Cartoon II for the holidays

 

"Well, there is one more procedure I've always wanted to try."

Cartoon for holidays I

 

"I was able to get in one last lecture about diet and exercise."

Asthma

 A friend of mine was rushed to the emergency room after being in the vicinity of an open jar of peanut butter; a relative of my husband’s nearly died after a sudden allergic reaction to the family cat. In an asthma attack, the airways narrow and the sufferer struggles to get air in or out. In the US, between 1980 and 2000, asthma rates doubled, but hospitalization rates tripled, suggesting that asthma is now not only more common but more severe.

Scientists don’t know what causes asthma. For a while it was thought to be a neurological disease—the nervous system sending the wrong signals to the lungs. Later, scientists believed it was an allergic reaction. Now, as one researcher notes, “It’s clear now that it is considerably more complicated than that. We now know that half the cases in the world involve allergies, but half are due to something else altogether—to nonallergic mechanisms. We don’t know what those are. I have spent thirty years studying asthma, and the main thing I have achieved is to show that almost none of the things people think cause asthma actually do. They can provoke attacks if you have asthma already, but they don’t cause it. We can do nothing to prevent it. All we can really say about asthma is that it is primarily a Western disease. There is something about having a Western lifestyle that sets up your immune system in a say that makes you more susceptible. We don’t really understand why.”

Some scientists suggest asthma is caused by the absence of certain gut microbes; others are suggesting viruses. The dogma has been that both the allergic and nonallergic asthmas involve inflammation in the lungs, but with some asthmatics if you put their feet in a bucket of ice water, they begin to wheeze immediately. That can’t be due to inflammation because it happens too fast. Maybe the cause is neurological after all. I think what we can say is that where asthma is concerned, no one knows much of anything.

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

Is it something I ate?

 The other night I was wakened about 1:30 with an acid reflux event (stomach acid coming up into my mouth). Yuk. I got to wondering if there was still food in my stomach, so I looked it up. Here’s more than you want to know about how long it takes the food you eat to travel through your intestinal system—from mouth to anus:

·       Stomach: 2-6 hours to empty. After food has been mixed with gastric juice and mashed up, it goes through the pyloric sphincter at the lower end of the stomach and slowly empties into the small intestine.  

·       Small intestine: 5-12 hours to empty. The small intestine is where most digestion and absorption occurs. Whatever undigested food remains in the small intestine goes through a valve to the large intestine.

·       Large intestine: Average 36 hours. Undigested food mixes with bacteria that ferment the food and produce important chemicals such as vitamin K. The time undigested food remains in the colon ranges from 4-72 hours.  After that, you know where it goes.

·       Total time: For a healthy adult, the transit time from mouth to anus is 24-72 hours.

So anyway, by 1:30 in the morning my stomach should have been empty. A good thing, I think.

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

“Covid fees” added to your medical bill

 My husband’s periodontist has raised his rates to offset the costs of “covid-proofing” his office. Among other modifications—which I guess include personal protective equipment—the doctor has installed fancy air purifiers. Apparently, adding charges to patients’ bills have become commonplace. They’re called “covid fees,” and they range from a few dollars to nearly $1000.

These fees are often billed directly to the patient and are not covered by insurance. For example, one dentist tacks on an additional $45 to patients’ teeth-cleaning bills. In some states, this is a violation of consumer protection laws. Some insurers reimburse part of these added fees, which, in dental offices, range from $12 to $45. If the insurance company does reimburse, they pay between $7 and $10—that is, if you have dental insurance. We do not.

While such charges have become commonplace in dental offices, they’re also cropping up elsewhere, such as assisted living facilities. One resident was charged a $60 fee for personal protective equipment on top of a one-mile ambulance ride that already cost $1,759 before the fee. Another woman was charged a one-time $900 fee for masks, cleaning supplies, and meal delivery.

Of course, dentists and other medical establishments are taking a financial hit because of the pandemic. But—I don’t know—adding a covid fee to our bills just doesn’t sit right with me. I object.

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

About those Covid-19 tests

 I haven’t had one, not that I haven’t tried. Here’s the deal with them: There are three kinds of tests—

PCR virus test. PCR stands for polymerase chain reaction, a system that analyzes DNA—the DNA of the virus in this case. It can detect an active infection from a sample you get by swabbing your nose or back of your throat. Because the samples go to a lab for analysis, it takes several days to get the results back. With PCR tests, false positive rates are extremely low and are usually caused by mishandling the specimens in the lab. False negative results can occur during the first week of infection, usually because the virus isn’t yet present in detectable quantities. According to a study in the Annals of Internal Medicine, the probability of a false negative PCR result is 100 percent on the first day of infection and decreases to 20 percent by the eighth day. This test is considered the most reliable.

Antigen test. An antigen is a substance that causes your immune system to produce antibodies against it. The antigen test looks for certain molecules on the surface of the virus. This test also requires nasal swabbing. Positive results from antigen tests are highly accurate, but the test has about a 50% rate of false negatives. In other words, negative results don’t rule out infection. Though less accurate than a PCR test, you get results in minutes, sort of like a pregnancy test. A number of companies are producing these tests. 

