Cartoon II for the holidays

 

                                              "Oh my God, it feels good to lie down."

Cartoon I for the holidays

 

                                      "Wheatgrass is highly effective at neutralizing joy."

Big bucks for long term care facilities

 As you probably know, the U.S. spends more than any other country on health care: $13,000 per person every year, compared to Japan, for example, that spends $4,700 a year. (Japan also has the longest life expectancy: 87.6 years compared to our 79.3.) The main reason for our outsized expense is that our health care system focuses on maximizing profits. Compared to other countries—which regulate the industry—we allow the market to operate more freely, a situation that began in the 1980s when the U.S. began moving toward a laissez-faire economy. (Competition often fails to bring down prices because the health care sector is so complex, with opaque pricing and bureaucratic insurance plans.)

Assisted living facilities, which are a case in point, are home to 85,000 older Americans. Half of these facilities earn returns of 20 percent or more than it costs to run them—far higher than the money made in most other health sectors. Many facilities charge $5,000 a month or more, then layer on extra fees: $12 for a blood pressure check; $50 per injection (more for insulin); $93 a month to order medications not used by the facility; $315 a month for daily help with an inhaler.

In searching the internet, I came across ads for going into the assisted living business. One said, “You can generate $36,000 of gross monthly income and net $10,000 of monthly cash flow by converting one single-family home into an Assisted Living Home (ALH). It’s easier to do than most people think.” Another site displayed this title: “How to make 42% profit margin in senior housing,” as touted by the CEO of Eldermark. In his talk he said this: "You have to dehumanize the fact of the person and call it a unit, because that's essentially what it is: unit inventory." Enough said.

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

Your body’s clocks

I think most of us are aware of our circadian rhythms—our bodies’ sleep cycles. They’re controlled in the hypothalamus part of the brain. In the evenings, our brains release hormones that lower our body’s temperature and blood pressure and make us feel sleepy. In the morning, cortisol and other hormones restore our alertness, make us warmer, and increase our blood pressure. Now scientists know that every cell in your body contains a group of genes that function as a sort of mechanical watch, keeping time everywhere in our bodies.

These “clock genes” represent every physiological system: skin, liver, immune system, kidney, heart, lungs, muscles, and reproductive system. Disrupting our circadian system can have a significant negative impact. Your liver, for example, determines when to rev up your metabolism based on when you eat.  If you eat in the middle of the night, your liver—which your brain has instructed to rest—will process the midnight food less efficiently than it would have during the day. Among other effects, eating at night increases the risk of glucose intolerance because the kidneys and pancreas are also primed to rest at night. Similarly, being exposed to light when our body ought to be resting can have a negative impact, including impaired glucose and cardiovascular regulation. Some studies have shown that light during sleep—such as leaving the TV on—is a risk factor for obesity.

A bunch of scientists are trying to influence hospitals to change their ways. (As I’m sure you’re aware, hospitals are one of the worst environments for maintaining circadian health—both for staff as well as patients.) For example, research has shown that premature infants who receive 12 hours of light followed by 12 hours of darkness are discharged an average of two weeks earlier than those who are exposed to near constant darkness or near constant light. Scientists are also studying the best time to take drugs. For example, they found that taking low-dose aspirin in the evening is more effective than taking it in the morning.

 The timing of our clocks varies by individual, which in turn is affected by genetic predisposition, the sun, indoor lighting, behavior, and age. In general, circadian researchers suggest getting as much sunlight as you can during your day, especially upon waking, dimming the lights before sleep, making your bedroom dark, and eating most of your calories earlier in the day. Easy for me; not so easy for night-shift workers.

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

Straightening your spine

I’ve recently turned my attention back to “the posture lady,” Esther Gokhale. Years ago, Gokhale was suffering from unrelenting back pain. She had surgery but the pain came back. So she embarked on a quest to get to the source of her problem, starting with learning about “anthropologically-based posture modification” at an institute in Paris, and then by observing, in person, indigenous people in various parts of the world. She discovered that our idea of a normal anatomical stance—the way we hold ourselves—had changed radically in the past century: we have significantly increased curvature in our low backs (lumbar) and upper back (thoracic). The illustration below makes this clear.

The image on the left is from an anatomy book published in 1990, showing what is considered a normal spine. The image on the right is from a book published in 1911, showing significantly less curvature. This is the spine Gokhale believes is the natural human stance. (She gives lots of reasons for why our stance has changed over the years.)

More and more medical people are buying into her view. I recently visited a neurologist (Stanford Neurosurgery Clinic) about my sciatica and gnarly looking spine. I told her that I’d recently had a one-on-one Zoom session with Gokhale. The neurologist was enthusiastic and told me that she often refers patients to Gokhale, as do many other physicians.

 I’ve recently embarked on a do-it-yourself program of improving my posture and movement to straighten my spine, using Gokhale’s methods. Gokhale has lots of offerings that you can find on her Web site. You can also find her on various YouTube videos, such as TED talks.

