Cartoons for the holidays II

"I have no objection to alternative medicine so long as traditional medical fees are scrupulously maintained."

"Well,  Bob, it looks like a paper cut, but just to be sure let's do lots of tests."

"That would be in Aisle Six, the worried well section."

Cartoons for the holidays I

On my refrigerator:

"Let's see, where should Jerry hurt today?" 

"I ate all the wrong things today."

"I recommend using your third wish to prevent joint pain in later years."

Imaging overuse

A consortium of professional medical societies, including the American Society of Radiology, is fighting the overuse of imaging. Examples include scans for uncomplicated headaches, routine chest X-rays, and nonspecific back pain. Between 2000 and 2007, the use of imaging studies grew faster than that of any other physician service in the Medicare population. One study determined that 20 to 50 percent of imaging provides no useful information. The problem with too much imaging (besides unnecessary costs) is that it can expose you to excessive radiation and can lead to over-diagnosis followed by unnecessary interventions that do more harm than good.

Here’s a rundown of various types of imaging tests:

• X-ray: quick and cheap; low radiation; usually the best way to assess injuries to arms and legs. Radiation exposure is the same as three hours of environmental radiation to which we’re all continuously exposed.
• CAT scan, or CT: a computerized composite of hundreds of X-rays; provides more detail than an X-ray. For example, it can detect an intercranial hemorrhage. The radiation dose is about the same as eight months of background radiation.
  
• MRI: provides excellent detail and doesn’t involve radiation; uses a magnetic field and radio waves. Good for assessing soft tissues of joints and detecting subtle brain abnormalities, but not good for visualizing air-filled structures, such as the lungs. (It’s best for chronic headaches, but the CT scan is best of sudden and/or severe headaches.) The tube-like MRI and CAT scan devices look similar.
• Ultrasound: does not entail radiation; uses high frequency sound waves; scanner is hand-held “wand;” used for imaging pregnancies and fluid-filled organs such as the heart and gall bladder.

I have started to decline x-rays on my teeth, mostly because they strike me as an unnecessary expense. Of course, this decision does not go unchallenged. But I’m sticking to my guns.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

How to monetize your thermometer

We have an old-fashioned thermometer—the glass kind with a bead of mercury in it. I think we’ve had it for nearly 60 years. To use it, you must first shake it to be sure the mercury is below a normal temperature, then you stick it under the tongue for… I forget how many minutes. It’s hard to read. You have to angle it just right to see the line of mercury and read the tiny numbers that indicate temperature. We probably haven’t used it in 40 years so we never considered buying a new one. But the new ones are a great improvement. Easy to use and see the results!

But now I think they’ve gone too far with thermometer technology. There’s a company called Kinsa that makes a fancy thermometer. It syncs up with a smartphone app that allows you to track your fever and symptoms. So far, it’s in use in 500,000 American households, and the company was only founded in 2012! Not only is this thermometer digitized and interconnected with electronic devices, the data it collects can be used by other companies for targeting ads.

For example, Clorox has paid Kinsa to use the information collected by thermometers to target ads for Clorox disinfectant wipes. Because the data includes zip codes of the thermometer users, Clorox can direct more of its ads to the areas that appear to be experiencing a rise in cold or flu symptoms, as indicated by temperature spikes. Similarly, other companies can start targeting ads for cough drops or chicken soup or whatever. Company spokespeople assert that they’re helping prevent the spread of illness through early detection. Right.

My old-fashioned thermometer now looks rather appealing.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

To stent or not to stent

My husband recently had a couple of stents inserted into his arteries. He’d been having occasional chest pain (angina) when on the treadmill. A stress test and angiogram indicated some blockage, so he was scheduled for an outpatient angioplasty (inserting and inflating a tiny balloon to widen the artery). Instead, when the procedure was underway, the doc decided to insert a couple of stents (tiny metal cages) into his arteries. He ended up staying overnight in the hospital. The stents may have been unnecessary—but nobody asked me.

In a study last year of 200 patients, all of whom had one profoundly blocked coronary artery and severe chest pain, half the patients received stents and the other half received a sham operation. Both groups received medications, such as for high blood pressure. The result: those who got the sham procedure did just as well as those who got the stents. In an editorial published in Lancet along with the study results, Dr. Rita A. Redberg, of the University of California, San Francisco, commented that stents should be used only for people who are having heart attacks. Other doctors agree. (There’s general agreement that stents can be lifesaving for patients in throes of a heart attack. In 2002, my husband had a stent implanted under this circumstance.)

Stents have long been controversial. A 2007 study of 2,300 patients with symptoms of clogged arteries showed that stents did not prevent heart attacks or deaths from heart disease. In this study, all the patients had a relatively stable form of coronary artery disease that generally progresses slowly—the situation with most Americans who receive stents. Similar studies have consistently shown that stents have no advantages over a medications-only regimen. Ditto angioplasty. (Stents generate nearly $3 billion a year in sales in the United States for Boston Scientific and Johnson & Johnson, the two companies that dominate the market. Inserting them costs from $11,00 to $41,000. Husband's bill was $105K.)

My husband is now treading without pain. Still, if/when I’m in his shoes, I’m going to say no to stenting. At least that’s my plan.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Ocular migraines

I had my first ocular migraine the other day. I’ve only had the one, but it was rather disconcerting. I was working at my computer and noticed zig-zag lines in my vision. It was sort of like this illustration.