Molecule test. It's a do-it-yourself test that checks for virus RNA molecules. You swab your nose, stick the swab in a container containing a chemical that changes color depending on the results, which take 30 minutes. The FDA just approved one of these tests: the Lucira COVID-19 All-In-One Test Kit. A positive result probably means you have the virus; a negative result does not necessarily mean you don't.

As to my experience: We were all set to have tests prior to a trip but cancelled the trip as well as our tests. At the same time, in the interests of science, I’d signed up to take the test for the Stanford CATCH study, which is tracking the spread of Covid-19 in the San Francisco Bay Area. But the couriers who deliver the test kit and pick up the sample couldn’t find my house.

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

Your nails know

 Recently, a specialist looked at my sister’s fingernails for a clue in diagnosing her ailment. Yes. The condition of your fingernails can signify various maladies:

·       White nails (the whole nail): liver diseases, such as hepatitis; low protein stores; kidney failure.

·       Yellow nails: respiratory disease such as chronic bronchitis; fungal infection.

·       Blue nails: lung issues, such as emphysema; heart problems; excessive silver consumption; bacterial infection of the nail; Wilson’s disease (a genetic condition that causes high levels of copper in the body).

·       Dark lines under the nail: possible sign of melanoma, but can also be moles, trauma, or medication-induced changes.

·       Clubbing (see photo below): lung disease; inflammatory bowel disease; heart disease; liver disease; thyroid disease; HIV/AIDS.

·       Horizontal indentations: diabetes; severe injury; past illness or medication exposure; zinc deficiency.

·       Pitting: psoriasis; connective tissue disorders.

·       Spoon shape (depressed and scooped out): iron deficiency anemia; hemochromatosis; heart disease; hypothyroidism.

·       Separation from nail bed: thyroid disease; psoriasis; injury or infection; reaction to drugs or consumer products.

I didn't say anything about how nails change as we age. My fingernails have curved inward from the sides. I found no information on that. 

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

Be patient!

 People are designed to be impatient. We do not like slow elevators or slow internet connections. We do not like waiting in lines or waiting on the phone for the customer support representative. But impatience comes at a price. According to Dr. Amit Sood, a researcher at the Mayo Clinic, impatience can result in anxiety, illness, injury, loneliness and even death. “An episode of explosive anger, stress or impatience can increase your risk of heart attack and sudden death by two to eightfold for the next few hours.” Most of us know that stress increases blood pressure and heartbeat. But studies have also shown that impatient people have shorter telomeres—the structures at the end of chromosomes that protect the end of the chromosome from deterioration.

Impatience is linked to lack of control, uncertainty, and boredom—conditions we humans try to avoid. (Researchers gave test subjects—all men—the choice to sit alone and get bored, or to give themselves a painful electric shock. About 70% chose the electric shock.)

During this coronavirus pandemic, our patience is sorely tested. But Dr. Sood tells us that being patient is a choice and that the pandemic offers a “tremendous opportunity” to practice patience. If you’re not good at that, try learning to be resilient. “You do not have any bullets, you do not have any swords. You can’t fist-fight with this virus…You can empower your billions of immune cells to fight with this virus. And when you are resilient, your immune cells are stronger in waging that war.”

I am not a patient person. I don’t like waiting for golfers ahead of me to get out of the way. I’m impatient to make a play in Words with Friends rather than taking my time to look for the best move. But I think I am a resilient person. So maybe it all balances out. I hope.

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

Arthroscopic surgery on knees--forget it

In arthroscopic surgery, a procedure that was started in the 1970s, the surgeon makes a couple of small incisions in the knee and inserts a fiber-optic arthroscope to take a look around, then washes out the joint with about ten quarts of saltwater to remove bits of cartilage, bony fragments, calcium crystals, and inflammatory cells.  He or she may also smooth out frayed cartilage and meniscus that cover the top and sides of the knee.

By 2002, fourteen studies had shown that arthroscopic surgery offered substantial pain relief. None, however, compared people who had had the arthroscopic surgery with those who hadn’t. In 2002, however, researchers at the Houston Veterans Affairs Medical Center and Baylor College of Medicine attempted to make this comparison using three groups of patients—180 in all. Two thirds had arthroscopic surgery, either just the washing or the cartilage cleanup. One third had a sham surgery: incisions, but nothing else (although the medical team acted as though they were performing all the treatments). One surgeon, the orthopedic surgeon for an NBA team, performed all procedures.

During the next two years the patients were evaluated for knee pain and function. It turns out, there was no difference in outcome. As reported in the New England Journal of Medicine, editors wrote, “Although smoothing cartilage and meniscal irregularities may sound appealing, larger forces within and outside the joint environment, such as malalignment, muscle weakness, instability, and obesity, which are not addressed by this type of surgery, may have greater effects on the clinical outcome…[the procedures] may simply remove some of the evidence while the destructive forces continue to work.”

Since then, according to my source, Dr. Paul Offit, “…fourteen randomized, controlled clinical trials and twelve observational studies, involving 1.8 million people, found that arthroscopic surgery for knee arthritis, with or without repair of a torn meniscus, was no better than physical therapy alone. Arthroscopic surgery, therefore, is no longer recommended for the treatment of knee arthritis. Yet, it remains one of America’s most common outpatient surgical procedures.” 

