Dr. Andy

US Death Rates

2010-01-23T10:52:00.002-05:00

From the same article in the previous post about US demographics in 2007:

Age adjusted death rates (death per 1000) over time

1915 21.7
1950 14.5
1980 10.4
1990 9.4
2000 8.7
2006 7.8
2007 7.6

So age-adjusted mortality has improved by

13% since 2000
19% since 1990
27% since 1980
47% since 1950
69% since 1915

I think those first 3 numbers are eye opening. Some combination of healthier living (e.g. less smoking) and better health care are really making a difference. Perhaps we are getting a better deal for the 1/7 or whatever it is of GDP we are spending on it.

US demographics

2010-01-23T10:41:00.003-05:00

The January edition of Pediatrics summarizes much interesting information about US demographics in 2007:

Births: 4.3 million
Deaths: 2.4 million

with a life expectancy at birth of 77.9 years.

The birth rate (per woman 15-44) is actually rising currently at 66.9 births/1000 and this is above the population replacement rate, meaning we don't seem to be facing the demographic time bomb to the same extent as Japan and much of Western Europe. I figure these kids will start paying social security taxes about when I retire.

An old post details how badly Allergy fellowship applicants fare when asked to estimate the number of births in the US each year.

Healthcare reform

2010-01-20T08:14:00.002-05:00

From David Leonhardt in the NY Times an argument that the current bills on healthcare reform under consideration in the Congress are middle of the road. Really? With no malpractice/tort reform? This is like a church where believing in God is optional.

The one big conservative idea that’s largely missing is malpractice reform. But the White House said several times that it was willing to negotiate on this issue. And think about it: Rahm Emanuel, the Obama chief of staff, likes to say the only thing that’s not negotiable is success. Don’t you think Mr. Obama would have gladly taken some heat from trial lawyers in exchange for passing health reform with bipartisan support and making himself look like a transformational leader?

Maybe now would be a good time to do more than says they'd be willing to negotiate. Maybe Obama should get out there and affirmativiely offer to put in malpractice reform in exchange for Republican support. He is President after all. And I am willing to apportion blame for HCR's likely failure to Republicans if they weren't/aren't willing to support HCR for political reasons even if Dems and Obama would compromise on malpractice reform.

And what about low-cost, high deductible plans that primarily provide catastrophic coverage? Those are not only not part of the current reform plan, but outlawed by it.

I'll be sorry to see HCR die (we do really need it) but I don't think you can excude the 2 biggest "conservative" ideas about how to do it.

2010 New Years Resolutions

2009-12-31T18:29:00.004-05:00

1. Run at least 20 miles at USC Fat Ass 50k 1/2. If I'm training for a marathon this spring I'm not sure I need to do all 30+ miles

2. Go sub 6:40 at Pittsburgh Indoor Sprints

3. Run Pittsburgh Marathon; finish sub 3:30. My interpretation is this would qualify me for Boston as I'll be 45 for the 2011 running

4. Run 1500 miles

5. Row 1 million meters

6. Be able to do 10 pull ups and 20 dips (I can do 7 and 14 now, so it isn't a huge reach)

7. Blog more. More than 100 substantive posts in 2010

8. Learn to "tweet"

9. Finish a 100 mile race in late 2010.

10. Qualify for Western States Lottery

Year in Review

2009-12-31T18:21:00.002-05:00

How did I do on my 2009 resolutions.

1. Finish Upper St. Clair 50K 1/3. No problem

2. Win Pittsburgh Indoor rowing sprints with time sub 6:35 1/2 and 1/2; won easily but 6:39

3. Finish Pittsburgh Marathon. Will probably run easy but would like to go sub
4 hours Fail. Didn't even get to enter as it was too popular

4. Finish Laurel Highlands (I'll say sub16 hours but I'm not really too sure how
it will go) Fail. Bowed out to go to a meeting about a new study. Probably worth it.

5. Finish a 100 sometime later in the year Fail; twisted knee at Oil Creek and dropped out after 50k. Was a wise decision

6. Run 1500 miles Close, but no cigar. 1371.5 which is not too shabby

7. Row 1 million meters Yep, 1,304,500 to the nearest 500.

8. Do more speedwork and enjoy it more Not really. Kept straining calf or hamstring. I think I need to find time later in the day to do this to avoid getting hurt when muscles are cold

9. Be able to squat all the way and keep both heels on the ground (I'm almost
there) Yes.

10. Read "In Search of Lost Time" all the way (I started early so I'm almost
done with the first book) Yes, and enjoyed it, although the endless descriptions of French society got a bit old

So 3 1/2 out of 10. I always say "If you always meet all your goals you should set some harder goals" but this was a pretty weak effort.