As to my own efforts, I don't have much to report yet. I’ve only just begun. 

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

Treat wounds with honey and vinegar

 Because antibiotic-resistant bacteria are on the rise, some researchers are studying the antimicrobial properties of historic remedies. One remedy, a mixture of honey and vinegar, seems to work well for treating infected wounds. It’s called oxymel and was prescribed by Hippocrates (460 BCE-375 BCE), among others.

Oxymel could be particularly valuable for treating chronic wound infections, such as those commonly experienced by people with diabetes or burn trauma. Bacterial infections can be difficult to treat, particularly when they’re protected within a biofilm—a complex system of bacteria that can attach tightly to surfaces such as flesh in a wound infection.

Honey stresses bacteria and fights infections with its high sugar content and acidity. Vinegar’s active component, acetic acid, is a natural antiseptic that breaks down bacterial DNA and proteins. In conducting their research, researchers focused on the common wound pathogens Pseudomonas aeruginosa and Staphylococcus aureus. They found that neither honey nor vinegar by itself was particularly effective. But together, the honey/vinegar combination (oxymel) killed up to 1,000 times more bacteria than vinegar alone and up to 100,000 times more than honey alone.

Unfortunately, the study report, which was published in the journal Microbiology, doesn’t include a recipe. Apparently, they need to do more research to figure out the best dose combinations. The researchers did use a “medical grade” honey, called Manuka honey, which is available on Amazon. They also indicated that pomegranate vinegar is one candidate for further study. (I had no idea there was such a thing.)

I suppose, if you have a wound that’s not healing, you could experiment with Manuka honey and pomegranate vinegar, although it sounds pretty messy.

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

When it’s too late for a doctor’s help

I’m a fan of Caitlin Doughty. She’s a mortician, based in L.A. and author of Smoke Gets in Your Eyes (about working in a crematorium) and From Here to Eternity (about how other nations and cultures deal with death). She’s a funny lady and good writer and an advocate for funeral industry reform. Here are a few things I’ve learned from her.

In America, death has been a big business since the turn of the twentieth century. America’s funeral industry has become more expensive, more corporate, and more bureaucratic than any other funeral industry on Earth. (American funerals cost $8,000 to $10,000 not including the burial plot and cemetery costs.) What’s more, our funeral system is notorious for passing laws and regulations to interfere with diverse death practices and enforcing assimilation toward Americanized norms. After Hurricane Katrina, a group of Benedictine monks in southern Louisiana began selling low-cost, handmade cypress caskets. The state’s Board of Embalmers and Funeral Directors drummed up a cease-and-desist order, claiming that only funeral homes licensed by their board could sell “funeral merchandise.” (Eventually, a federal judge sided with the monks.)

Many Muslims would like to be able to open funeral homes in the U.S. Islamic custom is to wash and purify the body immediately after death before burying it as quickly as possible, ideally before nightfall. They reject embalming, recoiling at the idea of cutting into the body and injecting it with chemicals and preservatives. Yet many states have draconian regulations requiring funeral homes to offer embalming and for all funeral directors to be trained as embalmers, even though the embalming process itself is never required.

An executive of Service Corporation International, the country’s largest funeral and cemetery company, admitted that “the industry was really built around selling a casket.” As more of us are choosing cremations, the industry must find a new way to survive financially by selling not a “funeral service” but a gathering in a “multisensory experience room.”

The problem with cremation is that the process uses the same amount of energy required for a 500-mile car trip; roughly the same amount of energy as a single person uses in an entire month. What’s more, it releases 400 Kgs of carbon dioxide into the atmosphere plus a host of other pollutants and carcinogens, the worst of which is mercury from dental fillings.

Alternatives to cremation are available in a few places (very few). Here are three I know about:

Composting: The Urban Death Project, available in Seattle.

Burial directly into the ground: Joshua Tree Memorial Park, California.

Open air pyre: Crestone End of Life Project, Colorado.

My husband and I are opting for composting, but it’s not yet legal in California. Maybe if we live long enough….

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

Fascia: attention must be paid

Fascia is the tough, flexible tissue that surrounds and connects muscles, bones, and organs. (Picture raw chicken.) Your body has two kinds: dense and loose. Dense fascia holds muscles, organs, blood vessels, and nerve fibers in place. It also helps your muscles contract and stretch and stabilizes your joints. Loose fascia is more slippery. It allows your muscles, joints and organs to slide and glide against one another.

Problems with fascia can range from annoying to serious. One in ten people have experienced plantar fasciitis in their feet (count me in). It’s an inflammation of the fascia that connects your heels to your toes. The most serious fascia problem is necrotizing fasciitis, an infection that spreads along the fascial plane and can cause deep tissue destruction, sometimes requiring limb amputation.

