Ultrawalking

As part of doing Prerounds, Nick, grand domo of Grand Rounds, suggested I blog more about my ultrarunning, that he thought people would be interested in this. I'm not so sure, but here is a link to my friend Ollie's description of a recent 24 hour walk he did Weather kept him from reaching his goal of 100 miles (there is a special "Centurion" award you get for doing this, Ollie has accomplished this in the past, but not at a race with judges to ensure good form), but he stuck with it as best he could:

I got up and finished a lap, but the next two laps (to get to 62 miles) were a death march. I had slowed to 57 and 51 minutes! I also threw up 5 times during those two laps. When I saw the judges, I acutally asked them to DQ me! Once when I asked, Ivo said "you can only get DQ'ed for running, and in the shape you are in, running is impossible."

Note that laps are just over 2 miles.

Grand Rounds 2:23

is here, continuing the recent theme of nice pictues to go along with the links

Clergy and evolution

Hat tip to Alison Thompson, sister of Dr. Andy for passing along the following article about Christian clergy being enlisted in the battle for evolution

Warren Eschbach, a retired Church of the Brethren pastor and professor at Lutheran Theological Seminary in Gettysburg, Pennsylvania helped sponsor a letter signed by more than 10,000 other clergy.

"We believe that the theory of evolution is a foundational scientific truth, one that has stood up to rigorous scrutiny and upon which much of human knowledge and achievement rests," they wrote.

Catholic experts have also joined the movement.

"The intelligent design movement belittles God. It makes God a designer, an engineer," said Vatican Observatory Director George Coyne, an astrophysicist who is also ordained. "The God of religious faith is a god of love. He did not design me."

This seems like a great idea to me, dispelling the idea that evolution is somehow incompatable with Christianity.

Wonder what my anonymous commentor will think?

Surviving Grand Rounds

I succesfully hosted Grand Rounds Tuesday. Beforehand, I'd have defined success as getting some sort of finished product up within a few hours of the deadline, but the comments would suggest I exceeded that goal by a comfortable margin (although someone always complains)

I really enjoyed hosting, it makes you feel special for the week before and after. Sort of like getting married but without the long-term commitment. I also learned the identity of several anonymous or quasi-anonymous bloggers, although some identities still elude em. I want to do a post soon about the pros and cons of non-anonymous blogging.

In the end, it was far less difficult than I'd anticipated. I got 41 submissions by the 5PM monday deadline, accepted 2 more that trickled in just a few minutes late and was mostly done by 7PM. I rejected 2 submissions that came in hours late (after I'd gone to bed) including one from a prominent medical blogger, then got up to check all the links (missing one and one was to the blog, not the specfic post) make a few minor edits and posted by 7am. Others have reportedly gotten 90 submissions, so I may have gotten off easy.

A few thoughts for future hosts or those interested in hosting

1. Pick a format early, stick to it. I decided >1 week out that I'd do a "top ten" and then break the others up into categories loosely based on the NEJM. That worked out fine. I also knew I wanted to do the pictures the way I did

2. Enter posts as they come in. I got my first post 10 days before GR, and got about 10-12 in the last 24 hours. By entering posts daily, I didn't have a ton to do at the end. I moved some posts into and out of the top 10, but that was simple cut and paste.

By the end I could read a post, write my blurb and link in about 3 minutes. Of course, there were so many good posts on so many good blogs I did spend some time checking them out.

3. I didn't think including everyone substantially increase my workload. By the time I'd read the post, it was pretty simple to link and write a blurb. Plus, I saved time by not worrying about whether or not to include a post, which I think some hosts have agonized over. I just linked in whatever appropriate category. If later I felt a post deserved to be in the top 10 I moved its link up (or vice-versa). I got lots of positive comments about including everyone so in my opinion that is the way to go.

4. Save often! Barbados Butterfly warned me about this, so after every session I not only backed up on blogger but copied the whole HTML text into word. Having been so diligent, I had not a single problem.

5. I sent emails to everyone who submitted. A few hosts have done that when I've submitted in the past and I really liked it. One thing I didn't do, but would in the future, is to include the link to GR in the follow up post. You have to have your http address set a week before, so that would be easy to do and might increase incoming links to GR

More discussion about GR is here, here, and here. I like the idea of using technology so readers can choose the most interesting post, but don't quite understand how that will work, other than having a dedicated Grand Rounds hosting site, which defeats some of the purpose of GR.

Well that's it for now. GR this week is a A chance to cut is a chance to cure, and I'll be working on updating my blogroll to reflect all the great medical blogs out there.

Flesh eating virus?

So the "most e-mailed" story on the New York Times website is "Why doctors so often get it wrong" by one David Leonhardt; it tells the story of one decision support software company started by the father of a child who almost died because of a missed diagnosis:

Dr. Britto was working at a London hospital in 1999 when doctors diagnosed chicken pox in a little girl named Isabel Maude. Only when her organs began shutting down did her doctors realize that she had a potentially fatal flesh-eating virus. Isabel's father, Jason, was so shaken by the experience that he quit his finance job and founded a company — named after his daughter, who is a healthy 10-year-old today — to fight misdiagnosis.

Flesh eating virus? I've never heard of that. Probably because it doesn't exist. Here is Isabel's story from the Isabel Healthcare website:

Isabel was finally diagnosed with Toxic Shock Syndrome and Necrotising Fasciitis (aptly described as the ‘flesh-eating bug’).

Of course, any second year medical student could tell you that toxic shock and necrotizing fasciiits are caused by bacterial infections usually staph and strep, not viruses. You'd think an article about imprecision in medicine would take pains to get it right.

Maybe another article can look at why the New York Times so often gets it wrong.

UDPATE: I emailed the author about this who responded very quickly that virus was wrong, that the web item would be changed soon and a correction appear. Advantage Leonhardt!