 It only lasted a few minutes, which is typical, although some can last 20 to 30 minutes. Apparently ocular migraines are quite common. They’re a called a “visual disturbance” and can be accompanied by a headache, although mine wasn’t. (I’ve only had a couple of headaches in my life and certainly never a migraine—lucky me.) 

Ocular migraines are not related to the eye; they are the result of activity in the visual cortex of the brain. Scientists don’t know what causes them, but surmise it has something to do with changes in blood flow to the brain or to particularly sensitive neurons. Apparently ocular migraines can be triggered by hormonal changes, flashing lights, chemicals in foods, medications, and so forth. In my case, it seemed to be nothing.

When I had mine, I knew what it was because my husband has had a few. The first time he experienced the “visual disturbance” he was rather alarmed: macular degeneration runs in his family. But a quick call to his opthamologist assured him that he had nothing to worry about. Ocular migraines are considered harmless. Usually they are painless, cause no permanent visual or brain damage and do not require treatment. Good.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Mirror touch synesthesia

Synesthesia is a sort of blending of the senses. For example, people with this condition often perceive letters or numbers as having certain colors. Or they may experience sounds as colors or colors as scents. Some people even experience certain tastes when hearing words: the word basketball might taste like waffles. Quite a few artists, musicians, and writers are synesthetes of various types. These include Vladimir Nabokov, Duke Ellington, Billy Joel, David Hockney, and Itzhak Perlman.

A rare form of synesthesia is called mirror touch. It’s kind of an extreme form of empathy. That is, people with this type of synesthesia can feel what another person feels. For example, one woman with this trait says she witnessed a man punch another man. “I felt it. I felt punched. I passed out.” Another says, “Just walking around every day I feel strangers hurting, and I feel it so thoroughly and completely. Crowds are overwhelming sometimes.” Kind of a tough way to live.

Two mirror touch people that I’ve read about both went into medicine; one a pediatric nurse, another a psychiatrist. Having mirror touch synesthesia when treating people can be helpful, but can also make for a tough day at work. For example, the nurse tells of caring for a child of an opioid-addicted mother: “One time when the child was really cranky, I started feeling panicky, shaky, and wanting to throw up all at once. And I thought, Oh, this is what withdrawal feels like.” 

Researchers hypothesize that mirror touch synesthesia is an exaggerated form of the mirror neuron  system we all possess. The system is a subset of our normal motor command neurons, but the mirror neurons fire when we watch another person. They perform a sort of virtual reality simulation of another person’s physical experience. It’s why watching a person fall off a bike will make us flinch or cringe as if it were happening to us. 

Empathy is a good thing, but I’m glad I have the ordinary variety.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Eat full fat dairy for your heart’s sake

I love this: A large new study has found that eating two or more servings of whole fat dairy foods, such as milk, yogurt and cheese, reduced the risk of heart disease. The study, recently published in The Lancet, included 136,384 people in 21 countries who were followed for an average of nine years. What the researchers found was a—

• 22 percent lower risk of heart disease
• 34 percent lower risk of stroke
• 23 percent lower risk of death from cardiovascular disease

The fat in dairy products is saturated, folks. It’s butter fat. It irks me no end when people, such as health columnist Jane Brody, continue to use the phrase “artery clogging saturated fat.” As I’ve said before, saturated fat is simply a fat molecule in which two hydrogen atoms are attached to each carbon atom; that is, carbon atoms are “saturated” with hydrogen atoms. What’s so scary about that?

As Dr. George Mann, professor of medicine and biochemistry at Vanderbilt University and former Director of the Framingham Heart Program, said, “For fifty years the public has been told by officials of the American Heart Association and the National Heart Institute that this epidemic disease [coronary heart disease] is caused by dietary saturated fatty acids and cholesterol. That advice is quite wrong. It is the greatest biomedical error of the twentieth century. The advice lingers, for selfish personal reasons and commercial avarice.” My man! (He wrote the preface to my book, Fat: It's Not What You Think. Unfortunately, he died in 2013 at the age of 95.)

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Ignore nutrition studies

Recently, an oft-quoted and respected food researcher who founded the Food and Brand Lab at Cornell University was booted from his position at Cornell because of “academic misconduct in his research and scholarship, including misreporting of research data.” He’s not alone with his misconduct; just a big name who was busted.

Nutritional research is plagued with credibility problems. One reason for this is something called “data dredging” wherein researchers run exhaustive analyses on data sets then cherry pick the “findings” that suit them. Another problem is incorrectly assuming cause and effect; that is, concluding that A causes B, when in fact some other factor may be causing B. To make matters worse, the press publishes the most newsworthy studies (eating a single mandarin orange will add five years to your life)! Many researchers go for newsworthy results.

For these reasons, I rarely write about nutritional studies—unless they support my own biases. Case in point: I recently wrote a post called “Eat full fat dairy for your heart’s sake.” A big study showed that eating two or more servings of full fat dairy was “associated with lower rates of cardiovascular disease and mortality.” The study was huge and went on for nine years and was controlled for age, sex, smoking, physical activity and other factors.

The journal report went so far as to state that “some saturated fats may be beneficial to cardiovascular health, and dairy products may also contain other potentially beneficial compounds.” Because the results of this study go against conventional “wisdom,” it won’t make headlines. I was lucky enough to find a brief mention of it in The New York Times.

As you can see, I cherry-pick my studies too. But I’m right!