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

Epstein-Barr virus: you probably have it

 More than 60 percent of human infectious diseases are zoonotic—that is, they’re the result of humans coming into contact with a virus-carrying animal. The virus takes advantage of the new host and colonizes it. Such is the case with the virus that causes Covid-19 as well as the one that causes AIDS. While the viruses that cause Covid-19 and AIDS are quite successful in their ability to infect people, the most successful of the zoonotic viruses is the Epstein-Barr virus (EBV), a very transmissible species of herpesvirus that may reside within at least 90 percent of us, including half of five-year-old children.

EBV is passed from person to person through bodily fluids, mostly saliva. With most of us, when we become infected we don’t get particularly sick and we develop immunity. The virus remains inactive within your body for the rest of your life.  If your infection doesn’t occur until you’re an adolescent, you have about a fifty-percent chance of getting mononucleosis.

But it’s not all that benign. EPV has been implicated in a bunch of diseases, especially autoimmune diseases such as lupus, multiple sclerosis, and rheumatoid arthritis. But it’s also been implicated in other diseases, including Parkinson’s disease, schizophrenia, and a whole bunch of cancers. It’s actually a rather long list. One medical journal states “Developing a vaccine for the Epstein-Barr Virus could prevent up to 200,000 cancers globally.”

 This is all rather horrifying. Sorry I brought it up. You have enough to worry about.

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

Nursing homes behaving worse: evicting the poor

 Across the country, reports of illegal nursing-home evictions are rising. It’s called “resident dumping.” The point is to get rid of unprofitable patients, mostly those who are poor and require extra care. Here’s how it works: a patient, usually with dementia, acts out in some way—throwing a bingo chip, yelling at a staff member, knocking over a chair. The nursing home sends the patient to a hospital for psychiatric examination. After the hospital discharges the patient, the nursing home refuses to take the patient back. By getting rid of people on Medicaid and replacing them with better-insured patients, the nursing home can get an extra $1000 a day, according to a lawyer for one of the patients.

There’s no national data on nursing home evictions. States do have nursing home ombudsmen, some of whom have said they have not seen nursing homes dumping patients. But in 16 states, some ombudsmen say the problem is getting worse. According to one report, problem residents are sometimes packed into vans and then abandoned in low-budget motels, or homeless shelters, or even onto street corners — or, in one reported instance in Maryland, into a storage facility. 

According to an ombudsman, Medicaid patients who require lots of staff attention “have a target on their back.” Lesson: If you’re on Medicaid and end up in a nursing home, be nice!

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

Do not refrigerate

Because we had to evacuate for more than two weeks to escape the CZU August Lightning Complex Fire, I learned a thing or two about refrigeration. Our power had been out during this period and our refrigerator had been sitting at room temperature. When we returned it was foul smelling, to say the least. Of course, we had to throw out much of its contents, the worst of which was the rotted meat (eau de dead person). But I didn’t throw out everything. I decided to sniff and taste.

The most surprising was the almost full quart of pomegranate juice. I tasted it. It was fine! So I started examining and tasting other items, such as olives. They were also fine. I ended up keeping more of the jars that sit in the refrigerator door than I threw away—such items as pickles, capers, mustards, hot sauces and everything else that was either salty, vinegary, or spicy hot. I guess that’s sort of a no-brainer, when you think about it.

I’ve never refrigerated items such as tomatoes, onions, potatoes, all kinds of fruit. But I did a little research and discovered that, in addition to the other items I’ve mentioned, you don’t need to refrigerate eggs (unless cracked, of course). I threw away three of them that I could have saved (they’re displayed in refrigerated sections at the market)! You don’t need to refrigerate syrups (spoilage bacteria can’t grow when the sugar content is high). You also don’t need to refrigerate butter—which I knew. I always leave one stick on the kitchen counter but refrigerate the rest, which I’ll keep doing just for convenience. On an earlier occasion, I also learned, thanks to friends who had been house-sitting, that you don’t need to refrigerate peanut butter. It’s so much easier to spread at room temperature! 

All of my spicy, salty, vinegary items are still in the door of the refrigerator. I’m used to them being there and know where to find them.

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

In poker, your arms give you away

 Michael Slepian, Associate Professor of Leadership and Ethics at Columbia University, studies the psychology of secrecy. He hit on the idea of studying poker players to determine whether the motions made by poker players as they placed their bets could reveal whether the players’ cards were good or bad.

In a series of three studies, Slepian asked undergraduates to look at clips of players from the 2009 World Series of Poker. In some of the clips, the students could see the full body (from the table up) and face of the players as they made their bets. Another set of clips showed only the chest and head (face) of the players. A third set of clips showed only the players’ arms as they pushed chips in on the table. The students were then asked to judge the quality of the poker hands—from very bad to very good—based on the clips they saw.

When judging the first two sets—those that included the heads and faces of the players—the students were no better than chance at guessing the quality of the players’ hands. In fact, when they studied players’ faces, their judgements actually dropped to below chance levels. Faces, it turns out, may actually give more false than useful information. But when the students looked at clips showing the motion of arms alone, their performance shot up. Even people who had no prior knowledge of poker seemed suddenly able to tell with some accuracy whether a player had a strong or weak hand. The players with the better hands executed their moves in a fluid manner and the students instinctively picked up on it. Apparently, smooth body movements suggest confidence; anxiety disrupts the smoothness.

At birth, our brainstems—the lowest and most primitive part of our brains—control our arms. That connection endures. We don’t think about the way we’re moving our hands and arms. For poker players, those movements can betray their carefully arranged facial expressions—their poker faces.