Compulsory vaccination

I occasionally have patients whose parents are strongly against vaccination, usually because they've confused correlation with causality and believe vaccines cause autism. They are often shocked to hear that I've actually given these "poisons" to my own children. I even enrolled my own daughter in a trial of a new combination vaccine as I do think if we could minimize the number of needle sticks that would be good. So I am strongly and consistently pro-vaccination. I regard anti-vaccination folks like creationsists who no amount of reason will reach; although at least I understand the source of creationsists conviction, religous belief. I've left Orac and others to refute the anti-vaccination hysteria.

What I hadn't thought much about was how compulsory vaccination should be. A recent article in the Lancet examines this issue. As a wishy-washy libertarian, I respect the argument that whatever the overall greater good, government compulsion is not to be taken lightly; as one Henning Jacobson argued in 1809, in refusing to be vaccinated against small pox:

A compulsory vaccination law is unreasonable, arbitrary and oppressive, and therefore, hostile to the inherent right of every freeman to care for his own body and health in such way as to him seems best; and that the execution of such a law against one who objects to vaccination, for whatever reason, is nothing short of an assault upon his person

The US Supreme Court rejected that argument. But I also know that there are a lot of idiots out there. In addition, since much of the benefit of vaccine is in herd immunity (no kid born in the US in 2006 is likely to ever actually get polio) there is an issue of equity in that those who forgo vaccination reap the benefits without sharing the risks (small those they are currently).

The UK does not have compulsory vaccination, but retains high vaccination rates as do several northern European countries. In the US, in contrast, school entry is contingent on vaccination, although conscientious objection is allowed in most states. As the article notes, using the school system has the advantage of entrenching the requirement in a bureaucracy that is pretty much immune to political pressure, lack of attention, etc.

I think the US approach gets it about right. Most unvaccinated kids are due to lazy parents and making school entry contingent on vaccination leads to higher vaccination rates. On the other hand, for those few who are really opposed to vaccination, I am not against exceptions. I do think getting an exception should require at least as much effort as being vaccinated, so it is not the easiest way out, as the article suggests it is in some states. I don't see requiring positive action (obtaining an exemption) as unduly burdensome on anyone's freedoms.

I do think there might be some instances (outbreak of disease) when exceptions to vaccination might not be acceptable, even with the loss of freedom that would entail.

The end of physical diagnosis

The physical exam is increasingly becoming a formality, as technology takes a bigger and bigger role in diagnosis, as summaized by Dr. Sandeep Jauhar in this Perspective piece in the NEJM.

For example, when I see an otherwise healthy child with peanut allergy, what exactly do I learn from the examination? Almost always the answer is little or nothing. Occasionally I can pick up evidence of environmental allergies on eye or nose exam, but that is the exception. For residents during their training, when admitted patients have already been examined several times and had multiple tests, the answer is even less.

In general, technology is increasingly dominant in defining actual pathology because it works so well. As Jaudhar notes, a chest X-ray is better at diagnosing pneumonia than "Sir William Osler with a stethoscope." As a medical student, I used to hate what I called "retrospective physical diagnosis." Patients with aortic regurgitation (when blood flows backwards from the aorta into the heart during diastole, when the heart is relaxing) have a "to and fro" murmur you can hear by listening to the femoral pulses. More than once on a cardiology rotation, I was sent in to listen for this fascinating murmur. Of course, not once had it been used to diagnose aortic regurgitation! Instead, once the echocardiogram revealed AR, everyone went back to listen. How useful is that?

What I think the exam is best for is picking up abnormalities and ruling out badness, especially in primary care where it can help guide use of technology. A normal neuro exam in a patient with headache is very reassuring.

And as I've noted, sometimes one or two abnormalities on exam can lead you to find something unexpected.

Trauma costs

According to the Feb 4th Lancet, the US now spends more on trauma care ($71.6 billion per year) than on cancer ($48.4B) or heart disease ($67.4B) I wouldn't of guessed that. Presumably spending a bit more on prevention would be cost effective

Not your average patient

This post at Barbados Butterfly about managing diabetes:

Ask known diabetics how often they check their BSLs (blood sugar level same as glucose-Dr. A), in the at home. What numbers (level) do they usually get? Do they write them down?

reminded me of my own experience with a diabetic. My lovely wife was retrospectively diagnosed with gestational diabetes aftern delivering our son at a whopping 11 pounds 10 ounces. (via c-section, thankfully). His head was so big the little cap they give newborns wouldn't fit him.

Gestational diabetes is similar to type 2 diabetes but occurs in pregnant women. It usually resolves after delivery, but women with gestational diabetes are at increased risk to develop type 2 diabetes later in life.

With our daughter, we and her doctors were more on top of things and she was placed on diabetic diet and told to check her blood sugars 4x/day. She was to follow up in 2 weeks. 2 weeks later on our way to the OB appointment, she told me she was a bit worried about what to do as we'd gone out to dinner one night and she'd neglected to check her blood sugar. Only having 55 of 56 values, she was afraid the doctor would be mad and did I think she should make up a value for the one she missed.

I replied that she obviously had no idea how compliant the average patient was; that she was probably the first patient in 3 years to be so diligent. Sure enough, the doctor was amazed what a good job she had done.

Such fastidiousness does have its rewards. On her final check of glycosylated hemoglobin (a sort of integral of glucose levels over time; higher levels indicate poor control of diabetes) her value was not only not elevated, but BELOW the normal range.

Our daughter still weighed 9 pounds 8 oz.

Eminent domain

In the case of Kelo vs. New London, the United States Supreme Court ruled that the government could confiscate private property pretty much as it saw fit, in this case seizing homes so they could be developed into more expensive homes, along with office buildings, a marina and offices. The Supreme Court agreed with the argument that this constituted "public use" although others would argue that term should be restricted to things like bridges or highways. Such confiscation is called "eminent domain."