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The roller coaster treatment for kidney stones

My husband has been treated for kidney stones many times over the last 50 years. No matter the method--and they have varied--it’s always a very painful business. One thing he’s never tried was the roller coaster treatment. But it works!

A doctor was inspired to study the roller coaster treatment after seeing multiple patients who had passed kidney stones after riding roller coasters at amusement parks. One patient passed kidney stones after each of three consecutive rides on the Big Thunder Mountain Railroad roller coaster at Disney World in Florida. (Apparently bungee jumping can have the same effect.)

To test the effect of a roller coaster, the scientists created a 3-D model of the ureter, bladder, and other appropriate parts and filled them with urine and kidney stones (calcium oxalate), then took the simulator off to Disney World and the Big Thunder Mountain roller coaster. (The journal article notes that “care was taken to protect and preserve the enjoyment of the other guests at the park.”) The stones were shaken loose! 

The scientists’ conclusion was that moderate-intensity, rattling coasters can be effective at dislodging little kidney stones (five millimeters or less in diameter) from the outer ducts of the kidney and propelling them toward the ureter (the tube that connects the bladder to the kidneys). “The idea is to displace these little stones before they become big stones and cause a lot of pain and suffering,” said David Wartinger, a professor emeritus at Michigan State University who was an author of the study.

More than 300,000 Americans seek emergency care for kidney stones a year, mostly because of severe pain from having a large kidney stone stuck in their ureter. By this time, it’s too late. You’ve got to ride the roller coaster prophylactically, that is, before you’re having the painful symptoms. If you’re a kidney stone sufferer, perhaps a yearly ride on a roller coaster would be just the thing. Shake those stones down before they get too big. Oh…and choose a seat in the back where it’s bumpier.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

A pharmacist responds to my blog post

My friend Donna passed along my blog post, “Pity the poor pharmacist,” to a retired pharmacist friend of hers. He was self-employed and never worked for a chain, but still found that his work could be stressful. Here’s his response (slightly edited):

“The pharmacy that I loved and trained for was not the same pharmacy I retired from 50 years later. I was very fortunate to have started as a delivery boy when I was 12 years old and continued working at the same pharmacy until I went away to UC at 19. During that time I learned a lot about pharmacy and pharmacists and had a fair idea what I could expect when I became one. The thing that I learned the most completely was that pharmacists are dealing with sick people. Most of them are nice and thankful for your help but some of them are real SOB’s and it is hard to tell if it is from their illness or if they were born that way. Either way, my job was to take care of them and this is where I got my satisfaction.

I have to admit that pharmacy has become harder and more stressful over time and less enjoyable. Most of these changes have come about not by pharmacists or other members of the health professions but by outsiders. The chain stores have their corporate chain of command responding to the shareholders who really don’t care about the individual pharmacist as long as he or she shows up for work and gets the job done.  

Most problems are caused by non-medical people controlling the money for third party payments. They were and probably still are a bunch of non-caring idiots placed in a position of power in a job they know nothing about. They caused me more grief in trying to get the medication to the patient but equally in my case being a store owner getting payment for prescriptions filled in a timely enough way that I wouldn’t go broke filling more prescriptions. I could write a whole book on the unfairness of their payment plans. They are the reason I would never go back into pharmacy. Not because I don’t like it; I love pharmacy, but the stress of not getting payments in a timely way so that I didn’t have to borrow money from the bank to pay the bills I had accrued filling prescriptions for their clients.  Now that is stressful!”

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Medicine in the wake of Kavanaugh

As a result of the Kavanaugh hearings, a primary care physician who practices in a women’s health group has been inundated with patients whose memories of abuse have been brought to the surface. “Stories of struggle and abuse, of trauma inflicted by people with power, have permeated my sessions with patients over the past couple of weeks,” she writes in the New England Journal of Medicine. “Today, it was my third patient of the morning: a woman with a history of childhood sexual abuse and an abusive marriage. She shared with me her distress, her escalating nightmares and flashbacks over the past week. She held out her left arm to me, where for the first time since her adolescence she had started cutting herself.”

The doctor says that her “…patients’ experiences reflect the prevalence of trauma in our country: more than one third of U.S. women have been the victim of contact sexual violence at some time in their lives.” She recognizes that health care services themselves, “with an inherent power differential between patient and physician” can also be re-traumatizing for survivors.

Sitting with these patients day after day has taken a toll on the doctor herself. “It can use up my emotional resources and leave not a lot of room for my family, friends, and community.” Doctors such as this one experience vicarious trauma, which she says can lead to compassion fatigue and burnout. Nevertheless, she is part of a movement to educate health care providers about the growing field of trauma-informed care which includes such principles as safety, peer support, empowerment, and trustworthiness. We are talking here of caring for patients whose past experiences may have left them unable to tolerate Pap smears. One example of trauma-informed care is simply asking the patient whether she prefers to have the door open or closed while waiting for the doctor.

Let's hope the medical profession is paying attention.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Heart palpitations

For a year or so, I’d been having episodes wherein my heart would pound after I’d lie down—as on the couch or in yoga class. The pounding would stop after a few minutes. I’d have these episodes two or three times a week. I was mildly concerned about this, thinking that the old ticker was starting to go.