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

Nursing homes behaving badly

 All of us learned, at the beginning of the coronavirus outbreak, that a nursing home in Kirkland, Washington, was at the center of the outbreak. A couple of months later, we learned about the nursing home in New Jersey where 70 people died and 17 bodies were found sequestered there. In fact, 40 percent of the nation’s fatalities have been residents of nursing homes. They have much to answer for:

• While it looks like nursing aids may be responsible for much of the virus spread, I don’t blame them. The national average pay for aids is $13.38 an hour, mostly without benefits. Thirteen percent live below the poverty line and almost 36 percent rely on some form of public assistance. They are not paid if they contract COVID and go out sick. To make ends meet, many work multiple jobs at multiple facilities, going from one to another in a single day. 
• Nursing homes are a $100 billion business. Around 70 percent of them are for-profit and more than half are affiliated with corporate chains. Just five companies own more than 10 percent of the country’s 1.7 million licensed nursing-home beds. Private equity has bought up four of the ten largest for-profit nursing homes. It’s a growth industry! (Studies have shown that when nursing homes are bought by private-equity groups, frontline nursing staff are cut, and residents are more likely to be hospitalized.)
• Nursing homes complain of being in financial distress because of low Medicaid reimbursements. This is actually not true. Three-quarters of nursing homes have created networks of sub-companies called “related parties” that trade with one another, including real estate, insurance, management, consulting, medical supplies, hospice, therapy, private ambulances, and pharmacy services—even interior design firms. This arrangement allows companies to siphon profits out of their nursing homes through overpriced transactions with their sister companies. By 2015, nursing homes were spending $11 billion a year on contracts with related parties. Nevertheless, Life Care Center of Kirkland has received nearly $919,571 in federal pandemic relief (Life Care is one of the biggest chains).
• To increase billing, nursing homes provide unnecessary therapy. Example: a 92-year-old man who was dying of metastatic cancer was allegedly given 48 minutes of physical therapy, 47 minutes of occupational therapy, and 30 minutes of speech therapy two days before he died.
• The five-star rating system for nursing facilities is a fiction. “Quality measures,” such as the number of residents who get pressure ulcers, are self-reported and rarely audited.
•  American Health Care Association, which represents for-profit nursing homes, devotes around $4 million a year to political lobbying, which consists primarily of asking Washington for less “burdensome” regulations and more empowerment to the free market.

I usually try to keep my posts short but was unable to in this instance. Even so, the above is only told part of the story.

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

New wrinkles in the placebo effect

 To gain FDA approval for a new drug, pharmaceutical companies must show that it outperforms placebos in two independent studies. This is not easy. For example, more than 90 percent of pain medications fail in the final stage of drug trials. In other words, most drugs did not perform better than placebos. Every clinical trial is actually a study of the placebo effect.

The placebo effect is powerful. It can evoke a real neurobiological healing response, using the pathways that affect bodily sensations, symptoms and emotions. As one scientist remarks, “It seems that if the mind can be persuaded, the body can sometimes act accordingly.” The healing response is also affected by healing rituals and acts of caring. The brain translates the act of caring into physical healing, turning on the biological processes that relieve pain, reduce inflammation, and promote health.

Scientists have recently discovered that the response to placebos varies among people depending on their genetic makeup. A particular snippet of our genome governs the production of an enzyme, called COMT, that affects people’s response to pain and painkillers. Some people have weak placebo responses and some have strong responses.

For years scientists thought that the placebo effect was the work of the imagination. Now, with the use of imaging machines, they can see the brain lighting up when a test subject is given a sugar pill. Those people who are strong placebo responders show consistent patterns of brain activation.

If drug companies can weed out the strong placebo responders from their trials, they’ll have better luck!

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

Allergic contact dermatitis

 I wrote this post--using an iPad--on September 2 while evacuated to a cabin at Huntington Lake in the California Sierra Mountains. September 2 was day 17 of our evacuation from our home in Boulder Creek, California, site of the CZU Lightning Complex fire. I'm editing this at home on September 7th. Huntington Lake is now the site of a wildfire. We left the day before it started.

While at the cabin, I read an interesting medical-related story and wrote this: A man was doing yard work when he felt a sting on his shin—an insect bite, he figured. He did see a puncture mark. A couple of days later, the spot had become a little red, so his wife suggested that he put Neosporin on it, which he did.

He also decided to see a doctor about it. After examining him, the doctor decided that the spot--which had become enlarged and darker red--was not infected. Nevertheless, she prescribed an antibiotic for him to take in the event that the red area became larger.

In the days that followed, the area did become larger and the man started the antibiotics—to no effect. In fact, the red area continued to enlarge until it was about the size of a hockey puck and was surrounded by red dots. Not only that, but a red area also appeared on his other leg at about the same location. Again, he sought medical help. This time several doctors examined him and ruled out Lyme disease, brown recluse spider bite, and several other possibilities. Finally, one of the doctors figured it out: he was allergic to Neosporin. 

Neosporin is a triple antibiotic ointment, which his skin mistook for an invader, triggering an inflammatory response: allergic contact dermatitis. It turns out that triple antibiotic ointments are among the top ten causes of allergic contact dermatitis, along with some of the common ingredients in lotions and fragrances. As to the fact that the man’s other leg developed the redness, it was because it had come into contact with the ointment on the affected leg.