In the past, doctors thought fascia was just packaging for more important body parts. Now we know that fascia is key to flexibility and range of motion. Because fascia is alive with nerve endings, it can also be a source of pain. The longer it is damaged or inflamed, the more sensitive it becomes.

If you’re sedentary for a long time, fascia can shorten, become overly rigid and congeal into place, forming adhesions that limit mobility. In fact, inactivity can cause fascia to reshape itself. Fascia that is too short, stiff, or sticky in one part of the body can lead to pain and dysfunction elsewhere. And, as you might imagine, it stiffens with age.

If you’ve got pain, it can be tricky to determine whether it’s coming from your fascia or from muscles and joints. As a rule, muscle and joint problems tend to feel worse the more you move, while fascia pain lessens with movement.

Like everything else, it seems, the most effective way to keep your fascia sturdy and elastic is to stay active. Experts say that the best activities are those that involve bouncing, such as dancing, jumping jacks, tennis, skipping. (I know—there’s no way ….) They also suggest dynamic stretching, such as twists, squats, or lunges. Happily, swimming is also good. Some lay people swear by other techniques, such as Rolfing, yin yoga, and myofascial release. While experts question the long-term effectiveness of such treatments, at least they don’t require jumping.

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

Screening for prostate cancer

Prostate cancer is currently the most diagnosed cancer (excluding non-melanoma skin cancer) among U.S. men. Most cancers are localized, meaning that they don’t metastasize and most grow slowly or not at all. No worries about those. Only about seven percent of patients have a disease that does spread—the cancer to worry about.

Screening for prostate cancer was approved by the FDA in 1986 and became widespread in the late 1980s and in the 1990s.Yet the approval occurred in the absence of evidence that early detection of prostate cancer leads to improved patient outcomes. Studies have shown a modest reduction in prostate cancer mortality with PSA (prostate-specific antigen) testing: Screening 1000 men may prevent deaths from prostate cancer in 1.3 men in the 13 years after initial screening.  The problem with screening is that it finds prostate cancer in some men who would never have had symptoms from their cancer in their lifetime. Treatment can cause complications without yielding benefit.

The point of screening is to find cancers that may be at high risk for spreading if not treated. The thing is, about three out of four men with a raised PSA level will not have cancer. A high reading can be caused by medications, urine infections, certain sports, and ejaculation. False positive readings, which are common in older men, can lead to unnecessary tests, such as biopsy of the prostate, and can cause men to worry about their health. Biopsies can be painful and result in infection and blood in the semen. (Men who are 70 or older should not be routinely screened. Men between 55 and 69 should make their own decisions about screening.)

Patients whose tests reveal localized cancer have two options: 1) Treat the cancer with radiation therapy or radical prostatectomy, or 2) “active surveillance,” which may include periodic biopsies, MRIs, and PSA tests. Research has shown that prostate cancer mortality is low, regardless of the treatment. Nevertheless, the patient and his doctor must weigh the trade-offs between the benefits and harms of treatments. Harms include urinary incontinence, erectile dysfunction, and bowel dysfunction. Considerations about what to do include the patient’s wishes, remaining life expectancy, and the risk of progression to metastasis and death.

I’m glad I’ll never have to think about this—for myself, anyway.

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

A personal story about a medication

In May and June of 2022, I had both knees replaced. I was given a prescription for diclofenac, a non-steroidal-anti-inflammatory (NSAID) and instructed to take one each morning and evening. I took only two or three, so had a lot left over. Lately, I’ve discovered that they are a great pain reliever for my sciatica, so I started taking them several times a week.

When researching the side effects of that drug, I came across research conducted by Washington State University College of Pharmaceutical Sciences that investigated the fact that, for some people, diclofenac causes heart damage. In the U.S., diclofenac could be purchased over the counter until 2013, at which time the FDA restricted it to prescription-only because of the heart damage reports. Nevertheless, more than 10 million prescriptions for diclofenac are written every year in the U.S., and it is one of the most widely used NSAID drugs worldwide, including countries in Asia, Africa, and the Middle East where it can be purchased without prescription.

I wrote to Bhagwat Prasad, one of the lead researchers. He wrote back. Here are excerpts from our several email exchanges. I began by introducing myself and explaining my history of taking diclofenac, after which I add the following sentences:

Me: Is there a way I can find out if I am one of those for whom diclofenac can cause heart problems? Diclofenac is the only medication I take.

Bhagwat: Our study suggests that individuals who don’t carry UGT2B17 gene are prone to higher levels of diclofenac in blood and risk to greater toxicity after oral administration. However, there are many factors that affect safety of diclofenac in different people.

Me: Since last writing to you, I had an MRI and learned that I have “severe spinal stenosis” (L4-L5). Painful sometimes. I do lots of stretching and exercising. Diclofenac is a big help.

I signed up with 23 and Me when the company first got started. I’ve contacted them and was able to search my raw data. I got the following response: “No genes or markers found matching UGT2B17.” I guess that’s bad news, but good to know. I’ll keep taking diclofenac on golf days anyway. It works.