A few months ago, on the night before we were to leave on a road trip, I’d gone to sleep and was awakened with my heart pounding like never before. I waited for it to stop, but after an hour of pounding, I decided maybe this was something serious. I woke my husband and we went to the emergency room. By the time we got there, it had stopped. Nevertheless, I had an electrocardiogram (EKG)—the test that uses electrode patches on various places on your skin to test your heart rhythm, blood flow, and whatnot. The results showed that my heart was fine.  

I was told that my problem was heart palpitations. Heart palpitations! I thought that was what Victorian women had when overcome with emotions. Like the vapors. I asked the doc what the deal was. He said, “Oh, some people just have these.” Basically, it’s caused by surges in adrenaline that affect your heart’s electric impulses. You might get these from coffee, stress or panic attacks. But from lying down in yoga class? Lying on the couch to read? Waking me after I’ve gone to sleep?

Anyhow, on the one hand, I felt embarrassed at having gone to the emergency room for heart palpitations. On the other hand, now I know not to be concerned about these episodes—should I ever have more. Oddly, it’s been several months since my ER visit and I’ve not had another episode. Maybe the last one jiggered the reset button on my heart.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Margarita dermatitis

That’s the jokey name for a skin condition I’d never heard of. The real name is phytophotodermatitis. It’s a skin reaction you get if you spill lime juice—or grapefruit, lemon, celery, carrots, parsnip or parsley juice—on yourself, and then go out into the sun. These juices contain chemicals called furocoumarins that cause a skin reaction when exposed to sunlight. The reaction takes about 24 hours to show up. What you get is a rash and/or blisters.

I Googled images of this condition and some are rather horrific—huge blisters. Here’s one image—one of the milder-looking photos.

Apparently this condition is often seen in beachgoers who have been squeezing lime juice into their Coronas and have gotten a little sloppy with the squeezing. In the photo above, I can picture the guy holding his Corona over his leg and attempting to squeeze the lime juice into the bottle—perhaps while sitting in a boat. By the way, this condition often flummoxes dermatologists.

I had considered squirting some lime juice onto my skin then going out into the sun to see what would happen. But apparently this condition can be quite painful and can last a couple of months! Forget it.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Pity the poor pharmacist

It never occurred to me that being a pharmacist might be stressful until I read an article about people who retire early. One was a pharmacist from Tennessee who retired at 38! He was making $150,000 a year but was miserable at his job. What he hated was the skyrocketing costs of drugs, dealing with sick people battling health insurance, the over-prescription of opioids, and the addiction crisis. He was constantly dealing with angry, financially stretched customers who often lashed out at him. “There were days when I had 12- or 14-hour shifts where I didn’t use the restroom, where I didn’t eat, because so much work was piled up on me,” he says.

I did a little research and discovered that being a pharmacist can be horribly stressful. One survey found that almost 70% of pharmacists experienced stress and work overload. A researcher at the Harvard Business School estimates that burnout in the workplace costs $125 billion a year in healthcare costs, and results in 120,000 deaths a year. Heavens!

In looking at online forums for people considering pharmacy as a profession, the causes of stress become clear. Here are some comments from pharmacists or ex-pharmacists:

• The big chains “own your ass…they are evil, they treat you like a robot or slave. The retail side of pharmacy will absolutely rape you to get a bottom line; i.e. overwork, understaff, cheat, etc.”
• “I've worked plenty of days where the pharmacist is crying in the back on their breaks.” (This from a pharmacy tech. They’re poorly paid assistants who help fill prescriptions.)
• “We must silently protect doctors and nurses from harming patients. The fact is and remains that the pharmacists are liable for the errors created by physicians, nurses, and pharmacy technicians.”
• “I have seen a steady decline in our profession. Now we are forced to give immunizations, (in between filling scripts) and it’s not going to get better. The corporate guys just watch the bottom line. Customers treat us like clerks."
• “Trust me, don't be a pharmacist, it sucks.”

Goodness! I hope it’s not so bad at our little family-owned pharmacy in town.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Reversing diabetes

If you have diabetes, your blood glucose (sugar level) is too high (hyperglycemia). It’s too high because your body’s cells have become resistant to insulin, the hormone produced by the pancreas that enables the cells to take up and use glucose for energy. Hyperglycemia can damage the vessels that supply blood to vital organs and can increase the risk of heart disease and stroke, kidney disease, vision problems, and nerve problems. The standard treatment for diabetes is medications.

The incidence of diabetes in the U.S. has risen dramatically since 1958. In 2015, 23.4 million people had diabetes, compared to only 1.6 million in 1958. My own opinion as to the cause of this rise is the misguided advice by the government and others that the bulk of our diets should consist of carbohydrates (bread, pasta, rice, and so forth). Carbohydrates readily convert to glucose.

A new year-long study, conducted at the University of Indiana, treated 262 people who have type 2 diabetes. The “treatment” consisted of low-carb diets along with continual care that consisted of monitoring the test subjects’ biomarkers, such as blood sugar, and around-the-clock consultation and supervision. After one year, here’s what happened to the test subjects:  

• 60% reversed their diabetes, meaning their average blood sugar dropped so low that they no longer could be diagnosed as diabetic
• 94% reduced or entirely eliminated reliance on insulin.
• On average, the group reduced their body weight by 12%

Meanwhile, a control group that followed the American Diabetes Association’s standard (high-carbohydrate) diet saw no improvement in health. (At breakfast with a diabetic friend, I was surprised that she had coffee cake and granola for breakfast.)

