Intelligent design

A good commentary by law professor/medical ethicist George Annas in this week's NEJM about the various guises in which creationists try to "sneak" their views into the classroom. I hadn't realized that "intelligent design" is just creationism repackaged:

By comparing the pre and post Edwards drafts of Pandas, three astonishing points emerge: (1) the definition for creation science in the early drafts is identical to the definition of ID [intelligent design]; (2) cognates of the word creation (creationism and creationist) which appeared approximately 150 times were deliberately and systematically replaced with the phrase ID; and (3) the changes occurred shortly after the Supreme Court held that creation science is religious and cannot be taught in public school science classes in Edwards.

Quote if from Judge John Jones opinion in the recent Dover, PA case adn Edwards refers to a US Supreme Court decision overturinng a previous law requiring teaching of creationism.

Unfortunately, the creationists are gearing up for a new assault, this one predicated on the idea that students deserve to be exposed to both sides of the "controversy" between ID and evolution:It looks as if this next wave will jettison the creationist and intelligent-design baggage and concentrate exclusively on a "teach the controversy" strategy. That this controversy is one largely manufactured by the proponents of creationism and intelligent design may not matter, and as long as the controversy is taught in classes on current affairs, politics, or religion, and not in science classes, neither scientists nor citizens should be concerned.

I don't see why everyone can't just accept that it was the flying spaghetti monster who created everything.

Human to human avian flu transmission?

Health officials have confirmed that bird flu has killed six members of a single family in rural Indonesia, and doctors have tried to determine whether the virus was passed from person to person

While not great news, I wouldn't be too worried yet, either. There has been apparent human-to-human spread before. From the WHO

Though rare, instances of limited human-to-human transmission of H5N1 and other avian influenza viruses have occurred in association with outbreaks in poultry and should not be a cause for alarm. In no instance has the virus spread beyond a first generation of close contacts or caused illness in the general community. Data from these incidents suggest that transmission requires very close contact with an ill person.

As long as this strain of influenza stops in this family I don't think it is any big news. Note also that all the family members were in close proximity to poultry, so they may have all gotten it directly from the birds.

Bronchial thermoplasty

Which articles do and don't get extensive media coverage has always been a bit of a mystery to me, but never more so than this one. Everyone from my sister to my secretary have e-mailed me about this.

I think it is mostly hype. So far, the results of 16 patients treated with bronchial thermoplasty (BT) have been published. That trail had no control group and showed modest improvements in their asthma: days without symptoms increased from about 1/2 to 3/4 of days. The peak flow (how fast patients could blog air out) also improved somewhat. But without a control group we can't know how untreated patients would have done. In addition, the patients in this study had relatively mild asthma.

I might considering this at least a promising avenue of investigation if the intervention was innocuous, but it isn't. The procedure involves putting a flexible tube down into the airway and burning the tissue to reduce the amount of muscle. And once isn't enough; patients get multiple bronchs so that enough muscle can be burned.
Most patients had side effects such as cough or wheeze. In addition follow up was only 2 years, so long term negative effects of the procedure may not yet be evident.

I don't know about you but I'd rather just take my Flovent or Advair twice a day.

In fairness, the article also mentions data from a larger controlled study was presented at the ATS (American Thoracic Society) meeting this week in San Diego, and they are recruiting for an even bigger study.

I'm very skeptical this will be useful. I suspect side effects will be intolerable in the really severe asthmatics who need the treatment most. For milder asthmatics, we already have safe, effective therapies available

The psychological toll of food allergies

Allergists and pediatricians are aware that food allergies lead to a lot of worry for parents. The psychological burden can be overwhelming, for reasons that aren't entirely clear. Unlike asthma, where many families can't be bothered to stick to a medication regimen, some paretns, especially mothers, seem overwhelmed by anxiety with food allergies. I'd guess the difference is that food allergies seem entirely controllable: if you (or your child) avoid the food entirely there will be no symptoms. Asthma on the other hand comes and goes; even patients who faithfully take their medicine will have symtpoms sometimes.

Just how burdensome food allergies are is made clear by this study

more than 60% of caregivers reported that food allergy significantly affected meal preparation and 49% or more indicated that food allergy affected family social activities. Forty-one percent of parents reported a significant impact on their stress levels and 34% reported that food allergy had an impact on school attendance, with 10% choosing to home school their children because of food allergy.

It is a small study (87 families) and there may be some selection bias (the more worried the parent the more likely they are to fill out a tedious questionnaire), but still, 10% homeschooled because of food allergies is an enormous number. I know many families who won't eat out because of concerns of inadvertant exposure. I usually try to get this type of parent to relax a bit, at least to the point of eating out, always checking with the kitchen to make sure the food is safe.