Update: we learned, on 9/11, that the cabin burned, a casualty of the Camp fire.

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

The AgeLab at MIT

 The Massachusetts Institute of Technology has an AgeLab. Among other things, they created a suit that simulates the effects of aging. The suit includes yellow glasses, neck harness, bands around the elbows, wrists, and knees, boots with foam padding, and special gloves that add resistance to finger movements. Writer Adam Gopnik tried the suit and discovered that every small task becomes effortful. More than that, he reports, “the concentration that each act requires disrupts the flow of life…the ceaseless flow of simple action and responses…mostly without effort.” The suit made him aware not so much of the “physical difficulties of old age, which can be manageable, but of the mental state disconcertingly associated with it—the price of age being perpetual aggravation.”

Well, maybe Gopnik was perpetually aggravated while wearing the suit, but I’d guess that most of us old people are only aggravated part of the time. As for our activities requiring added concentration, he’s right about that. I’m more careful than I used to be about walking down the stairs and around impediments. Until reading his words, I hadn’t been aware of the “willful attention” now required for activities that I’d previously managed without thinking about it. He also equates the "ceaseless flow of simple action" as the "happiness of life." "Happiness is absorption, and absorption is the opposite of willful intention.” That’s a bit over the top, I think.

The purpose of the MIT AgeLab is to encourage and incubate new technologies and products for old people. They quickly learned that old people “are a market that cannot be marketed to,” the reason being that old people will not buy anything the reminds them that they are old. For example, after developing the neck pendant (“I’ve fallen and I can’t get up!”), they discovered that no one wants one. That would be me. Happily, the iPhone and Apple Watch have a red panic button app that alerts your emergency contact people. No one need know.

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

The Stanford Prison Study debunked

 This post follows the same theme as last week’s: fraudulent science.

You are probably familiar with the famous Stanford Prison Study conducted in 1971 by Phillip Zimbardo. Students were assigned roles as either “inmates” or “guards.” in a mock prison. Soon after the experiment began, the guards began mistreating and even torturing the prisoners who passively took the abuse. What this study supposedly demonstrated was that innocent people, when thrown into a situation where they have power over others, will begin to abuse that power.

This study has been widely documented in books, films, and textbooks. Zimbardo was even consulted in a 2004 hearing on the Abu Ghraib prisoner torture. Now, after 50 years, his study has finally been debunked. Among other things, the study’s critics tracked down many of the “inmates,” including one who had screamed ‘I’m burning up inside” and found out that his pain was a performance. As the student recounted, “I have a great job. I get to yell and scream and act all hysterical. I get to act like a prisoner. I was being a good employee. It was a great time.” The “guards,” who were coached to be cruel, reported similar experiences. One said he pretended to be a sadist for kicks. “I took it as a kind of improv exercise. I believed that I was doing what the researchers wanted me to do… I’d never been to the South but I used a southern accent.” In other words, the students weren’t unleashing their ingrained sadism. They were acting.

So now you can rest easy. You probably do not harbor a monster inside of you waiting to emerge in the right context.

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

What information can you trust?

The world of scientific research is competitive: grant money and livelihoods depend on getting research published and journals select articles that make splashy news. At the moment, a greater number of post doctorates are competing for fewer jobs and grant resources. What this has led to, in the words of one researcher, is an “epidemic of fraud.” The “fraud” in this case consists of such deceptions as leaving out contradictory data, cutting corners, or even making up data.

Example: You may have heard of “mindless eating,” the idea that the unconscious decisions we make about food can have profound effects on our diet and weight. The man responsible is Brian Wansink, a Cornell University professor, who became quite well known for his experiments such as the one showing that serving bowl size affects food consumption. He has influenced consumer behavior and even national policy. But he was forced to resign after thirteen of his papers were retracted because of data irregularities and gross statistical errors. In the words of Cornell, he committed “academic misconduct in his research and scholarship, including misreporting research data.”

In the field of psychology, one researcher started a “reproducibility project:” he selected one hundred published psychological experiments and tried to reproduce the findings but was only able to reproduce fewer than half of them. In the field of genomics, Stanford’s John Ioannidis (very trustworthy) found that only a tiny fraction of papers on that topic stood the test of time. For more examples, you can check out the blog, Retraction Watch, which strives to post every single academic retraction and keeps a top ten list of the most highly cited retracted papers. When I looked at it, it had already listed thirty-three retracted papers on the coronavirus.

Now, for myself, I select only those studies that support my own biases, which are always correct, of course.

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

Crazy bills for coronavirus tests

Two friends, Jimmy and Pam, were going on a kayaking trip with other friends. For peace of mind, they decided to get tested for the coronavirus prior to their trip. They both got drive-through tests at Austin Emergency Center in Austin, Texas. Jimmy paid $199 cash just to avoid insurance hassles. Pam, who was using insurance, was charged $6,408 for her test. (Hers was later negotiated down to $1,128, but she was still responsible for $928 of that. After a television show told her story, her bill was dropped entirely.)

Another man who was tested at the same place got a bill for $5,649, of which his insurance plan paid $4,914. He’d been assured he’d be tested for only the coronavirus, but his bill showed he’d also been screened for Legionnaires’ disease, herpes, enterovirus, and others. (He also got out of that bill.)