Admittedly, a San Francisco company called Virta  funded the study. For a fee, the company provides you with the resources to accomplish such results. For sure, a low carbohydrate diet would be involved. You'd be burning fat instead of glucose for energy. If I had type 2 diabetes, I’d go for it.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Curing yourself using worms

It’s called helminthic therapy. Helminths are worms, such as hookworms, tapeworms, and pinworms. Some people are infecting themselves with these worms to cure themselves of allergies or autoimmune diseases. Most commonly, people use helminthic therapy to treat Crohn's disease, ulcerative colitis, inflammatory bowel disease, celiac disease, multiple sclerosis, and asthma.

Here’s the deal: These types of diseases occur only in industrialized societies. Scientists who study this therapy believe that such diseases are caused by the loss of species diversity within our bodies—species with which we co-evolved millions of years ago but which we have eliminated by modern sanitation, water treatment, and medical practices. The absence of species from our biome leaves our immune systems in a hypersensitive state which, when combined with environmental triggers and genetic predisposition, leads to allergic and autoimmune diseases.

Scientists have long noticed the absence of allergic and autoimmune diseases in less developed countries and had considered the idea of reintroducing helminths into patients in the hope of rebalancing their immune systems. In 1976, a researcher infected himself with hookworms and succeeded in putting his own seasonal allergies into remission (as reported in the Lancet scientific journal).

Desperate people are turning to helminthic therapy. Unfortunately, a doctor can’t help: helminthic therapy is not approved as a medical treatment anywhere in the world. But there’s plenty of information on the internet. The best is a Wiki site. It is extremely thorough and includes everything you need to know, including lots of testimonials. Here’s one, contributed by someone who used the therapy to treat Crohn’s disease:  “When I began taking helminths my gut was in awful shape and my GI doc wanted to preform another surgery. I chose to begin helminth therapy hoping that it would save me and my gut. Helminths did what no stop gap surgery or drug could do, it put my CD in remission (after 30 years of coping) and has controlled it since then. It will be 10 years in Jan. 2016. Best choice I have ever made.” 

Of course, the worms can make you sick, too. But if I were continually having chunks of my intestines removed. I’d go for it.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Hay fever: only for the well-to-do

Well, that was the case in the mid-nineteenth century. In March 1819 Dr. John Bostock reported the first case of hay fever—his own—to a medical society in London. More cases were soon reported. In looking into this new phenomenon, Bostock noted that the condition appeared only among the upper classes. “I have not heard of a single, unequivocal case occurring among the poor.”

Because hay fever was associated with affluence, it became a rather fashionable affliction. In the U.S., entrepreneurs capitalized on this effect and established “retreats” for the sniffling, sneezing gilded class. One attendee noted, “Only individuals of the highest intellectual grasp, and the strongest moral fibre have the disease.”

The reason only the upper classes were affected is that they had begun to clean up their environments. Cities in both the U.S. and U.K had begun to institute major sanitary reforms. For the first time in human evolution, certain microbes and parasites were being removed from the human organism. Our bodies would never work quite the same way again.

Our immune systems evolved to anticipate certain types of microbial and parasitic input—the bacteria, worms, etc. commonly found in vegetation, mud and water throughout evolution. Lack of exposure to these agents suppresses the natural development of our immune systems. It’s not just allergies that are affected, but also autoimmune diseases and many others.The way this works is enormously complicated and scientists don’t agree on some of the fine points. But nobody disputes the facts that people who grew up on farms have far fewer allergies than those who did not.

There’s not a lot you can do to ameliorate this situation (probably too late to take up farming), although some desperate people have taken to infecting themselves with worms. More on that later.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Oh Canada!

We spend about twice what Canada does on health care administration. In fact, we rank number one in the world! No surprise, I guess. About 30 percent of our health care dollars goes for administration:  

• Out of the $19,000 that U.S. workers and their employers pay for family coverage each year, $5,700 goes for administrative costs.
• For every 10 physicians providing care, almost seven additional people are engaged in billing-related activities.
• Physicians spend about three hours per week dealing with billing-related matters; for each doctor a further 19 hours per week are spent by medical support workers (in doctors’ offices).
• Administrative costs amount to $68,000 per year per physician.

In the U.S., administrative costs are high because of the complexity of our health care system. Most importantly, our health care providers must deal with a multiplicity of payers, including various public health programs plus a host of private insurers, each with its own set of procedures. In Canada, with its tax-funded single-payer system, medical practices spend a fourth of what we do on dealing with payers. (Canadians can buy private insurance for certain services such as dental or home care.)

A particularly big headache for medical practices in the U.S. comes from generating bills and collecting payments. Among other things, our providers must chase down patients for the portions of their bills not covered by insurance. Studies show that, for bills exceeding $200, only 67 percent are paid within a year. As the patients’ out-of-pocket payments increase, providers devote more resources to collecting it.

Single-payer anyone?