In general there has been a broad-based movement to fight back against abuses of eminent domain:

In a rare display of unanimity that cuts across partisan and geographic lines, lawmakers in virtually every statehouse across the country are advancing bills and constitutional amendments to limit use of the government's power of eminent domain to seize private property for economic development purposes

Unfortunately some people think eminent domain should be expanded. In an article recently published in JAMA (alas, no free full text), 2 Harvard professors argue for the government's right to abrogate pharmaceutical companies patent protection:

In the face of growing concern over excesses in pharmaceutical patent protection, another legal instrument exists that can protect the public health: eminent domain. The controversial Supreme Court decision of June 2005 in the case of Kelo v New London confirmed the government’s broad authority to assume control of private property in the name of a higher good. The court ruled that a municipality could take over individuals’ homes to facilitate construction of office space and more upscale residences because the proposed development would be a “public good.” Viewed in this light, eminent domain may be a tool to help address situations in which manipulation of biomedical patents threatens the public good even more directly.

And they don't just think that this should only be used as a last resort, say to increase supply of olsetamivir (Tamiflu) in the event of an avian flu pandemic. The authors also cite
the fact that

elevated drug prices reduce adherence to medication regimens, especially for low-income patients, and mounting drug costs have forced states to cut back covered services, increase co-pay requirements from indigent patients, or limit eligibility criteria.

suggesting that almost any inconvenience is a reason for the government to confiscate pharma companies property.

Of course in the long run, we'll all suffer as pharma will stop investing in the research that underlies development of new medicines.

UPDATE: added link to JAMA article which I inadvertantly admitted.

Grand Rounds 2:22

Hello and welcome to Grand Rounds 2:22. I decided to highlight 10 posts that I found most outstanding among all those submitted. This was hard as there were many excellent posts. The top 10 are not listed in any particular order.

And take heart if you, like me, suffer from a subclinical case of seasonal affective disorder. Spring is definitely coming! (click on pictures to enlarge)

Featured Articles

Kim at Emergiblog takes a look at what she has learned from blogging and reading other health/medicine related blogs. As she notes, one of the best things about something like Grand Rounds is seeing the world of medicine and health from others' eyes.

Redstatemoron (his title, not mine) comments on the costs, both financial and physical, of defensive medicine. I've always felt physicians were by nature defensive (something about the obsessive-compulsive traits needed to get into and through medical school) and that, more than fear of malpractice suits, drove overcautious practice. His examples, however, are persuasive.

Clinicalcasesandimagesconsiders the utility of medicine specific search engines. These "vertical" search engines cover less area than the more common horizontal ones (e.g. Google) but results are more likely to be relevant. I tried them using my own name and found Omnimedicalsearch worked well, weeding out non-medical references (but also all but one reference to my blog) whereas Kosmix was useless. YMMV.

Dr. Bob relates life lessons unintentionally imparted to him by a patient on a recent call weekend. Conclusion: Knives, hookers, and cocaine don't mix. Warning, the post itself is fine, but the linked photos are not pretty.

Mary, a nurse and child advocate at The Mote in the Light agonizes over the decision to remove a baby from her mother, not because of outright abuse, but because mom just couldn't provide the level of care needed given the child's medical problems. The decsion is the right one, but heartbreaking nonetheless.

Orac, in new digs at science blogs, gives a list of clues that you may be an "altie;" that is someone who is such a believer in alternative modalities of treatment that your fervor is almost religious. Very well done in sort of a highbrow Jeff Foxworthy kind of way.

Know what a transplant coordinator is? It's someone who goes and asks the family of dying people if they can have the organs (no it's not like in Monty Python's Life of Brian). Along with working with abused kids it's about the toughest job I can imagine. On call at all hours, a subject no one wants to talk about and other lives hanging in the balance. And most good candidates for donation, I think, are young and dying unexpectedly. Ouch. One of those jobs I'm grateful someone else does. Wonder what it's like? Then read this from a real life transplant coordinator at Donorcycle

Bob at Insureblog posts about how big pharma is using the new Medicare drug benefit to discontinue programs which provide drugs free or at reduced costs to the poor. Good grief, Charlie Brown.

Dr. Erik Novak writing at Thismakesmesick.com which is dedicated to cleaning up the mess that is our malpractice system (Good luck! but I like the idea of approaching things from a variety of different angles) blogs about new found sense in the justice system: many bogus lawsuits are now being dismissed. Now if they would just sue the plaintiffs lawyers for malpractice we'd be on even footing (I am deadly serious about this).

Doctor Inspector Charles solves a case of unusual bruising in this literary post "the unusual case of Mr. Black". Anti-tobacco zealots should probably pass on this one, what with the furor about smoking in movies and all.

Clinical applications of basic science

In an elegantly illustrated and detailed post, Bora from Circadiana, a blog all about chronobiology, shows how lithium, commonly used to treat bipolar disorder, also affects circadian rhythyms. This suggests that the underlying cause of bipolar disorder (also known as manic-depression) may have to do with dysfunction of the body's own clock. Very interesting

Gloria posts at Biotech-weblog about a new instantaneous method of meauring fetal hypoxia. As Redstatemoron notes in his post featured above, the question of when to intervene with C-section for fetal distress is one of the most difficult in medicine. Hopefully this will help.

Blogmeister at Anxietyaddictionanddepressiontreatments notes a controversy brewing about the possibility of treating addiction with medicines. I'd comment than when one side is publishing papers in Nature Medicine and the other rebuttals in the New York Times I think I know who's going to be right in the end.

Reports from the front

Keith from Digital Doorway reflects on two patients rescued from difficult social situations by family and wonders if he'd be as willing to bring a troubled family member into his own home.

TheBlogThatAteManhattan (which combines two of my favorite topics, medicine and food) posts about the problems that happend when the doctor is out sick, specifically what happened when she had to take time off to fight hepatitis C. No disasters, but a lot of things can fall throught the cracks.

