discuss some strategies to get your levels of HDL and LDL in the optimal zones for a healthy heart.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 17th, 2007 by Dr. Val Jones in News
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Physicians have known for at least 40 years that infectious bacteria (like staphylococcus aureus) can be transmitted on clothing. And now, as part of a comprehensive plan to reduce hospital infection rates, Britain’s National Health Service has recommended against physicians wearing white coats.
An interesting research study showed (back in 1991) that the dirtiest part of physicians’ coats are the sleeve tips and pockets. But surprisingly, coats that were washed at 1 week intervals and coats that were washed at 1 month intervals were equally capable of transmitting bacteria. Now that multi-drug resistant bacteria have become so common, they too can hitch a ride on coat sleeves and make their way from patient to patient.
During my residency, I clearly remember being horrified by the grunge I saw on my colleagues’ coats, all hanging up together on hooks outside the O.R.s. and in various parts of the hospital. I used to wonder if they were spreading diseases – but comforted myself that many bacteria need a moist environment to survive – so while the coats were certainly filthy, by and large they were not moist. Unfortunately my self-comfort was somewhat ill conceived – gram negative bacteria (like E. coli) do indeed need moisture for survival, but many viruses and gram positive bacteria (they usually live on the skin) do just fine in a dry environment. Other studies have confirmed that stethoscopes also carry a high bacterial load if not cleaned between patients. In fact, in reviewing some research studies for this blog post, I found that researchers have analyzed everything from hospital computer keyboards, to waiting room toys and patient charts. Infectious bacteria have been cultured from each of these sites.
Which leaves me to wonder: can we ever create a sterile hospital environment? Not so much. Although I agree that infections can be spread by white coats, and that a short sleeved clothing approach might help to reduce disease spread, I’d like to see some clear evidence of infection rates being reduced by not wearing coats before I’d prescribe this practice uniformly (pun intended). Bacteria can be spread on any type of clothing, by blood pressure cuffs, by stethoscopes, by dirty hands, by hospital charts… and we certainly can’t dispose of all of these. What would be left?
White Coat Rants (a wonderful new ER blog) describes the “ER of the future” – adhering to all the possible safety concerns of oversight bodies. Take a look at this whimsical perspective on what it would take to make the Emergency Department truly “safe” and imagine what it would take to make the hospital totally sterile.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 7th, 2007 by Dr. Val Jones in Expert Interviews
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Two new studies reported increasing suicide rates in teenagers. The first noted a trend between decreased use of anti-depressant medications (SSRIs) in teens and an increase in suicide, the second reported an increase in female teen suicide in particular.
What could be causing these tragic increases? I interviewed Revolution Health psychologist, Dr. Mark Smaller and child psychiatrist, Dr. Andrew Gerber, to get their take on this disturbing trend.
1. In previous research,
increased suicidality was associated with SSRI use in teens. Now this study
suggests that lower SSRI use is associated with increased suicidality. How do
you explain this?
Dr. Smaller: Following the previous research, parents and some physicians cut back on SSRI use for depressed teens. However, in doing so they may have neglected those teenagers who could have benefitted from an antidepressant. The problem with these medications is that they effect so many parts of the brain that it’s difficult to predict how different patients will respond to them. Also, these medications are often prescribed in too high a dosage. What needs to happen is that the patient, teen, child, or adult must have a full psychosocial evaluation that takes into account the whole person, and the environment in which he or she is living. A clear treatment plan combining talking therapy (individual or family) and perhaps medication must be implemented. This is not being done in enough instances. With a proper evaluation and a carefully designed treatment plan (as well as close monitoring of the teen) therapy may be further customized to the individual.
Dr. Gerber: The possibility of an association between suicidality and SSRI use in children
and adolescents is of clear concern to many people, including all psychiatrists
and parents of children on medication. Despite all the accumulated research to
date, it is still very unclear how this association works. However, we do know a
few important things.
First, in all the studies of SSRI use in children, there
is no report of a completed suicide attempt in a child who was taking an SSRI.
This goes to show that completed suicides in children, while tragedies whenever
they do happen, are rare events and therefore very hard to study methodically.
Second, in those studies that have shown a possible association of suicidal
thoughts (though not actual suicides) with SSRIs, there is a lot of disagreement
and controversy over how to best measure these thoughts in an accurate way. How
one does this influences the results considerably.
Third, it is important to
keep in mind all the ways in which an association between SSRIs and suicidal
thoughts may appear to exist because of how the data are collected, even if SSRIs
really don’t bring about suicidality at all. For example, it’s certainly true
that doctors are most likely to give medications to the kids who are the most
depressed and the kids who are the most depressed are most likely to be
suicidal. So it might look like SSRIs are related to suicidality, when they are
really being used to treat those kids who are most likely to develop it.
The
best way to really tease these apart is to randomly assign enough children
either to SSRIs or non-SSRI treatment and then observe what the differences are.