During the pandemic, there’s been a wide variation in the amount providers bill for the same basic diagnostic test, with some charging $27 and others $2,315, for example—even if they’re conducted at the same location. The differences reflect different insurers’ market clout. A large insurer can demand lower prices, while small insurers have less negotiating power.

So, not only are tests notoriously unreliable and may take weeks for results, the charges attached to them are ridiculous. The discrepancies arise from the fact that the government does not regulate health care prices. What a mess.

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

Mammogram stats

Every year in the US, hundreds of thousands of women are diagnosed with an early stage of breast cancer. But most early breast cancers are actually precancerous tumors that may or may not progress to true cancer. Thus, three out of four who are diagnosed with breast cancer suffer the complications of surgery, radiation therapy, hormone therapy, and chemotherapy with no benefit. Moreover, about one in four mammograms result in false positives, requiring multiple follow-up treatments and doctor visits, only to learn that they had no cancer after all.

No recent study has ever shown that mammograms have prolonged the lives of American women. Although mammograms save some lives, given the advances in breast cancer treatments, mammograms haven’t had an impact on overall mortality.

Here are the recent stats: For every 1,000 women screened every two years, most will have a false-positive mammogram during the next ten years, 146 will have an unnecessary biopsy, 7 will have a fatal case of breast cancer prevented, and 19 will be diagnosed with a cancer that never would have killed them. Among the 19 per 1000 who are over-diagnosed, 99 percent will have surgery, 70 percent radiation therapy, 70 percent hormone therapy, and 25 percent chemotherapy—all without benefit.

Scientists have no way of knowing who will benefit by screening. You might reasonably choose to have mammograms on the off chance that you might be one of the seven who has her life saved by screening, but also recognizing that you might be one of the nineteen who will undergo unnecessary treatment. Or, like me, you could skip the whole business. (I think I had one or two mammograms about 30 years ago.)

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Safely opening gyms in Norway

Norway, especially Oslo, has plenty of Covid-19 cases. (Oslo’s population is about 681,000. As of July 18, they had 9,029 cases and 255 deaths.) Nevertheless, they have opened their gyms as a result of a scientific study in which scientists conducted a randomized trial to test whether people who work out at gyms with modest restrictions are at greater risk of infection than those who do not.

The research included five gyms in Oslo with 3,764 members ages 18 to 64 who had no underlying medical conditions. Half were invited to go back to their gyms and work out. The other half were not allowed to return to their gyms. Those who returned to the gyms were required to wash their hands and to maintain social distancing: three feet apart for floor exercises, and six feet apart in high-intensity classes. They could use their lockers, but not the saunas or showers. They were not asked to wear masks. During the two weeks of the study, 79.5 percent of the members used their gyms at least once; 38.4 percent went more than six times.

Over the course of the two-week trials, there were 207 new coronavirus cases in Oslo, but no one using the gym contracted the disease. Skeptics are questioning the results, thinking that no one was infected in the gyms because there were very few COVID-19 cases in the city when the study was done—not because working up a sweat on the treadmill or lifting weights in the midst of a pandemic is safe. But hey:  1,896 people worked out at the gyms and none got infected! I’m a glass half full person.

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My own pointless doctor visits

The other day, I looked up my old my medical records using an online “patient portal.” I wanted to see how it worked. Because I normally resist seeking medical attention, I didn’t have many records. (I don’t do annual checkups, so that eliminates a lot.) But it got me to thinking about the value of those occasions that I did seek medical attention: vertigo; alarming heart palpitations; pain in groin and huge bump on elbow after falling onto pavement from chair I was standing on; infection in finger that kept getting larger and lasted a couple of months; knee and hip pain.

In all these cases, the problems either resolved on their own or because of my own ministrations. Nevertheless, I was glad I sought medical attention, mostly to find out what caused the problem: glad to learn that vertigo is caused by out-of-place crystals in the inner ear, which I now know how to fix; glad to know my heart is fine—some people just get palpitations (they stopped, by the way); glad to learn that my bones are strong (nothing broken); glad to know my immune system handled the finger infection; glad to find out what was causing my knee problems, allowing me to work on them in my own way.

My sister tells me that her doctor visits were rarely helpful: “Most of my medical visits—especially specialists—have not yielded anything real. I've had two kidney tests with radiation and injections; a lung biopsy; carotid artery ultrasound; three-day heart tests and some I've forgotten. None told me anything except that I had no problems.”

Try it yourself! Make a list of your doctor visits and see what you come up with!

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“The Best Care May Be No Care”

The above title is the headline of a recent op-ed piece in the New York Times by cardiologist Sandeep Juahar. It’s right up my philosophical alley. Juahar is referring to the fact that, as a result of the pandemic, people have been avoiding medical care. Nevertheless, “a vast majority of patients seem to have fared better than what most doctors expected.” In fact, he says, “perhaps Americans don’t require the volume of care that their doctors are used to providing.”

Juahar maintains that a substantial amount of health care in America is wasteful. He cites a number of reasons: doctors practicing “defensive” medicine to avoid lawsuits; a reluctance to accept diagnostic uncertainty, which leads to more tests; exorbitant prices; lack of consensus about which treatments are effective; and the pervasive belief that newer, more expensive technology is always better.