Keagirl, a female urologist at Urostream tells of the gender discrimination she faces from male patients. I have heard tales of woe from men in OB/GYN but this turns things around. I also like this post from her relatively new blog.

Dr. John Crippen at NHS Blog Doctor comments on the reluctance of UK doctors to tell patients that they are dying, and the reluctance of patients to come out and ask. Stiff upper lip and all can't help, but this is a hard subject for doctors everywhere.

Neonataldoc comments on a patient with holoprosencephaly, a severe failure of brain development, who for some reason is put on a home monitor when (in at least Neonataldoc's opinon) death would be the best thing for everyone involved. Don't miss the first comment by a mother of a child with a degenerative condition who is nearing the end of his life about her struggle with the idea of a "do not resuscitate (DNR)" order.

Enoch Choi at Medmusings dreams about what a really good electronic health record could do. Take home message: we've come come far, but we've got even farther to go.

Healthyconcerns notes a recent case in Canada where a surgeon refused to operate on a smoker. Seems unfair, until you read that in the surgeon's judgement, the risks of wound infection or poor healing outweigh the benefit of the operation. I don't see how any system could require surgeons to operate on any patient who thought they needed it.

Commentary

Dr. Joel Furhman of DiseaseProof.com gives us the top 10 reasons to be skeptical of the recent trial showing no benefit of low-fat diets.

Medviews considers both this paper and the one showing no benefit in calcium supplementation for women, both products of the Women's Health Initiative. Woody Allen is mentioned.

Marcus at Fixin' healthcare has similar thoughts, using the analogy of blind men trying to describe the elephant: studies focus on this or that intervention when what is needed is a focus on doing many small things we already know are good for us.

I have a few thoughts about these studies as well.

Gloria at Straightfromthedoc notes the introduction of a centralized pharmacy history for patients. I've always marvelled how hard it is to figure out exactly what medicines a patient is on. I know there are privacy concerns, but something like this is sorely needed.

Tara Smith from Aetiology (I had to look it up too) blogs about why "Pox parties," designed to ensure infection with chicken pox are a bad idea now that we have an effective vaccine. I had no idea these still went on; the Simpson's rerun Sunday night featured a pox party and I thought it was dated. Good comments, too.

Sumer, a radiologist in Delhi, comments on a recent NEJM piece about outsourcing reading of radiological studies. Don't hold your breath Sumer, U.S. radiologists will fight tooth and nail to keep this from happening

Wanderingvisitor considers the question of whether medical events cluster around the full moon, as the nurses he's worked with believe. Count me a skeptic (other than animal bites, which may just reflect people being out in nature more when there's some light). I suspect a signficant publication bias in the studies he quotes. WV is a very new blogger, this being only his 5th post! Might be some kind of record.

Thecheerfuloncologist considers the recent JAMA study predicting elderly patients risk of death. He introduces us to an index that purports to measure mortality risk, or at least degree of burnout, in interns. Don't miss his links, one of which (the Camel ad) is priceless.

Tony Chen at Hospitalimpact summarizes a number of recent posts about hospital strategy. Not only is "hospital strategy" not an oxymoron, but some hospitals apparently have strategies other than maximizing overall annoyance

Kate Steadman at Healthpolicy examines donut hole (mmm donut holes) health plans. These offer 1st dollar coverage, then a "deductible" after a certain threshold, then at a higher dollar level coverage resumes. Good for the very well (routine doctors visits covered) but as she points out the deductible has to be larger to save money since some of the insured will never reach it.

Medicofone considers an alternative explanation for the drop in cancer deaths.

DB at the eponymous DBsmedicalrants considers what is and what isn't primary care. He concludes that the primary care of complex patients should be seen as a specialty in its own right.


Patient's Perspective

Diabetes mine, a recently diagnosed type I diabetes patient, attended a postgraduate conference on diabetes care. Her perspective is as a patient, not a provider, but she liked the free goodies just like everyone else

Difficultpatient shares her frustration with those who don't believe ADHD (attention deficit hyperactivity disorder) exists because it does and her son is affected. I agree with her that it may be overdiagnosed (in my opinion teacher's who want compliant students are a prime driver) but there are some kids who are just out-of-control unless on stimulants.

Advice for Patients

Dust in the Wind has some advice for parents bringing their child to the ED which should apply to office visits with kids as well. My rule #1 is "listen to the nurses."

Dr. Emer at Paralleluniverse recommends staying away from McDonalds french fries, which contain 1/3 more trans fat than previously advertised. He does acknowledge that they taste good.


Occasional Notes

Doctor, nee Medical Madhouse Madman, complains about his difficulty in getting listed on Medlogs, which is a medical blog aggregator.

Grunt doc asks other ED docs to pledge not to offer expert opinion unless it is in concordance with accepted standards of care. I'm just guessing this has been a problem in the field.

Rita at MSSPNexusblog reflects that even health chare workers sometimes have bad hair days. Some of us just have them more frequently than others.

Insider at Pharmagossip takes a revealing glance at hiring practices of big pharma in this NOT SAFE FOR WORK post. You were warned.

Geeknurse gives some suggestions about communication in the medical blogosphere. Unfortunately he doesn't link to the bad example he cites. Oh well, not everyone can be in-the-know. I sympathize with the problem of anonymous flames.

And finally, if the above links aren't enough for you, here is another entire carnival dedicated to doctors only natural enemies, lawyers. The focus is on health care law.

Next week Grand Rounds is at Achancetocutisachancetocure.

PS My intention was to include everyone who submitted by the deadline; if I inadvertently left you out, I apologize.

Womens health initiative

The Womens health initiative (WHI) is a large, federally funded study of several interventions designed to make people healthier. Unfortunateley according to several recent publications they don't seem to work

Three articles in last week's JAMA showed that a low-fat diet didn't protect against either cancer or heart disease. Then in this weeks NEJM, we find out that calcium supplementation did little if anything to increase bone density or prevent fractures and nothing to prevent colon cancer.