The problem, is that (1) the data are so good that SSRIs help many kids with
depression that it would be unethical to withhold treatment from half the
children in order to complete such a study, and (2) suicidality is rare enough
that this study would have to be enormous, and thus is impossible to
do.
With all this said, it is not surprising at all that an overall
decrease in the use of SSRIs, most likely due to the greater caution that
clinicians now have in using these medications in children, would lead to more
suicidality on a broader scale. We know that SSRIs help most children who take
them and this is undoubtedly a more powerful effect than any extent to which
SSRIs cause suicidality (if this is true at all).
2. Is there a role for
SSRIs in teens?
Dr. Smaller: I think so but only after a full diagnostic evaluation is made by a skilled mental health professional who works with teens, family and is familiar with the developmental phase of adolescence.
Dr. Gerber: There is unquestionably still a role for SSRIs in teens as long as they are
monitored carefully by a well trained clinician who, following agreed upon
guidelines, has decided that an SSRI is the right treatment for this teen. Of
course, as always, other treatments and their advantages and disadvantages
should be considered too. But for the best interests of kids and teens, SSRIs
need to remain a possibility.
3. What would you counsel
parents about these drugs?
Dr. Smaller: Get a full physchological evaluation and treatment plan so that you can make an informed decision about what might help. The mental health professional and the parent must have a working alliance to insure that the treatment is successful.
Dr. Gerber: I would advise parents that it is always good for them to be well informed and
vigilant about the risks and benefits of all treatment that they consider for
their children. There is much that we do not know about child psychiatric
illness and we are working furiously to learn more. In the meantime, though we
have to be careful to keep an open mind to both sides and to not make premature
judgments either in favor or against any one treatment. SSRIs have shown
themselves to be useful with many children and, in the hands of a well trained
professional, can continue to be very helpful to the right children and their
families.
4. What do you make of
the suicide rate increase in girls? What could be behind
this?
Dr. Smaller: This is alarming. The onset of adolescence for girls and boys is a hugely disruptive developmental phase, and maybe more so for girls with the onset of puberty. The teen years can be fraught with family issues that exacerbate moods and create symptoms. Our culture puts huge demands on all of our adolescents and this research might be showing that it is taking a high toll on girls. Social roles, peer pressure and issues, academic demands and family strife all contribute. The high incidence of eating disorders among teenage girls is a clear example of a symptom to which many teenage girls are vulnerable.
Dr. Gerber: The greater increase in suicide rates among teenage girls is surprising and
experts are unsure of how to interpret this. Since the overall number of
suicides is small – 94 in 2003 and 56 in 2004 – it is hard to interpret what was
different in this group of teenage girls. There are so many increasing pressures
on teenage girls today – from issues around body image and weight to balancing
complicated societal expectations, what some experts term pressure to live up to
a “superwoman ideal” – that one might speculate it is leading more and more
teenage girls to feel overwhelmed and hopeless. However, what we really need, as
with the SSRI controversy, is more carefully collected data and thoughtful
discussions between families, patients, and clinicians, to understand what is
happening and how we can prevent it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 5th, 2007 by Dr. Val Jones in News
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Like most of us, this headline made me squirm – visions of the Minotaur, mermaids, and Dolly the sheep with a human face, danced in my head. But as much as this form of experimentation seemed ethically wrong, I decided to figure out what exactly they were proposing.
The Human Fertilisation and Embryology Authority (HFEA) ruled that British scientists could now use animal eggs to host human stem cells. Because there is a shortage of human eggs to use for experimentation, they asked that rabbit or cow eggs be used.
Stem cells are the first kind of cells created when an egg is fertilized and divides. They are capable of developing into any kind of human cell – and are therefore quite interesting in terms of their potential to heal. (Transplanting these cells into damaged tissue can actually repair the tissue to some extent – no matter if its brain, heart muscle or other tissue). But these stem cells have to incubate inside an egg (kind of like a tiny soft shell) if they are to divide.
So the scientists are asking to use animal egg shells (without the nucleus that contains the majority of their DNA) as mini incubators for human stem cells. The HFEA approved that use – but has NOT approved mixing human and animal DNA in a human egg. Such a blend would serve no useful scientific purpose.
Ultimately, the goal of this human-animal embryo experiment is to allow for the creation of many more human stem cells without harvesting human eggs to do so. It also may help scientists to understand what these egg “shells” do to influence the growth of stem cells – if we knew how that worked, we may not need to use human eggs to retrieve stem cells, but could create them from any cell in the body.
So, although this embryo experiment sounds alarming at first – it’s actually a way to do stem cell research without using so many human eggs. Now, that doesn’t mean that I necessarily condone the idea – but it helps put into perspective what the scientists are proposing. Rest assured that there will be no Minotaurs resulting from these particular experiments.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