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Steer clear of new medical devices

I recently watched a new Netflix documentary called "The Bleeding Edge," which tells horror stories about medical devices. Here are some of the devices it discussed:

• Hip and knee replacements containing cobalt (metal on metal). The cobalt makes its way into patients’ bloodstreams. Not only does it damage the tissues around the implant, it affects patients' brains and causes dementia, tremors, blindness, and other neurological problems.
• Essure, a metal contraceptive device that’s inserted into the fallopian tubes. Many thousands of women have been made seriously ill, probably for their lifetimes. There’s no fix: when trying to remove it, the device breaks apart and pieces are left in their bodies.
• A surgical mesh used to repair pelvic floor problems, such as incontinence. When used as a sort of sling around the bladder and vaginal area, the mesh shrinks, degrades, perforates nearby organs, and other horrors. Like Essure, it is nearly impossible to remove the entire mesh.
• The DaVinci robotic surgical instrument. It has caused plenty of botched surgeries, including burns, tears, organ punctures, internal bleeding and infection and has damaged blood vessels, bowels, bladders, vaginal cuffs, urinary tracts, kidneys and other tissues.

Manufacturers can get these (and many others) quickly to market because of the FDA's fast-track process—known as a 510(k), which exempts products from full review if they are "substantially equivalent" to ones already on the market. It does not require submitting clinical data demonstrating safety and effectiveness There’s plenty of politics and money involved.

As far as I can tell, the only way to be sure a device is safe is if it has a substantial track record and has been used on thousands of patients without adverse effects. Older is better.

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Got milk?

In the old days, kids drank milk. We drank it with our meals. Schools supplied little cartons for lunch. It’s what we served our kids at mealtime. Fruit juice was something that you only drank at breakfast—usually orange juice.

That all began to change sometime around the late fifties and early sixties when an influential scientist, Ancel Keys, using what has now been debunked as erroneous “science,” determined that saturated fat was bad for you. The government and nutritionists bought into this notion and encouraged everyone to stop eating fat, including milk, which contains butter fat. Not only that, the government created a food pyramid in which carbohydrates, such as bread, formed the base of the pyramid, telling us that we should eat 6 to 11 servings a day. Because of the fear of fat, mothers switched from giving their kids milk to giving them juice. We now know that the government’s food pyramid was all wrong—that carbohydrates (sugar!) is linked to diabetes, obesity, and heart disease.

Nevertheless, the effect of Key’s influence lingers on and is easy to spot. You rarely see kids drinking milk. Mothers give their kids juice boxes, as do nursery schools. Even government programs designed to provide healthy food for children include juices in their offerings. Studies show that more than half of preschool age children (ages 2 to 5) drink juice regularly, and that they consume on average 10 ounces a day.

Fruit juice is nothing more than a sugary beverage. One 12-ounce glass of orange juice contains 10 teaspoons of sugar, which is roughly the amount in a can of coke. There’s no evidence that shows that fruit juice improves health. Plus it contributes to tooth decay in children. A pediatric dentist reports that he “routinely treats children, as young as 14 months, their upper front teeth destroyed, often beyond repair, by sleeping with or carrying around bottles of juice (among other sugary drinks.) Juice is soda without the bubbles.”

I doubt that milk drinking will ever come back into vogue. Well, I guess you can't go wrong with water.

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When bacteria go rogue

This is part two of my staph infection saga, written at week six. (See last week’s post for an introduction.) The “rogue” in the title refers to the fact that my normally benign skin bacteria turned against me. It is very creepy when bacteria appear to be eating your flesh. It’s especially creepy if you Google images of flesh-eating bacteria.

Week five. Week six is similar, minus raw area.

   What started as a tiny break in the skin on my finger grew day by day until I had a raw, stinging, pea-sized wound. The antibiotic ointment the doctor prescribed had no effect. The wound kept growing. After about two weeks of religiously applying the ointment, I quit. It seemed to make matters worse. All I could do was compulsively stare at it to see if my immune system would come to the rescue. It did, but it's been an extremely slow process. I was used to wounds healing in a couple of days.

I told myself I’d seek further treatment if the wound exceeded the
size of the original “blister.” It never did. To look at it, my wound doesn’t seem like any big deal. But it could be. I know of someone whose finger infection required IV antibiotic treatment 24/7, administered with a device strapped to his body. If the antibiotics don’t do the trick, his finger will be amputated.

This little trauma of mine makes me appreciate the forces at work keeping our bodies in balance, especially considering the thousands of bacteria and other organisms we naturally carry around with us. One false move…

I am now very curious about the bacteria that live on my skin and have sent a sample to The American Gut Project (UC San Diego), which will analyze it and tell me what kinds of bacteria I have. It’ll be a few months before I get the results back. I’ll let you know.

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My staph infection!

After spending a couple of hours in the hot sun pruning a large shrub (wearing gloves), I noticed something on the inside of my ring finger that looked like a pink blister. After a week or so, a tiny open wound appeared, which, over the days, continued to expand. I sort of freaked out and went to the doctor who seemed unconcerned but prescribed an antibiotic ointment (more about that next week).

Infection at four weeks

The bacteria that likely caused my staph infection is Staphyloccus epidermidis—normal members of everyone’s skin flora. That is, they’re always hanging around our skin and mucous membranes, and comprise about 5% of the 1000 bacteria species that live on our skin. They’re generally not harmful and can even be beneficial by preventing pathogenic organisms from colonizing on your skin. But they are considered “opportunists” and sometimes cause infections if they are able gain a foothold. (They’re also the most common cause of infections that occur on knee and hip replacements.)

The reason that we’re not permanently covered in staph and other infections is that our immune systems produce cells (neutrophils) that kill bacteria that penetrate the skin barrier. But our immune systems may have evolved not to over-react to bacteria, otherwise we’d be in a constant state of inflammation. At the same time, the bacteria have evolved defense mechanisms to protect themselves from being ingested by our immune cells. It’s a very tricky balancing act.