Bhagwat: Thank you so much for these updates. First, I should thank you for taking care of yourself and prioritizing your health. You have become my role model! This is all very impressive that you have 23andMe data available for you to consider when taking medicine. [He goes on to recommend sharing this information with my physician and reducing the dose, etc.]

Me: I want to share a bit of alarming information from a book I read recently, called From Here to Eternity, by Caitlin Doughty. The book describes various ways in which different peoples from around the world deal with death. In Mumbai, the Parsis build platforms on which they place their dead bodies for vultures to devour. Doughty writes, “The vulture population has dropped 99 percent. In the early 1990s, India allowed the use of diclofenac (a mild painkiller similar to ibuprofen) for ailing cattle. Hoof and udder pain were eased, but when the animal perished and the faithful vultures soared down for the meal, the diclofenac caused their kidneys to fail.”

Are you familiar with this? As you can imagine, that paragraph caught my attention!

Bhagwat: Yes, I am aware of the vulture being vulnerable to extinction with diclofenac use. It’s a huge man-made disaster as we are killing the scavengers. The problem has recently been noticed in Spain and UK as well. Diclofenac causes vasoconstriction and damages kidneys of vultures. There are multiple reports of kidney related problems of diclofenac in humans with chronic use. [So far, email exchanges end here.]

Maybe I shouldn't even take diclofenac on golf days.

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

Nighttime mouth breathers: try taping your lips closed

 This is the second blog I’ve posted on forcing yourself to breathe through your nose by taping your mouth closed at night. I’m revisiting it because of readers’ comments following an article published by The New York Times (summarized briefly in the next paragraph). Many readers said that the practice was “life changing.” So, while I have no experience with the practice, maybe some of you would find it to be valuable.

The benefits of nasal breathing are many: it humidifies and filters the air; activates your lower lungs; lets you take deeper, fuller breaths; helps your body relax; helps filter out allergens, pathogens, and dust; helps lower blood pressure; improves blood flow; improves air flow; and reduces snoring. Sleeping with your mouth open can cause you to wake up with dry mouth, which can contribute to cavities, bad breath, a hoarse voice, and dry, cracked lips. 

If you normally struggle to breathe through your nose, taping your mouth closed is probably not a good idea. If you want to try it, choose a tape, such as surgical tape, that comes off easily. Some people recommend SomniFix sleep strips, also 3M Durapore. (One person recommended using an adult pacifier!) You can ease into the practice by starting during the day, taping your mouth for about ten minutes a day, then working up to 20 or so minutes.

For more information about mouth vs. nasal breathing, see my earlier blog on the subject.

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

Diet and cognitive decline

Scientists from the Harvard School of Public Health and Rush University Medical Center performed a landmark study to determine if a Mediterranean-style diet could protect people against cognitive decline. (Short answer: No.) The study, called the MIND Diet Trial, was considered “landmark” because the researchers used the “gold standard” of research: the randomized controlled trial. Because such trials are expensive and take a lot of time, they’re rarely undertaken for nutrition studies. (Most nutrition studies are “observational” and thus not trustworthy.)

After screening 1,929 people, researchers selected 604 older adults who were either overweight or obese, whose diets were “suboptimal,” and who had a family history of dementia, putting them at a high risk for the disease. The participants—none of whom had dementia—were divided into two groups: one who ate a MIND diet with “mild caloric restriction,” and one who ate their normal diets, but also with caloric restriction. At the beginning of the trial, all participants were given cognitive assessment tests and brain scans.

As you’d probably guess, the MIND diet consists of whole grains, leafy green vegetables, nuts, beans, berries, occasional poultry and fish, and olive oil. Specifically, it calls for at least six servings of leafy greens and two servings of berries each week. It restricts pastries, sweets, red meat, cheese, and fried foods to less than one serving a week, and limits butter to less than a tablespoon a day.

The trial lasted for three years, at the end of which participants were again given cognitive assessment tests and brain scans. As reported in The New England Journal of Medicine, outcomes “did not differ significantly between those who followed the MIND diet and those who followed the control diet….”

Perversely, this outcome pleases me. I get so tired of the sanctimonious advice-givers touting the Mediterranean diet. Bring on the cheese and butter! 

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

Urinary tract infections

A recent article in The New York Times covered many of the basics about urinary tract infections (UTIs, aka bacterial cystitis). Here’s a summary:

• Over half of us women will get a UTI at some point in our lives. Fourteen percent of men will get UTIs. (Their number is smaller because of their longer urethras, which makes it more difficult for bacteria to reach the urinary tract.)

•  UTIs are mostly caused by E. coli bacteria, which live in the gut and sometimes hang out in the area between the anus and vulva (or scrotum).  How and in what circumstances the bacteria migrate into the urethra and urinary tract is “not 100 percent worked out” (an understatement).