It's not that we have too many doctors

In 2003, the United States had fewer practicing physicians, practicing nurses, and acute care bed days per capita than the median country in the Organization for Economic Cooperation and Development (OECD). Nevertheless, U.S. health spending per capita was almost two and a half times the per capita health spending of the median OECD country

My impression, which could be wrong, is that it isn't that doctors make that much more here, either. From an article suggesting that we'd spend less and more efficiently if we utilized information technology in healthcare more efficiently. I agree, although I don't think there are any easy answers.

Weight loss update

Weight this week: 205

Weight last week: 205

Change this week: 0

Starting weight: 206

Change from start: -3

No change in weight this week, but I am definitely getting thinner. I am reporting my Saturday am weight, which was my lowest in a week last week and the highest in a few days this week, so I definitely think things are going in the right direction.
For more on my diet see here

Calculate your cardiovascular risk

using this calculator. You just need to know your total and HDL cholesterol and your systolic blood pressure.

I come up with a 1% risk of heart attack in the next 10 years, which seems pretty low.

Why we scratch

Why do we scratch?

A simple answer would be because we itch, but how does scratching make itching (or pruritis in doctor lingo) better. But the real answer is

the most characteristic response to itching is the scratch reflex: a more or less voluntary, often subconscious motoric activity to counteract the itch by slightly painful stimuli. This itch reduction is based on a spinal antagonism between pain- and itch-processing neurons

In other words scratching causes a mild, painful sensation that inhibits transmission of the "itch" signal:

I never knew that!

Evolutionarily this makes sense: noxious (e.g. painful stimuli) cause withdrawl, but itching usually signifies something on or under the skin. The pain from scratching prompts closer inspection.

The linked article has everything you'd ever want to know about itching and more.

Shangri-la update

Well I promised to follow the Shangri-la diet and update readers on my progress. I had some issues with illness and injury and didn't really follow the diet for a while. I finally got healthy and over a nasty cold last weekend and started both exercising and following the diet regularly. I'm trying to take 1 tablespoon of extra light olive oil (ELOO in Sharngri-la terminology) 2x a day.

To control for exercise and trying to lose weight, I'm going to compare my progress losing weight to the same time last year when I was also exercising regularly, hopefully at similar volume. Not exactly a placebo control, but at least I'm comparing apples to apples.

The line part graph shows weight at the end of the week in both years and the columns my weekly mileage (which is a combination of running, ergometer running with a few miles added for each strength session). I'll try to update weekly

IQ and health

I've blogger previously about the paradox that class seems to matter more than absolute income in determining health. For example

blacks in the United States have about 4 times the income of men in Costa Rica or Cuba, but about 9 years’ shorter life expectancy.

Part of the answer may be that IQ, not income is a key predictor of health.

A recent study in the BMJ showed that correction for IQ attenuated but didn't eliminate much of the trend toward better health in higher socioeconomic classes (also see commentary here). Of course the two aren't independent as income and IQ are strongly and positively correlated.

This makes intuitive sense as two people with similar IQs but vastly different incomes (say a professor at a small liberal arts school and a manangement consultant) should both be able to follow similar lifestyles from a health perspective. While one makes more than the other, both should recieve good health care and be able to afford things like quality food and gym membership. As we move down the socioeconomic ladder, however, effects of deprivation might become more pronounced even with similar IQs, although in Scotland, access to health care should not differ.

Doctors communicating

Flea has a great post about specialists not giving credit to primary care docs for staring the work-up and, often, making the diagnosis before the specialist even sees the patient:

In his letter, however, the gastroenterologist failed to mention any of the work-up that I had performed, and stated matter-of-factly that he had made the diagnosis.

In a collegial manner, I offered that at best the diagnosis was a joint effort.

My colleague's reply was "My goodness, I didn't think you guys (i.e., you fleas) actually read these letters!"

I respond in his comments, but I'd like to lodge a complaint from the other side of this interaction. Specifically, any workup you do is of no use to me if I can't get hold of it.

Again and again I see a patient referred for "immunodeficiency." Like many kids, the patient has been on antibiotics a lot. The primary (PMD) has sent some lab tests and apparently they were abnormal. I say "apparently" because I don't have them. The parents assumed the PMD's office would send or fax them but they didn't. Our nurses are happy to call, but don't appreciate being on hold for 15 minutes, then being told the office is too busy to fax it over right away. At times I have to personally call the doctor to plead with him to have someone fax them right away. Meanwhile, the family sits for an hour while we wait for the results of these tests. Usually, the tests are fine (one lab locally doesn't correct the "normal" immunoglobulin range for age, so all kids come back artefactually low), and I can reassure the patients, but it would sure be helpful if I had those tests right away.

So, primaries, think about using your consultants wisely. Everyone benefits when the workup you've done is available to the consultant: it makes my life easier, I can communicate what I think to the patient and parents in person not in a phone call later, and unnecesary and duplicate testing is avoided.