Why? Well one problem is that it is hard to get people to change their lifestyle much. The women assigned to a low-fat diet still ate 25% fat 1 year in and 28% after 5 years, dowm for 37% at baseline. In the calcium supplementation study there was actually substantial improvement in patients who actually tood the supplements. But the 40+% of women who were assigned to take them and didn't (defined as <80% of pills taken) are included in the primary statistical analysis, diluting out the effect.

Most trials are analyzed based on what is called "intention to treat" meaning that everyone randomized to a group (calcium supplementation or placebo in this case) is included, whether they took the treatment or not. The reason is clear if you think of say a trial of a new medicine for cancer. If you exlude patients who didn't finish treatment (say because they died) you might make the treatment look better (by kicking out sicker patients). So you analyze the data looking at everyone randomized to get treatment.

In lifestyle interventions, this reasoning is not so clear. What we really want to know is whether making change X will decrease the risk of disease Y. We already know it is hard to get patients to substantially modify their behavior, that is why so many people still smoke. But that doesn't mean that paitents who do change won't benefit.

In summary, both a healthy diet and calcium supplementation may be good ideas, at least from the view of the individual. From a public health perspective, it is hard to know if patients will follow the advice enough to make a difference. As William James said it is easy to have beliefs, the hard part is getting our beliefs into our muscles.

Scary patients

Allergist are always being made fun of because the lifestyle is good and people think the patients aren’t very sick. Not so! At least about the patients. Yesterday, I saw two patients with life-threatening allergic disease.

The first was a nice man of 35, a businessman in Pittsburgh. When younger he had noted some trouble breathing after eating crab, so he avoided it. Then in December, he was visiting family in New York and they went out to lunch at a Chinese seafood restaurant. He ate a variety of fish and shellfish and drank about 1/2 a beer. Soon after starting he felt unwell. He stood up and immediately vomited and fainted. He was unresponsive. 911 was called and he was rushed to an emergency room where he was treated with epinephrine, steroids, fluids and benadryl with complete resolution of his symptoms. Presumably he had an anaphylactic reaction to fish or shellfish which he eats infrequently. As part of his job he travels frequently to Asia, including China. Imagine what might have happened if he had been eating alone, or in his hotel room. I sent off tests and prescribed him an Epi-Pen (self-injectable epinephrine) along with recommending strict avoidance of all fish and shellfish (at least until the tests come back) and getting a Medic-alert bracelet.

The second was even scarier. A teenage girl I’d seen a year ago with mild asthma. The only thing unusual was that her symptoms seemed to get worse quickly, but she’d only had one hospital admission a couple years ago and an ER visit just before seeing me. I did allergy testing which showed her allergic to many things (cat, dog, molds, pollens). I sent her on her way with an inhaled steroid and said to follow up in a few months. She never did, but often they don’t. She did well on the medicine for a while then stopped taking it because she thought she didn’t need it. Thursday night she went to a friend’s house and the friend had a dog. She got home and had trouble breathing. She told her mom she couldn’t walk upstairs to get her medicine and then that she thought her heart was going to stop. By the time the EMT’s got there they had to bag her (use a bag and mask over her mouth and nose to get air into her lungs) and she got intubated in the ED and was still “tubed” when I saw her. Scary

A certain subset of asthmatics is what we call brittle. They may not have daily symptoms, but they go down hill fast. Of course you don’t really know who they are until something like this happens. She was a lucky one. EMS got there in <5 minutes and she’ll be fine. Unfortunately there is no way to know when this might happen again. Hopefully, the patient and mom will understand the need for daily medicines to fight the inflammation in her lungs a bit better.

Grand Rounds update

Keep those submissions coming at macginnitie at excite.com

I have 13 submissions already, including several excellent ones from blogs I wasn't previously familiar with.

My submission guidelines are here, and all appropriate (i.e. medically related) submissions will be included, so consider submitting your best recent work.

You can read the pre-rounds about me (free registration required), which Nick, godfather of Grand Rounds, writes each week about the host here.

If you don't recieve acknowledgement regarding your submission within 48 hours, email me back. My excite mailbox seems to file messages in random order, making it easy to overlook one.

Predicting death

How long will I live? Except for those with teminal illnesses, there is no way to answer that accurately. But you might be able to get an answer to the related question “how likely is it that I’ll die in the next 4 years.”

A study in JAMA this week looks at a point system to predict 4 year mortality in older adults. You get points for being old, having chronic diseases, etc. as follows:
Now total up your points and risk of death of dying in the next 4 years is as follows:

0-5 pts <4%
6-9 pts 15%
10-13 pts 42%
14+ pts 64%

Note that being normal or underweight increased mortality, whereas a high BMI (i.e. being overweight or obese) is associated with decreased mortality. One reason may be that people tend to lose weight from chronic diseases like cancer and COPD (chronic obstructive pulmonary disease), but it may also be, as I've blogged on before, that current weight categories based on BMI don't reflect actual health status.

Stem cell treatment for lupus

Systemic Lupus Erythematosus (SLE or lupus) is a devastating autoimmune disease. It primarily affects women of childbearing age and can cause irreversible damage to the kidneys and other organs. Before the advent of modern immunosuppression is was nearly 100% fatal. Even today treatment does not generally cure lupus and increases the risk of severe infections. Some SLE patients do not respond to even high doses of immunosuppression.

Presumably, the underlying "cause" of SLE is immune cells that have become dysregulated, allowing them to recognize self-antigens (that is proteins and other molecules produced by the patient's own body) as dangerous and attack them like they would an infection. This hypothesis is supported by the finiding that SLE patients make antibodies to various self-antigens and that damage to the kidney is mediated by the complement system, which normally acts against bacteria or virally-infected cells

Since SLE generally develops in adolescence or later, it seems that it is due to deviation of the immune system toward self-reactivity. If the immune system could somehow be "reset" it might cure the disease. A new trial, published in JAMA, suggests that a treatment akin to bone marrow transplantation might accomplish this in some patients.