•  A UTI can occur anywhere along the urinary tract (urethra, bladder, kidneys and, in men, the prostate). Symptoms vary, but common ones include burning and the constant sensation of needing to pee.

•  Whether or not sexual practices cause UTIs is debatable. Studies have not been conclusive. Hygiene practices—wiping front to back, avoiding tightfitting underwear, how well you bathe, etc.—are “not rooted in scientific evidence.”

•  Antibiotics are not always needed: “Young, healthy patients find that the body can eventually flush out bacteria on its own.” (See comments below about this one.)

•  Cranberry products—juice, tablets, or capsules—reduce the risk for women with recurrent infections. For older women with decreasing levels of hormones, vaginal estrogen can prevent infections.

Over 700 people—many of whom were physicians—wrote comments in response to the article. Here are some worth noting:

Important:

• Antibiotics: One physician wrote, “Delaying treatment of urinary infection can cause serious damage before it can be stopped. Before the introduction of antibiotics one of the most common causes of death among women was ‘Brights disease’—kidney failure from recurrent and chronic UTIs.” Other physicians made similar comments. For example, “A UTI affecting the kidney (pyelonephritis) can lead to sepsis…it’s very, very common!” A lay person added, “My mother developed a UTI in her assisted living facility which became sepsis and she died from it.”

• Delirium in the elderly:  Many people, including physicians, made comments such as, “UTIs in elderly patients are likely to be manifest as confusion or delirium, increased lethargy, blunted fever response, new-onset incontinence, changes in personality, and anorexia.” These symptoms go away after the infection has cleared up.

Worth considering: Many commenters swore by a product called D-Mannose powder to prevent infections. There’s some truth to this. The powder is a type of sugar that might stop bacteria from latching on to cells in the urinary tract.

Sex: Lots of people mentioned sex as a culprit, for example: “I had UTIs constantly, until I divorced and came out as a lesbian.” “A friend’s recurrent UTIs cleared up after her husband became too ill to have intercourse.”

Interesting symptom: Three people mentioned that, when urinating, they experience tingling in their hands, and/or pain and discomfort in their hands and arms.

Eyebrow-raising:  Many commenters contributed their remedies for UTIs, including boric acid suppositories, a gallon of water every 24 hours, 100% cotton underwear, oil of oregano, forgoing toilet paper, avoiding consumption of chicken, and, my favorite, washing “down there” with tequila spritzer.

As for myself, I had a UTI once in my 20s, and have had a couple more recently. Even though I resist taking antibiotics, the minute I felt the symptoms I grabbed the first antibiotic I saw in the medicine chest, which happened to be my husband’s amoxicillin. I took it for two days and the symptoms went away. (I also saw a doctor and got a different antibiotic for future infections.)  As a preventive measure, I use a vaginal estrogen cream once a week. So far, so good.

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

No shame in taking meds

 I’m a big fan of Dr. Aaron Carroll. He writes sensible op ed pieces about medicine in The New York Times. I was surprised by his latest article in which he discusses his struggles with depression, anxiety, and obesity. He’s resisted taking medications for these conditions, partly because he viewed them as a “crutch” that would make him feel like a failure and partly because “the medical understanding of them seemed vague.”

 After a panic attack, he gave in. His doctor prescribed a selective serotonin reuptake inhibitor (S.S.R.I.) called sertraline. It worked. “It had a remarkable effect on my mood…I was more optimistic, friendlier and more engaging.” Neither he, nor other medical people, can explain why the medication works for him or for anyone else.

 

Dr. Carroll also began taking one of the new obesity drugs, such as Ozempic and Wegovy. (At the moment, these drugs are approved only for diabetes, so are not covered by insurance. As with S.S.R.I.s, doctors don’t fully understand why the treatments work.) He’s had a lifelong struggle with his weight. Even though he exercises and eats healthfully, he recently slipped into obesity, according to his body mass index. “Though I’ve tried every diet, nothing has really helped. I’d lose up to 10 pounds and then plateau until my weight crept back up. …I felt like a failure, which led to self-hatred and anger.” After starting the new drug regimen, he lost 15 pounds in five weeks, and “I’ve done it with ease. I’m not hungry all the time. I’m not thinking about food incessantly.”

 

As with his need for anti-depressant drugs, he feels shame about needing meds to control his weight. “We make assumptions that people with depression aren’t trying hard enough, that people with obesity lack willpower.” Neither of these assumptions is true. Like other maladies, something in his body and brain is off balance. The drugs are correcting the imbalance. No shame in that.

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

 

You’re not going deaf. It’s your TV.

We use closed captions when watching most TV shows (we don’t use it for Jeopardy and a few other shows). We just can’t understand what people are saying, especially the dialog on British shows. We assumed our problem was advanced age.