Doctors themselves admit that 15 to 30 percent of health care is probably unnecessary. And studies suggest that up to 20 percent of surgeries in some specialties are unnecessary. A long list of medical societies, such as the Society of General Internal Medicine and the American Academy of Neurology produce lists of procedures to avoid. You can see these lists at choosingwisely.org. The lists run to more than 65 pages!

As Juahar says, “If beneficial routine care dropped during the past few months of the pandemic lockdown, so perhaps did its malignant counterpart, unnecessary care. …More care doesn’t always result in better outcomes.”  You go, Dr. Juahar!

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How to make a vaccine

The goal of a vaccine is to prepare your immune system to fight a bad virus or bacterium. It does this by stimulating your body to make antibodies that can quickly recognize a foreign invader and trigger an effective immune response. In the case of the SARS-CoV-2 virus, teams of scientists are working on three types of vaccines, all of which stimulate the body to make antibodies:

• Whole inactivated virus: You grow the bad virus in the laboratory then inactivate it with chemicals or other methods, rendering it harmless. This was the method Salk used for the polio vaccine. At the moment, a Chinese company, Sinovac, is in clinical trials using this method.
• Recombinant nanoparticle: You synthesize pieces of the virus protein and grow them in insect cells along with a special compound. The government has paid Novavax $1.6 billion to develop this vaccine. 
• Gene-based vaccine: You take a bit of RNA or DNA from the virus then stitch it into the genes of a vector, such as the virus for the common cold. This method was used to make a vaccine for Ebola.
• Viral-gene snippet: You take a snippet of a viral gene (m/RNA) which can enter the human cell and induce it to make the virus’ spike protein. The resulting antibodies latch onto the spike proteins. A company called Moderna is using this approach and is in the first phase clinical trials.

In Russia, they're experimenting with giving people the Sabin Oral Polio Vaccine, which is a live, but weakened polio virus. It's safe, available, and inexpensive. While the polio vaccine doesn't promote antibodies specific to the Covid-19 disease virus, it is a powerful stimulant to the innate immune system, priming it to attack invaders. This would be a stop gap measure.

Of course, the laboratories making the other vaccines must conduct a series of clinical trials to determine dosages, side effects, safety, and efficacy. Sinovac’s trials are encouraging, as are Moderna’s, although a few test subjects in Moderna’s trials have gotten sick, probably because of dosage issues. After the trials are complete, companies must then manufacture and distribute the vaccine, a process that normally takes years. To speed up the process, some companies are already preparing for production. This will be interesting.

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Forget that ice pack

In 1978 an influential doctor, Gabe Mirkin, published a bestselling book: The Sports Medicine Book. In addition to sports medicine, Mirkin was an expert in many other fields. He was also a competitive marathoner and a charismatic guy. In his book, he promoted a method on how to treat sprains which he called RICE: rest, ice, compression, elevation. RICE became the go-to treatment for decades to follow. It turns out that his RICE idea was based more on instinct than evidence.

Beginning in 1989 researchers began performing experiments to test the theory. The tests continued through 2013. Their conclusion: there is no evidence that ice helps with pain, swelling, or speed of recovery. Ditto for rest, compression, and elevation.

The studies showed that cold packs actually worsen outcomes. That’s because inflammation—which increases blood flow—is the key to healing: increased blood flow increases clotting factors, brings immune cells to the rescue, and helps to manufacture more collagen. Thus, anything that decreases blood flow only lengthens the time to healing. In fact, heat is better than ice.

In 2013, Dr. Mirkin recanted his earlier advice: “There are no data to show that ice does anything more than block pain. And there are data that show it delays healing. RICE is just something that stuck—and it’s wrong.” As to rest, Mirkin said, “Nobody believes in rest anymore. You can get a hip replacement and you’re on the bike 12 hours after surgery.”

Yet doctors still give us ice packs. It takes years for old ideas to die. But once the no-ice idea catches on, sales of frozen peas will probably drop.

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Fear

I’m not afraid of getting Covid-19. This is partly because, knowing how the disease is contracted and that its prevalence is relatively low in my county, it’s unlikely that I’d get it. That’s my rational brain at work. My lack of fear also seems hard-wired. I can’t help it.

The degree to which we experience fear has a genetic component. Researchers have developed lines of mice in which all members are fearful. A newborn mouse from a fearful line who is reared by a fearless step-mother will still be fearful as an adult. Studies of adopted children as well as identical and fraternal twins reared either together or apart have also shown that fearfulness has a clear genetic component.

Multiple genes and multiple processes are involved in fearful responses. For one thing, if you lack functional nerve cell receptors for a certain chemical (gamma-amino butyric acid), you will be more fearful. That’s because the higher regions of our brains use the chemical to tone down our lower brain’s initial impulses, which could result in an overly fearful response to stimuli. (The “lower brain" is the amygdala and is involved in fight or flight impulses.) Genes also affect our bodies’ uses of serotonin, which regulates anxiety, as well as stress hormones.

Some researchers have figured out a treatment to lessen the power of fear. It’s called “eye movement desensitization and reprocessing” (EMDR). Therapists use it to treat PTSD and other fear-related problems. The technique includes having patients move their eyes in specific ways while either recalling traumatic events or being exposed to a fear stimulus. Scientists don’t know exactly how it works, but it has to do with tamping down the amygdala’s fear response while activating brain pathways involved in controlling emotion. Researchers can test the efficacy of these methods using fMRI scans and by measuring electrical skin conductance, which is a measure of fear. The methods seem to work.