Bone marrow transplantation started as a way to give cancer patients more chemotherapy and radiation. Since these treatments kills off immune cells, it predisposes to infection and if you give too much the immune system might never recover, by giving back immune cells you can give more chemo and radiation. It turns out to be more complicated (more detail is in this previous post) but that's the basic idea.

Doing a transplant for SLE turns that idea on its head. Here the rationale is to kill off immune cells. Hopefully when the immune system is regenerated it will no longer react against normal proteins.

To minimize side effects, the investigators didn't give the patients someone elses bone marrow, but rather gathered the patients own stem cells (which can differentiate into all the different types of immune cells) then treated them with doses of chemotherapy that don't completely eradicate the existing immune system (this is called "non-myeloablatve" whereas "myeloablative" therapy completely destroys the immune system). After this treatment, sten cells are reinfused and, hopefully, a new immune system develops that doesn't cause lupus.

Note, I wouldn't technically describe this treatment as a transplant since cells are collected and reinfused from/into the same patient. A true transplant moved cells from one person to the other.

In the trail, about 1/2 of the patients were "cured" as defined by being alive without needing signficant immunosuppression 5 years later, although lupus did redevelop as late as 5 years later (not all patients have been followed for 5 years, so the cure rate is a stastical measure). Only 1 patient died from complications thought to be related to the transplant and overall survival at 5 years was estimated at 84% which is higher than would have been expected for an untreated group of patinets with severe lupus refractory to standard treatements.

As one of the authors notes in a press release

"Fortunately, the majority of patients with lupus can be successfully managed with our available medical therapies. However, for the very severely ill subset of lupus patients who have failed conventional therapies, stem cell transplantation provides a promising new alternative."

Race and continent of origin

I'v posted several times before about the use of race in medicine, specifically the case of BiDil, which may or may not work better in blacks than whites. One concern I and others have had is if self-reported race accurately reflects actual genetic background. The answer to that question seems to be yes, at least in Cleveland:

According to a letter (full text only for subscribers) in a recent NEJM, whites have DNA that is almost entirely of European origin, whereas blacks have DNA that is an admixture, but with a majority of African origin (more accurately of recent African origin, as all human DNA is of African origin if you go back far enough).

This matters because if you believe that self-reported race may be useful in medicine, as I tentatively do, it is because race is a marker for genetic differences. As micro-array technology (DNA chips) progress we'll bypass the need for race and look at genetic differences directly, but until that is possible race may at times be a useful marker.

Plumpy'nut

When I think of technology improving lives, I'm not sure treatment of malnutrition is what comes to mind. But that is exactly what it is doing. In the past, refeeding of malnourished children was problematic. In poor countries you simply couldn't admit every child to the hospital as there weren't enough beds or resources. And admitting the sickest child in a family potentially hurt other children as a parent (usually the mother) was away from home, staying at the hospital. Finally, having a bunch of sick, malnourished (and therefore immunocompromised) kids staying in tight quarters could lead to outbreaks of infections


But it was equally hard to send kids home. Formulas and other nutritional supplements usually required remixing with local water, which could cause the same sort of gastrointestinal infections that contributed to the malnutrition in the first place.

Solution: Plumpy'nut

Unlike fortified powdered milk formulas, Plumpy'nut does not require mixing with clean water, which can be difficult to come by in some war-torn and famine-stricken areas. Plumpy'nut is a ready-to-eat mixture of peanut paste, sugar, fats, minerals, and vitamins. One pouch of Plumpy'nut alone packs 500 calories and costs as little as $0.35 cents a packet. Malnourished children will consume as many as three packets a day at nine feeding session

You won't often hear an allergist say anything good about peanuts, but this sounds fantastic. According to this article (free full text) in a recent New England Journal of Medicine, the feasability of outpatient treatment of malnutrition in making a big difference in Niger, allowing doctors and hospitals to concentrate on the worst cases:

Children who do not eat what they are fed at a nutritional rehabilitation center usually have serious infectious or metabolic disorders that necessitate hospitalization. But for most other children, and for children whose condition has been stabilized in an inpatient setting, weekly medical consultation is sufficient for health care providers to diagnose and treat the common, non–life-threatening complications and infections associated with severe malnutrition. Most children in outpatient programs for severe malnutrition who are treated with the new solid therapeutic foods are cured in four weeks, without having to be hospitalized.

Outpatient treatment also avoids taking the parents out of the process of treatment.

Grand Rounds: call for submissions

I will be hosting Grand Rounds 2:22 on Tuesday 2/14. Email submissions to me at macginnitie at excite.com

1. Overal submission guidelines are here

2. There have been a number of discussions lately about the purpose and direction of Grand Rounds. Some have advocated for more proactive hosts to pick only the most noteworthy posts, others value inclusiveness. Some wise commentors have suggested a hybrid, with some "featured posts" with all appropriate posts also listed.

I will try out this new style by selecting the 10 posts I deem most worthy and featuring those. Note I did not say the 10 best posts, nor the 10 readers would most enjoy. My decisions are final. I will include all other submissions with a brief description.

3. The number of submissions has increased significantly over the past year and so has time invested by the hosts. The majority of posts seems to come near the deadline. I have full days of clinic both Monday and Tuesday and my family to spend time with Monday night, so the firm deadline for ALL submissions is 5PM EST on Monday 12/20. Any submissions recieved after that time will not be included.

As an incentive to get submissions in early, a minimum of 5 of the "Top 10" featured posts will be selected from those which I recieve by 5PM EST on Sunday 12/19, giving me more time to get it together.