 I discovered, in a recent New York Times article, that 50 percent of Americans and most young people use subtitles, especially on streaming services such as Netflix. According to the article, the main problem is the speakers on your TV. Because TVs keep getting thinner and more minimal in design, their speakers are tiny and crammed into the back or bottom of the display where they blast sound away from your ears instead of toward them. One solution is to buy separate speakers, called soundbars. They cost $80 to $900.

 

But the problem is more complex than just bad speakers. To begin with, there’s the technical aspects of mixing, calibrating, and compressing sounds that must meet different specifications for different devices. There’s also the creative trend of “realism” in filmmaking. That is, actors no longer use “elocution” techniques, such as distinct pronunciation and articulation. These speech patterns would sound phony to us. Realistic dialog is often fast paced, mumbled, and accented. What’s more, music and other sounds compete with the actors’ speech, and darker imagery makes it more difficult to see mouth movements.

No wonder we—and most people we know—use closed captions.

Now, for your edification, I looked up what “closed” refers to. Here’s the answer: Closed captions can be turned on and off by the users. Open captions cannot.

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

How stress affects your gut

Scientists have recently found two pathways by which psychological stress causes inflammatory bowel disease such as Crohn’s disease and ulcerative colitis. Under stress the brain releases a hormone called CRH that sets off a chain reaction: first, it stimulates the pituitary gland, which then stimulates the adrenal glands on the kidneys, which then release hormones called glucocorticoids. What happens next is rather complicated. Suffice it to say that glucocorticoids induce an inflammatory response in the gut and also impair the movement of food through the gut.  

The reason your gut is so sensitive to stress is that it has its own nervous system, called the enteric nervous system (ENS). The  ENS is a web of sensory and motor neurons embedded in the wall of the gastrointestinal system. It’s a wide-ranging system that processes information and generates signals that affect other bodily systems. This web of neurons stretches from the lower third of the esophagus right through to the rectum. It’s been estimated that the ENS contains more neurons than the whole of the spinal cord. No wonder our guts are so sensitive to our mental states!

 While people with inflammatory bowel disease are often treated with immunosuppressants such as steroids, researchers believe that psychotherapy and stress-management techniques can play an important role in treating flareups. Even if you don’t have inflammatory bowel disease, you can see why your gut is so sensitive to your mental states. Don’t stress about it!

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

Do nonprofit hospitals deserve their tax exemptions?

 Our nearest hospital, in Santa Cruz, California, was founded in 1941 by the Adrian Dominican Sisters of Adrian, Michigan. Like other hospitals founded by religious organizations, Dominican was expected to focus on relieving the suffering of poor people. In 1988, Dominican—as it is now known—was taken over by Dignity Health to become one of 41 hospitals in that organization, which includes more than 60,000 employees and 10,000 physicians. Big business.

Hospitals are one of the largest industries in the United States, with annual revenues exceeding $1.4 trillion. Nonetheless, roughly 60% of community hospitals, including Dominican, are incorporated as nonprofit institutions, which means that they are tax exempt. To maintain their tax-exempt status, they are required to provide “community benefit,” including charity care, such as providing services for patients unable to pay and making emergency departments available to all people.

The value of tax exemptions for non-profit hospitals was estimated to be $28.1 billion in 2020. Studies have shown that 72 percent of private nonprofit hospitals spent less on community benefits than they received in tax breaks. What’s more, many nonprofit hospitals generate substantial profits from the federal 340B Drug Price Program that was designed to serve low-income patients. The idea was to “buy low” and “sell low.” But hospitals have turned this into a "buy low, sell high" program for well-insured patients. Some hospitals have adopted aggressive revenue-enhancing activities, such as declining to offer charity care to eligible patients and suing patients and garnishing wages because of unpaid medical bills.

Unfortunately, I was unable to find out whether Dominican shirks its community benefit obligations. I do know it’s gotten fancier over the years. For example, it installed a “rehabilitation garden.” Does that benefit the community?

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

It’s not easy to be a food purist

The term “processed food” has negative connotations. We’re told it’s bad for us. But, as Adam Gopnik notes in a New Yorker article (“Sickening”), what makes something processed rather than preserved is not easy to define. Food has a natural tendency to spoil. Humans have always tried to delay that outcome through cooking, pickling, curing, salting, smoking, and soaking it in brine.

As Gopnik notes, “… it is not always easy to separate prudence from puritanism.” Sauerkraut, which is now a fashionable food, is processed. For that matter, much of our fresh produce is processed by way of breeding. Where do you draw the line? Some purists are scornful of added flavorings. Does that include curried rice, a centuries-old staple of India? And now we have “molecular gastronomy,” which is cuisine, such as transparent noodles, created from the perspective of chemistry. You can get this food at high end restaurants. One wit called it “ultra-processed food for rich people.”