What I have not been able to find out is why otherwise benign bacteria became pathogenic. One friend got a staph infection from a bee sting (common); another has become infected a few times from cat bites. I have concluded that the bacteria must gain their foothold when a very small object—maybe a sticker, in my case—pierces the skin in a certain way under certain conditions. That’s the best I can come up with.

Because all my other wounds have always healed quickly, I always thought my immune system could handle anything that came its way. “Pride goeth before a fall.”

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Psychedelic therapy

Therapists and researchers are increasingly interested in testing psychedelic drugs to help people struggling with psychological problems, such as depression, for which the pharmacological toolbox has little to offer. In addition to depression, institutions, such as Johns Hopkins, New York University, and UCLA are conducting trials to test the efficacy of psychedelic drugs for people who are dying and who are addicted to alcohol and/or nicotine.  

Dying: For those who are dying, the purpose of using psychedelic drugs is to alleviate anxiety and depression. It seems to work. Almost uniformly, patients come to view death as a transition into another type of existence and rather than the absolute end of everything. They also—even the atheists—have the feeling of being bathed in God’s love. Most also felt powerful feelings of connection to loved ones. Weeks after his session, one man even felt the happiest in his life.

Addiction: Most of the people treated found the experience to be helpful, mostly because they gain a radical new perspective on their lives. They are able let go of a pattern of thinking in which their selves and their addiction are the center of their lives. Apparently, the sense of awe experienced during a psychedelic “trip”—a sense of the small self in the presence of something greater—also enables patients to recognize the harm they’re doing not only to themselves but to loved ones.

Depression: As with electroconvulsive therapy, treatment with psychedelic drugs performs a kind of brain "re-boot." Most of the people treated with psychedelic drugs found their depression had lifted. As one patient said, “it was like a holiday away from the prison of my brain. I felt free, carefree, re-energized…I feel like I used to before the depression.” Unfortunately, more than half of the people treated saw the clouds of their depression eventually return. Nevertheless, they feel they have gained a new perspective on life and been given new hope.

Note: These experimental treatment sessions were conducted with a trained guide in a tightly controlled environment. Don’t try this at home!

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Your brain off the leash

I recently finished Michael Pollan’s new book, How to Change Your Mind (with long subtitle). It’s about the resurgence in studies of psychedelic substances, such as LSD and psilocybin, and how they affect the brain (including his). It’s also about how they might be useful therapeutically.

For me, the most interesting bit was learning about the default mode network—brain structures first described in 2001. I’d never heard of this network (DMN). It links parts of the cerebral cortex with older (evolutionarily speaking) parts of the brain and acts as a sort of orchestra conductor, keeping order in a system that might otherwise “descend into the anarchy of mental illness.” It acts as a kind of filter, admitting only the information required for us to get through the day. Otherwise, the torrent of information coming at our senses at any given moment would be difficult to process. It also plays a role in the creation of various mental constructs, the most important of which is our sense of self (our egos). It’s most active when we are involved in higher-level cognitive processes such as self- reflection, mental time travel, and trying to imagine what it is like to be someone else. By the way, the DMN isn’t operational until late in a child’s development.

When the default mode network goes quiet—the effect of psychedelics—our other centers of mental activity are “let off the leash,” allowing material otherwise unavailable to us to float to the surface. In this state, people feel a loss of ego and that they are a part of nature. Here’s a graphic image comparing the brain activity when the DMN is in charge (left) and when it is not (under the effect of psilocybin).

Kind of exciting, don't you think? (I'll discuss therapeutic uses next week.)

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Getting to know your gut bacteria

The ability to sequence DNA has made it possible for scientists to learn about our microbiome—all the organisms that live on and within us. At the moment, there’s a big push to learn about the bacteria in our guts, which harbor about 1000 different species of bacteria. Researchers have found that bacteria affect most of our physiologic functions, including our immune systems. One of the ways scientists are learning about gut bacteria is to study the variations in bacteria among diverse populations all over the world.

To determine the relationships between gut bacteria and health, they’re also comparing the bacteria of healthy individuals to those of diseased people and have found some connections. So far, it appears that gut bacteria play a role in the development of arthritis, colorectal cancer, colitis, obesity, diabetes, and even heart diseases. They have also found that most of these diseases are more prevalent in the US than in many other populations. A key reason for the link between our microbiome and these diseases has to do with our fiber-poor diets—a paltry 15 grams of fiber daily. As hunter-gatherers, we were likely eating close to ten times the amount of fiber than we do today. (In last week’s post, I explained how fiber keeps our gut bacteria in good working order.) Our use of antibiotics, which negatively affect gut bacteria, also contribute to the problem.

Unfortunately, there’s not a lot you can do to change the makeup of your gut bacteria other than increase dietary fiber and, maybe, probiotic food, such as yogurt. These foods can alter the relative abundance of the various species. But to dramatically change the population of bacteria you’d need a fecal transplant, which the FDA approves only if you are harboring Clostridium difficile (c. diff). Of course, you can always do it yourself.

In the interests of science, I signed up for one of the studies: the American Gut Project. (This requires a stool sample, of course.) I got a lengthy report complete with colorful graphs that show the relative abundance of the various phyla and families of bacteria in my gut. Unfortunately, the report doesn’t rate the quality of my bacteria—whether good or bad. Elsewhere, however, I learned that a ratio of more Bacteroidetes to fewer Firmicutes (these are phyla)—is correlated with lower body mass index. Unfortunately, my ratio is the opposite, but not by much. I’m a little fat. I think that means I need to eat more fiber. On a happier note, I did learn that my most abundant microbe (family Prevotella) is inversely correlated with Parkinson’s disease. So that’s something.