4. Please email me your link and a BRIEF description of it, particularly if it is lengthy.

Grand Rounds, St. Valentine's day edition

is here. Very creative format

Remember Grand Rounds will be here next week. Guidelines will be forthcoming.

A good day

As doctors we get surprisingly little feedback on our performance. My hospital interviews a sample of patients about their satisfaction, but we see results twice a year in confusing bar graph form.

So today I got two pieces of great feedback. First, a parent wrote us a letter saying how pleased they were with everything during their visit. It's always nice to hear this kind of thing and she also praised the nurses and administrative staff which means there happy and smiling as well.

Second, I saw back a very unusual patient. She had recurrent episodes of life-threatening throat swelling. You can imagine how unnerving it would be to walk around knowing you could start suffocating at any time.

There is an unusual genetic disease called hereditary angioedema which can present with similar symptoms, although it usually starts earlier in life. She saw an outside allergist/immunologist whoe tested her, but they were normal. I knew there were rare cases in woman only thought to be associated with estrogen, but with no defined cause or abnormality.

There is no known treatment for this rare type, but I found one case report of a patient treated with androgens, which are male sex hormones. Androgens are effective in the more typical . Testosterne is the natural angrogen, but other drugs have been designed to have less side effects in women (which are typically unpleasant things like increased body hair, deeper voice, and acne as well as some toxicity to the liver).

Well it has been 18 months and she has had zero problems. We've slowly lowered her dose from 3 pills a day to one pill every other day and she is doing great.

Of course I'm skeptical enough,to wonder if she'd have gotten better even without treatment. At some point (not yet) I'd consider taking her off, but don't think she'd agree.

Obviously she is thrilled to be free of this and I'm happy for her. It is also nice to (apparently) pick up a rare disease.

Ooops

I was trying to modify my blog template last night to decrease the amount of dead space at the sides. I played around with other templates before figuring out how to do it directly. Unfortunately republishing with the preformatted templates deleted sitemeter and my blogroll.

I reinstalled sitemeter, but it'll be a day or two before I get my blogroll up and running. I've needed to update it for some time now, so this will be an opportunity to do so.

The cartoons

Well, I try not to get bogged down too much in politics, but I will say that this Charles Krauthammer column captures my opinions about the cartoons:

There is a "sensitivity'' argument for not having published the cartoons in the first place, back in September when they first appeared in that Danish newspaper. But it is not September. It is February. The cartoons have been published, and the newspaper, the publishers and Denmark itself have come under savage attack. After multiple arsons, devastating boycotts and threats to cut off hands and heads, the issue is no longer news value, i.e., whether a newspaper needs to publish them to inform the audience about what is going on. The issue now is solidarity.

The mob is trying to dictate to Western newspapers, indeed Western governments, what is a legitimate subject for discussion and caricature.

Were they offensive? Maybe; personally I didn't see the original 12 as too bad, but then I wasn't offended by Piss Christ or the picture of Mary with elephant poop all over it. I have no problem with people peacefully protesting the printing of the cartoons, writing letters to the editor, etc. But once people start acting violently it is important to stand up for free speech. And the hypocrisy of papers like the NYTimes which publish images offesive to Christianity while refusing to publish the cartoons is stark, but not unexpected.

Bird flu

is spreading, not only to Europe, but to Africa as well.

While attempts to contain infectection by culling poultry may work in Europe, there is no way most countries in Africa have the resources to do this.

At this point, I think there is no hope of containing spread among birds. And it is probably just a matter of time until the virus either reassorts with an influenza virus that effectively infects humans and creates a hybrid that combines the unfortunate features of being immunologically new to the human immune system and efficient at human to human spread. Or, worse, develops the ability to spread effectively between humans on its own.

My sense is that this pandemic will be less severe than some fear (some data indicates many peo0ple are infected, but don't necessarily have severe disease, much less die), but it is definitely coming.

My own medicine, a book review

Disclosure: Geoff Kurland, author of My own medicine: a doctor's life as a a patient, is a colleague and a very nice guy, as well as a fellow ultrarunner.. Nonetheless, I'd have liked this book even if I had never come to Pittsburgh

This book recounts Dr. K's experience fighting leukemia. He has some ongoing respiratory symptoms after completing a 50 mile race, so he gets a chest x-ray. This shows a mass in the middle of his chest. One things leads to another and he is diagnosed with hairy cell leukemia, a rare form of blood cancer. He decides to seek treatment at the Mayo Clinic where his father is on the faculty. Given how weird it would be to be a patient where you are also a faculty member (UC-Davis at the time) I think that was a good idea.

Anyway, Dr. K has a lot of insight about what it's like being a patient (e.g. sitting in your hospital room all day, waiting for the doctor who comes in for 5 minutes), and brings a unique perspective to the experience of being a patient. He is also an excellent writer. He includes a lot of reflection about his life as a doctor and what pediatric residency was like, which I enjoyed, and the struggles in his romantic life, which I enjoyed less.

To give you a taste, late in the course, when he seemed to be doing well, he developed a long fever of unknown origin. Thin to start, he wasted away in the hospital with ongoing fevers which no one could figure out:

I am pretty sure I will die, for the nightly fevers, a hollow appetite, and apathy have conspired together, leaving me silently anguished and empty. I tell myself that this is what it is to die slowlyl. I am not afraid of dying as much as I thought I'd be. Instead, I feel a sadness that the cause- the infection, the tumor, or whatever it is- eludes my physicians.

Luckily, his physicians eventually figure it out. He goes on to be cured and fulfills his dream by completing the Western States 100 Mile Run twice, the final time last summer, when I fill in for him in his usual role as doctor at the major checkpoint in Foresthill, 62 miles into the race. While I think I did a credible job as an MD, I failed to live up to Geoff's ability to entertain the other workers with bad jokes.