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The seven sins of medicine

Below is a story I read in the New England Journal of Medicine as an illustration of the seven sins of medicine. The seven sins were put forth by Dr. Richard Asher in 1949. Asher, a Brit, was regarded as "one of the foremost medical thinkers of our times" who emphasized the need "to be increasingly critical of our own and other people's thinking.” His list of the seven sins of medicine is still relevant today.

Here’s the story: A guy has a dizzy spell. He goes to the emergency room, which, it turns out, is just the beginning of his medical misadventures which included the following: electrocardiogram, blood tests, x-rays, CTs of his head and neck, an MRI of his brain, treadmill stress test, “pharmacologic stress test,” two angiograms, ultrasound, audiogram, and, finally, a recommendation that he see a neurologist “because I can’t rule out a problem with your central nervous system.” At that point, the guy stops with the tests and goes with the suggestion of his niece, a young internist who has told him that he has BPPV (benign paroxysmal positional vertigo), a common condition that I and many of the people I know have experienced.

The seven sins are the following: 

1. Obscurity. "If you don't know, don't admit it. Instead, try to confuse your listeners."
2. Cruelty. Not following the Golden Rule.
3. Bad manners. Being rude.
4. Over specialization. Undervaluing generalists.
5. Love of the rare. In hearing hoofbeats, thinking zebras instead of horses.
6. Common stupidity. The opposite of common sense.
7. Sloth. For example, ordering excessive tests instead of taking the time to take an adequate history.

The guy in the story is particularly furious at what he calls “mental laziness.” “Where’s the science?” he says. “I’ve got this fleck of calcium tumbling around in my inner ear, and they tell me maybe it’s a heart attack!” The bills for all of this amounted to $74,542.

In researching Richard Asher, I was flabbergasted to learn that we knew his son Peter, a music producer. Peter lived down the street from us in Los Angeles. Our son, Rob, recently met up with Peter in Manhattan.

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Unregulated implants

I’m talking here about devices such as artificial joints, pacemakers, stents, surgical mesh, vein filters, insulin pumps and the like. In 2015 the FDA received around sixteen thousand reports of deaths associated with such medical devices. But the number is surely higher: 99 percent of “adverse events” are not reported. The more serious the event, the less likely it is to be reported. The true number of those deaths could be as high as 1.6 million, making them one of the leading causes of death in the US. About 1,100 of these devices are recalled annually. In 2013, 33,000 inferior vena cava filters were recalled. Instead of stopping blood clots from reaching the heart, the filters actually caused clots to form.

Regulation of these devices is lax. Depending on the level of risk, manufacturers can simply register them with the FDA prior to putting them on the market or provide “reasonable assurance” of their safety and efficacy. Clinical testing is the exception rather than the rule. Since 1976, the FDA had approved more than a thousand high-risk devices, such as pacemakers. Of those, only sixteen percent had gone through rigorous clinical testing before sale. Of the four hundred moderate-to high-risk implants approved for market between 2008 and 2012, no clinical testing was required. These devices included stents, replacement hips, surgical mesh, and similar implants.

Of course, device makers make huge profits from their products. In 2014, the industry’s estimated revenue was more than $136 billion. To increase sales, they strive to constantly innovate. Thus, more untested devices come onto the market.

Unlike Canada, Australia, Japan, New Zealand and several European countries, the US has no registry of implants that would provide the FDA, doctors, and patients with the risks and benefits of implants over time. Repeated efforts to implement a registry system in the US have failed, thanks to the implant industries’ powerful lobby.

   

As it is, people with implants are participants in a large uncontrolled experiment.

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Hospitals are hurting. Boo hoo

Our health care system is market driven. Every player—insurers, hospitals, pharmaceutical companies, doctors—must have a profitable, self-sustaining, business model. Like hotels, hospitals aim to keep their beds full with well-paying customers in need of knee replacements or heart procedures. Even though, in 2017, the CDC warned of the need to stockpile supplies such as ventilators and protective gear, the warning was ignored. Because stockpiling offers no return on investment, hospitals have zero incentive to do so. That’s the reason for the shortage of these items.  There's no money in being prepared for a pandemic.

Because they’ve had to postpone lucrative elective surgeries, hospitals will receive tens of billions of dollars as part of the coronavirus relief package. But get this: at least half of the top 10 recipients have paid millions in penalties for improper billing and other shady practices. For example, the Florida Cancer Specialists and Research Institute, one of the nation’s largest oncology practices, recently received a $100 million penalty for engaging in a nearly two-decade-long antitrust scheme to suppress competition. Nevertheless, it received more than $67 million in bailout funds. Dignity Health, the hospital conglomerate in my area, received $180.3 million in bailout funds despite having submitted false claims to Medicare and TriCare, the military health care program.

Many of the big hospital conglomerates have huge cash reserves, but receive bailout money anyway. The Providence Health System, which received $509 million, is sitting on nearly $12 billion cash, which, when invested, yields $1 billion in profits. Mayo Clinic has also lost money. Things are so bad it had to dip into its $10.6 billion cash reserves and investments. Boo hoo.

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