Michael Pollan tells us that “Great-Grandmother never cooked with guar gum, carrageenan, mono- and diglycerides, hydrolyzed vegetable protein, modified food starch, soy lecithin….” But, as Gopnik notes, why is guar gum, extracted from one seed, any more artificial than cornstarch, extracted from another? Carrageenan comes from seaweed, lecithin comes from egg yolks, vegetable protein gets hydrolyzed when proteins are exposed to acids—a regular product of fermentation and pickling. Technical names make the familiar seem alien. Yet luteolin, hydroxytyrosol, apigenin, oleic acid, and oleocanthal are natural components of extra-virgin olive oil.

OK. I think most of us are not food purists. Like me, you probably have plenty of processed food in your kitchen, but most likely not Cocoa Puffs.  

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Leprosy in the U.S.

 Having recently read Abraham Verghese’s A Covenant of Water—part of which takes place in a leper colony—I was drawn to an article about leprosy in The New York Times.  According to the article, 159 new cases in the U.S. were reported in 2020, the most recent year for which national data are available. Apparently, the disease pops up regularly in Florida, especially the central part. New cases are also reported in California, Louisiana, Hawaii, New York, and Texas.

Leprosy, also known as Hansen’s disease, is caused by slow-growing bacteria called Mycobacterium leprae. Happily, most of us are resistant to the bacteria, which are transmitted by droplets from the nose and mouth of an infected patient, but only after close, sustained contact. Caught early enough, leprosy can be cured with standard antibiotic drugs.

Left untreated, the disease may damage skin, peripheral nerves, the upper respiratory tract and the eyes. By slowly destroying muscles, it leads to deformities in the hands and feet. It starts with either discolored, numb patches on the skin or with tiny nodules under it. Early symptoms can be mistaken for other skin conditions such as psoriasis or eczema.

While the disease is rare in the U.S., roughly 200,000 cases crop up all over the world each year, mostly in Southeast Asia and India. In the U.S., new cases are often found in people who have traveled to other parts of the world. But since 2015, more than a third of the cases in the U.S. have been locally acquired. Interestingly, Armadillos carry the bacteria.

Because leprosy is rare in the U.S, and because most of us are immune to the disease, you don’t need to worry about it! Just try to stay clear of Armadillos.

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

Anxiety and Xanax

The other day I stumbled on a Netflix documentary about Xanax (“Take Your Pills: Xanax”). It features psychiatrists as well as Xanax users. Here’s what I learned:

The use of Xanax has skyrocketed in the last twenty years: roughly one in eight adults take the pills for anxiety, panic disorder, and insomnia. Xanax is in the class of drugs called benzodiazepines, which also includes Librium, Valium, Klonopin, and Ativan.  They work by enhancing a neurotransmitter in the brain that reduces communication from one brain cell to another.

As the users in the program say, “It takes the edge off'"; “All the weight that’s on you is gone"; “It made me feel like a better version of myself"; and “I need to numb myself to be able to sleep.” But also this: “Knowing what I know now, I would never have taken that first prescription. Never.”

 Anxiety is complicated. It seems that both nature and nurture may be involved. For some, anxiety may be part of their baseline temperament, as seems to be the case for Scott Stossel, author of My Age of Anxiety and editor of The Atlantic magazine. “I was a nervous kid. I’d get panic attacks.” Other people mentioned the long-term effects of bullying, parental expectations, and sexual assault.

The psychiatrists viewed Xanax as a useful tool to use occasionally for acute anxiety. But if you take them every day, multiple times a day, abruptly discontinuing them can have serious consequences, including severe anxiety and insomnia. Some patients have no problems reducing their dosages and some are sensitive to even the smallest dose reductions. Stossel, whose anxiety is debilitating, tries not to take Xanax, but he does take Lexapro, an antidepressant.

The man who was sorry he had ever started on Xanax had been taking three milligrams a day for 15 years. When he decided to quit by tapering off, he lowered his dosage from three milligrams to two and a half. He was soon extremely ill: fatigue; heart palpitations; burning skin; muscle twitching; brain fog, etc. Not realizing his symptoms were those of withdrawal, he consulted 35 specialists including some at the Mayo Clinic. None concluded his symptoms resulted from Xanax withdrawal. They were wrong. More than a year later, he was still tapering off, using titration techniques to reduce his dosage by tiny fractions. This takes years. A memoir, called Blood Orange Night: My Journey to the Edge of Madness by Melissa Bond, chronicles a similar experience. Both people finally found the information they needed in the highly regarded The Ashton Manual.

As one of the psychiatrists noted, “I think benzos erode the resilience that we must rely upon at some point in our lives. If you’re mediating your anxiety through a Xanax, you’re not really confronting it. What’s going to get you on the other side of anxiety is to go through it and experience it and understand it and make some sort of peace with it.” For many, I’m guessing, this is easier said than done.

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

For improved health, eat ice cream

Extensive research has shown that, among diabetics, eating half a cup of ice cream a day was associated with a lower risk of heart problems. As reported in the May, 2023 issue of The Atlantic magazine, numerous studies, beginning 20 years ago, kept coming up with similar benefits of eating ice cream. Of course, the researchers didn’t like the finding. Data was double-checked. No errors could be found. Nutritionists tried to make it go away, but their debunking efforts have been largely futile.