In summary, I really enjoyed this book. Given that prominent themes include ultrarunning, struggling to make your way in academic medicine and living in Pittsburgh, this may not be surprising. But it is an excellent book, very well-writtent and with good insight. I recommend it to all.

Grand Rounds 2:20

is here at Science and Politics

I'll be hosting in 2 weeks so get those keyboards humming.

The video case for universal healthcare

I am not a proponent of universal health care and don't think this video is very convincing, but since someone thought it was worth sending to me, I figure I'd pass it on.

Executives make loads of money in every industry; I don't think we need to nationalize the computer industry because Michael Dell and Bill Gates have made so much money. quality t

Breastfeeding is bad for kids!

UPDATE: Welcome to Grand Rounds visitors. I'll be hosting next week, and submission guidelines are here if you are interested.

During residency, a conference was devoted to a Jeopardy type game with each question about some aspect of breast feeding. It quickly became apparent that whatever answer made breast feeding seem best was the correct one.

The same theme seems to be at work in this article about breastfeeding and the risk of infections in infancy, which concludes

This nationally representative study documents increased risk of respiratory tract infection including pneumonia and recurrent OM in children who were fully breastfed for 4 vs 6 months. These findings support current recommendations that infants receive only breast milk for the first 6 months of life.

Let's look at the data on pneumonia. Here I present the odds ratio for no breastfeeding and various durations of exclusive breastfeeding (that is not taking anything else by mouth). Odd ratios can rougly be thought of as the increased chance of an outcome (e.g. OR 2.0 means something is twice as likely).

Duration OR
BF>6 months 1 (reference group)
BF 4-5 mo. 4.27
BF 1-3 mo. 1.97
BF <1>6 months) so random variation was probably accounts for a lot of the difference.

Don't get me wrong. I am all in favor of breastfeeding; an enormous amount of data shows it is best for babies. Both my kids were breastfed and this was very important to my wife and I. But, this data needs to be presented in an honest way, not massaged and manipulated so to always put breastfeeding in the best possible light.

In this study the number of patients in each group were as follows:

BF>6 months 136
BF 4-5 mo. 223
BF 1-3 mo. 343
BF <1 mo ~1200

I think we might be better off trying to get more moms to start breastfeeding or do so a little longer rather than holding up exlcusive breastfeeding as an unrealistic ideal.

UPDATE: when I put the first update at the top, blogger garbled the end of the post. Interestingly the same problem happened when I posted the first time. Curious. But now fixed.

Why HIV is so successful

In people with untreated HIV infection, every possible point mutation in the entire genome arises daily

which the authors of this commentary in Nature Immunology note, gives the immune system a very difficult job. Of course, the ability of HIV to increase fitness from random mutation demonstrates that natural selection and evolution do occur. My sense is that most thoughtful creationists (and no, I don't think that is necessaryily an oxymoron) accept this sort of small scale evolution but deny that evolution could explain the emergence of new species.

Stem cell smackdown

The conventional wisdom is that Woo Suk Hwang bears all the blame for fabricating his human stem cell data. Science, the prestigious journal that published the paper, blameless, as it merely published what appeared to be legitimate results.

Not so, say Evan Snyder and Jeanne Loring, a pair of stem cell scientists, writing in the New England Journal:

Nevertheless, flagrant duplication of photomicrographs in the absence of key control conditions (e.g., analysis of mitochondrial DNA) should have been caught before publication.

Trust me, in the world of science, this is about as nasty as it gets. Of course, it's easy to say the deception should have been caught once it's been revealed; I don't remember these authors questioning the data before it became clear there were problems.

BTW, mitochondrial DNA is the small amount of DNA that is inheritied solely from the mother. Since somatic cell nuclear transer replaceds the nuclear but not mitochondrial DNA of a ova, a good control for cloning experiments is to show that the nuclear DNA and mitochondrial DNA come from different individuals (the nuclear and ova donor, respectfully).

Light posting and the Super Bowl

Posting has been lighter than usual lately mostly due to having a lot going on at work. I've had 3 talks in the last 2 weeks, the last today and am slogging through getting the various approvals needed to get a clinical research study up and going. In addition to my 7 1/2 days of clinic per week and usual conferences, teaching, etc. With all the talks done, things should lighten up a bit.

I've lived in Atlanta, New York City, Chicago, Boston and now Pittsburgh and only Chicago can compare to Pittsburgh as far as sports-craziness. The Pittsburgh Post-Gazette today has a front page article in which a sports psychologist gives advice to FANS about how to deal with the stress of the Super Bowl. Unbelievable.

UPDATE: I have no ideal who'll win, but if it were Pittsburgh fans vs. Seattle fans the line would be Steelers by 100.

Grand Rounds 2:19

is here. Better late than never (that is my recognizing it, not GR itself).

Oral allergy syndrome

An unusual, little known type of food allergy. Proteins in certain foods, usually fresh fruits and vegetables, can cross react with pollen proteins in patients with allergic rhinitis (aka "hay fever") and cause symptoms like oral itching.

This article does a good job summarizing the phenomena.

I am surprised how often I ask patients with allergic rhinitis is they get an itchy mouth with certain foods and they look dumbfounded and wonder how I knew that.

Cooking usually denatures the protein, so patients can often tolerate cherry pie but not cherries. Luckily, in general the symptoms are self-limited and patients can just avoid the food that gives them trouble.

Does less salt = less asthma?

This study hopes to answer this question. I assume, but don't know there is pre-clinical data supporting the salt/asthma link.

One problem with these kinds of studies is how hard it is to get people to actually follow a restricted diet. If humans were good at that type of thing there wouldn't be so much obesity.

UPDATE: Need to look before posting. There is even a Cochrane Review on the topic, which concludes

Based on currently available evidence it is not possible to conclude whether dietary salt reduction has any place in the treatment or management of asthma. The results of this review do indicate an improvement in pulmonary function with low salt diet, however further large scales trials are required before any firm conclusions can be reach.