UPDATE: added link to Fleas and his original post which I swore I'd already put in.

Free Advice

As medicine increasingly becomes a business, will it's characteristic collegiality be eroded?

As a specialist, I am often asked for "curbsides" about patient I don't see and for which I don't get reimbursed. As one of my life's overall goals is helping sick kids (or keeping them well in the first place) and as a faculty memeber at an institution that promotes learing, I don't particularly mind this. Plus, there may be some indirect benefit in that docs who I give advise to are more likely to send me patients in the future. In fact, many who call for advice already refer a lot of patients my way. Plus, I see most pediatricians as overworked, (relatively) underpaid, and struggling to keep up with the constant flow of new information about how to treat every disease of childhood as well as what is and isn't recommended for well-child care. To the extent I can help, I'm happy to. Heck, I answer all the crazy and not-so-crazy emails I get from people who read this blog and want free medical advice

But a recent experience has me wondering if this kind of attitude won't change. A few months ago I got a call from a physician I didn't know and spoke with him for 10 minutes or so about chronic urticaria (hives). I even sent him a review article on the subject. Later I found out he operates a "concierge" practice in which he charges patients just to be in his practice. The fees are steep (>$1000 a year for younger kids, less for older) and I presume he makes a lot more than the average pediatrician. I found myself a bit mad that he'd felt free to take up my (uncompensated) time so he could pass the information on to parents (probably crediting it as coming from a specialist at my locally prestigious hospital) and justify his fees, which effectively exclude most children.

I'm still not sure exactly how I feel about this issue, and I still talk to whoever calls me, but if calls from concierge docs became more frequent, I'd consider tryng to charge them for advice. My rationale would be they've made their practice into businesses first and foremost, why shouldn't that same principle apply to them?

More CPOE

In December, I discussed a concerning publication from my own institution showing increased mortality in the ICU after implmentation of a computerized physician order entry system.

Well, the establishment has now had it's chance to respond, in a series of letters either critiqueing the study or arguing that the hospital didn't implement the CPOE properly (not that anyone could dispute that). I don't find them entirely convincing, but you can judge for yourself if your institution has free access.

And yes I took and extended break for no real reason. I've had a fair amount going on, got a bad cold, felt like I didn't have much to say, etc. I should be posting more regularly for the next while at least

That's a lot of ecstacy!

From the February issue of the journal Psychosomatics

Mr. A, 37 years old, used ecstasy between the ages of 21 and 30. . . . An estimate of lifetime consumption yielded a total intake of more than 40,000 tablets. At the time of his presentation, Mr. A reported current cannabis consumption, together with a previous history of polydrug misuse (i.e., solvents, benzodiazepines, amphetamines, LSD, cocaine, heroin). After three episodes of "collapsing" at parties, Mr. A finally stopped his ecstasy use. . . . He eventually developed severe panic attacks, recurrent anxiety, depression, muscle rigidity (particularly at the neck and jaw levels), functional hallucinations, and paranoid ideation. The Mini-Mental State Exam revealed disorientation to time, poor concentration, and short-term memory difficulties. Decrease in level of cannabis intake led both to disappearance of his paranoid ideas and hallucinations and reduction of his panic attacks, but remaining symptomatology persisted. Administration of the Wechsler Memory Scale (3rd Edition)3 suggested the existence of global memory-function impairment, with no subtest score being above the 10th percentile. Assessment of daily functioning skills identified major behavioral consequences of his memory loss (i.e., repeating activities several times). Although Mr. A was able to fully understand the instructions given, his concentration and attention were so impaired that he was unable to follow the sequence of the tasks required. A structural MRI brain scan revealed no focal cerebral lesions;

Curiously, a recent commentary in the Lancet (which is where I heard about this individual) suggests that this case demonstrates the adverse effects of ecstacy may be LESS than previously thought:

But the case of a man who emerged from a decade-long period of intensive MDMA use—during which he is estimated to have taken 40 000 pills—with no signs of the profound neurotoxicity that has long been feared to result from even limited consumption of ecstasy, has re-energised calls for more research into the real side-effects, and therapeutic potential, of psychedelic drugs.

One shudders at the thought of the shape this guy would be in if he'd had more bad sequalae.

But there are apparently people who've developed persistent psychosis after a single use of ecstacy. From that case report, here is a description of the various bad things that can happen after using ecstacy:

There is a widely held belief that MDMA is a "safe" drug, but a growing body of literature has documented both medical and psychiatric adverse reactions to MDMA. Medical consequences include renal failure, rhabdomyolysis, disseminated intravascular coagulation, hepatitis, cerebral infarction, seizures, delirium, and coma. In terms of psychiatric sequelae, MDMA use has been associated with depression, anxiety, panic attacks, flashbacks, perceptual changes, depersonalization, and derealization

Other than that it sounds perfectly safe (more here)