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Fiber: it’s not just for “roughage”

I think most of us thought that the value of eating fiber-rich foods was for the roughage it provides—undigestable bulk that keeps food moving through your digestive tract. It turns out that eating fiber is way more important than that. It feeds billions of bacteria in our guts, keeping them happy and, in turn, keeping our intestines and immune systems in good working order.

Here’s how it works: enzymes in our bodies break down food molecules, enabling us to digest the food. But our bodies make a limited range of enzymes, so we can’t break down many of the tough compounds in plants. That’s where the bacteria come in. Hundreds of species of bacteria live atop a layer of mucus that line our intestines. Some of them have the enzymes needed to break down various kinds of fibers—the kind present in vegetables, fruits, and nuts. After they’ve used the fiber for their own purposes, they cast off the leftovers in the form of short-chain fatty acids, which are absorbed by the intestinal cells that use it as fuel. Some of the short-chain fatty acids pass into the bloodstream and travel to other organs, where they act as signals to quiet down the immune system. Intestinal cells also rely on chemical signals from the bacteria to work properly: to make a healthy supply of mucus and to release bacteria-killing molecules when needed.

Scientists have found that diets low in the fiber result in a variety of negative effects. For one thing, certain populations of bacteria crash; many common species become rare and rare species become common. Without a steady stream of chemical signals from bacteria, the intestinal cells slow their production of mucus as well as bacteria-killing poisons, which are needed to wipe out the bacteria that get too close to the gut wall—a condition that kicks the immune system into high gear. In the words of one of the scientists, “The gut is always precariously balanced between trying to contain these organisms and not to overreact.  It could be a tipping point between health and disease.”

I hate to be tiresome, but I'm afraid it's important to eat those fruits and vegetables.

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Pickle juice for leg cramps!

I used to get leg cramps at night. To combat this problem, I took a daily mineral supplement containing magnesium, sodium, potassium, calcium and other minerals. It did the job nicely, but I hated taking the pills. They are big and rough. I am a terrible pill swallower and have problems even with small pills such as aspirin. (I know: the problem is psychological.) After a while, I quit taking the pills with no ill effects. For years, the cramps didn’t resume—until recently.

I remembered reading something about drinking pickle juice to stop leg cramps. The next time I got a cramp in the middle of the night, I opened a jar of pickles, and took a couple of big swigs. The cramps didn’t return that night. Because this could have been coincidental, I tried some experiments. One night I would swig pickle juice before turning in and get no cramps. The next night, I’d not swallow the juice and would get a leg cramp, at which time I’d get up and go for it again. I tried variations of this pattern for about a week. Once I tried just eating a pickle, which seemed to work. 

I wasn't sure if there was a real cause and effect relationship in my experiment--whether the juice really worked. So I did some Google searches on this topic, mostly on runners sites. It turns out that quite a few scientific experiments proved that pickle juice does indeed help. First, researchers determined that it wasn’t the salt in the juice that did the trick. The latest thinking is that muscle cramps are caused by a glitch in the neuromuscular mechanism that usually keeps extreme muscle contraction in check. The muscles get stuck in an “on” position. The acidic quality of pickle juice triggers a reflex when it hits a nerve center on the back of the throat that sends a signal that shuts down the overactive neurons causing the cramp.

You can buy little bottles of pickle juice for just this purpose! Or  you can swig from the pickle jar, as I did.

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Maybe just let that skin cancer grow

After receiving the bill for Mohs surgery to remove two basal cell skin cancers on my face, I vowed I’d ignore new ones and let them grow. My portion of the bill was around $600. I was horrified. (In the Mohs type of treatment, the surgeon cuts away a bit at a time, checking between cuts to see if the edges are clean—that no cancer is left. If the edges are not clean, he or she cuts some more, and so forth.) The charge for each cut was about $1,200—even more horrifying. I thought that my surgeon might be more expensive than others because his practice is in a high-end community near Stanford. But I discovered that his charges were typical.

Having gone through this before, prior to the surgery I instructed the surgeon take “big hunks.” He said he followed my orders. Nevertheless, while the cancer on my forehead took only one cut, the one at my jaw line required three before the edges showed no more cancer.

Basal cell carcinoma is slow-growing. Knowing this, in my initial visit to my dermatologist for the biopsy on the suspicious growths, I asked about leaving the cancer alone. She said she thinks about this and has decided that if it looks like you’ve got five years of life left in you, you should have it done. In my case, she recommended that I have them removed (she does not do the surgery). But she told me about a man in his early 90's with dementia and in very poor health, who she counseled to not have the surgery. Now in his late 90's, he has an open sore on his leg.

I discussed this same topic with the surgeon. He agreed with the dermatologist but told the story of a woman in her 90's whose GP told her to forgo the surgery. At the age of 103, the woman complained that the sore on her foot made it impossible to wear her pumps. My surgeon removed the cancer.

I am too good at detecting the cancers. I can feel them when they’re tiny invisible bumps that the dermatologist can’t even see but which the biopsy proves are cancer. Now we’ll see if I have the nerve to ignore them.

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