Medical data collected by Harvard since the 1980s found that men who consumed two or more servings of skim or low-fat milk a day had a 22 percent lower risk of diabetes. But so did men who ate two or more servings of ice cream every week. Of course, no one wanted to talk about this finding.

Mark A. Pereira, an epidemiologist at the University of Minnesota, had stumbled on a similar association more than 20 years earlier. He found that, for overweight people, “dairy-based dessert” (ice cream) was associated with dramatically reduced odds of developing insulin resistance syndrome, a precursor to diabetes. Oddly, the effect of ice cream was 2.5 times the size of what they’d found for milk. “We analyzed the heck out of the data.…This study surprised the heck out of me.”

Ice cream’s glycemic index, which measures how rapidly a food raises blood sugar, is lower than that of brown rice. One scientist mentioned that ice cream is better for you than bread. “It’s got fat, it’s got protein, it’s got vitamins.” One man ate 2,000 calories a day of ice cream plus 500 calories of protein supplements, plus liquor (Irish whiskey milkshakes). After 100 days, he’d lost 32 pounds and had better blood work than before he’d started this regimen.

Of course, I love this sort of thing. As The Atlantic article mentioned, “Once you start contemplating all the ways that cultural biases can seep into science, it doesn’t stop at dairy-based desserts.”

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

Moral injury in the medical profession

 In the world of medicine, moral injury refers to an emotional wound sustained when the demands of administrators, hospital executives, and insurers force practitioners to stray from their ethical principles. Seventy percent of doctors work as salaried employees of large hospital systems or corporate entities, taking orders from administrators and executives who do not always share their values or priorities. (Note: A new study finds that private equity firms own more than half of all specialists in certain U.S. markets, a situation associated with higher prices.)

Medical personnel are pressured to make decisions based on financial considerations. The emphasis is on speed, efficiency, and relative value units (R.V.U.), a metric that rewards doctors for doing tests and procedures and discourages them from spending too much time on less remunerative functions, such as listening and talking to patients. Making matters worse, in the eyes of their patients, doctors become the scapegoats, the instruments of betrayal by the health care system.

This situation has been taking a toll for years. The suicide rate among doctors is higher than the rate among active military members; one in five health care workers has quit his or her job since the start of the pandemic, and an additional 31 percent have considered leaving. In the remarks of some doctors: “Every day, you’re reminded how savage the system is;” “It’s turned us into a widget factory of just throughput, getting people in, getting people transferred onto money-making specialties, without really addressing their health care needs. And it’s demoralizing and it’s not good care.”

To address the problem, some doctors join unions, such as The Valley Physicians Group of Santa Clara County, California, not to increase their pay but to improve working conditions. Others have opened direct-care practices in which patients pay a monthly fee. Such solutions don’t eliminate all the problems, such as fighting with insurers, but at least they reduce moral injury.

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

Electronic medical records

The passage of the American Recovery and Reinvestment Act, spearheaded by Obama, required that healthcare providers adopt electronic medical records by January 1, 2014. Adoption was mandatory if providers wanted to maintain their existing Medicare and Medicare reimbursement levels.

Digital records were expected to improve accuracy, support clinical decision-making and make a patient’s records easily accessible to multiple providers and organizations. These benefits may have come to pass, but by now, most of us know that the technology has undermined face-to-face patient care. In their limited time with you, docs are looking at their screens, not at you. (Abraham Verghese calls this the “iPatient” phenomenon.)

Electronic medical records have also contributed to physician burnout. A report from the National Academy of Medicine revealed that, on an average, nurses and doctors spend 50 percent of their workday treating the screen, not the patient. A study of emergency room doctors revealed that putting information into the computer consumed more of their time than any other activity. A doctor needed to make six clicks of the computer mouse to order an aspirin, eight clicks to get a chest x-ray, 15 clicks to provide a prescription, and so forth. All in all, a ten-hour emergency room shift included 4,000 clicks of the mouse.

One solution is to hire medical scribes—people who enter patient information into the computer. The physician then reviews the notes, makes corrections, and signs off on them. Some scribes work remotely (I’m not sure how that works). Anyway, it’s estimated that in 2021, 100,000 scribes were working in medical practices around the country. In fact, medical scribing is the fastest growing healthcare profession in the nation.

In 2011, I had some experience dealing with electronic medical records. I was hired to write a user guide by one of the companies vying to get their product into the marketplace. I don’t think they succeeded. Their product was quite complex and rather unwieldy,  I still have my drafts and a few images. Here’s one I found:

Electronic medical records are here to stay, of course. I recently had my knees x-rayed at a radiology lab. When I showed up, all they asked for was my name and birthdate because all my info was in their system. Pretty nifty.

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