Other things were okay this year, so it wasn't all bad.

New Years Resolutions

2009-01-19T20:22:00.000-05:00

1. Finish Upper St. Clair 50K 1/3
2. Win Pittsburgh Indoor rowing sprints with time sub 6:35
3. Finish Pittsburgh Marathon. Will probably run easy but would like to go sub
4 hours
4. Finish Laurel Highlands (I'll say sub16 hours but I'm not really too sure how
it will go)
5. Finish a 100 sometime later in the year
6. Run 1500 miles
7. Row 1 million meters
8. Do more speedwork and enjoy it more
9. Be able to squat all the way and keep both heels on the ground (I'm almost
there)
10. Read "In Search of Lost Time" all the way (I started early so I'm almost
done with the first book)

Great Eastern Endurance Race 100K Report

2008-09-30T16:00:00.001-04:00

Prologue: This was the worst mentally I’ve ever come into a race. It was gloomy, cloudy and misting to raining my whole 5+ hour drive down from Pittsburgh to Waynesboro. I checked into my hotel and headed out to packet pickup, arriving at 4:30 only to learn the race briefing was at 6 and it was highly recommended for 100k runners. I left my laptop and a book sitting in my hotel room so that was a waste of time. The briefing was okay, but no great shakes. The course is very well marked and I would not have gotten lost if I hadn’t attended. I ended up getting lost looking for a supermarket and staying up later than I intended. If I’d paid better attention, I’d have shopped, etc. and arrived just in time for the briefing.

At 3:45 on race morning I was awoken by a very loud thunder clap and the sound of torrential rains outside. Ugh, I really didn’t want to face a whole day trying to run in a downpour. I got ready and then drove to the race site through more torrential rains. I was on the verge of turning around and heading home but figured I’d at least go to the start and see if I could find my friend Lorne who was also running. The rain had eased up by the time I got there so I made the decision to at least start the race. I resolved to have fun and just do 50k if I felt miserable. I hoped the weather would clear up as the day went on, which it did.

Race: I figured out who Lorne was and we started out together for the first 1/3 mile or so. I then pulled ahead, stopped to use the woods and pulled ahead again. After one mile on park road, there is a tough, rocky climb and then some rocky, rolling but mostly uphill trail into the first aid station. There were 150+ total runners (most doing the 50k) and it is very hard to pass and by going out slowly I was behind a lot of people. The weather was okay, but the whole course is very rocky and the rocks were very slippery. It took me ~1:35 to do the first 5.7 miles which was way slower than I’d anticipated. But I got in and out of the aid station and ran the next 2+ trail miles basically on my own. From there it was an out and back on the Blue Ridge Parkway and down a steep gravel road to an aid station. I really cruised here, passing a fair number of people and making up a lot of time. Despite my lack of motivation prior to the race, I was really enjoying myself. We were back on trail after this section and I was moving okay. However, I realized there was no gel at the aid stations! I had neglected to ask about this prior to the race, assuming they’d have it. You know what they say about assuming! So I was forced to eat real food at the aid stations, which was okay, but I missed the constant influx of calories every 25-30 minutes especially as some aid stations were up to 7 miles apart. Prior planning prevents poor performance! If I had been better prepared I could have carried enough gel with me and refilled at aid stations, but I didn’t. The solids also contributed to the need for several pit stops later in the race.

There is a big climb to thee 25.2 mile aid station on top of Bald Mountain, where the 50k runners turn and head for home, while the 100K idiots keep going. We’d climb up to this aid station 2 more times. I continued passing runners up to this point, but here the character of the race really changed, as I’d only rarely see other runners from here on in. We’d traverse some jeep “road” several times from here on out, and this was the poorest excuse for road I’d ever encountered. I almost couldn’t believe anyone could drive on it as it was extremely rutted and rocky. Even better, low spots were filled with water, often with no way around. Once I tried to just run through, but it turned out they were knee deep with slippery mud at the bottom. Later, there were vehicles on the road, but I wouldn’t drive anything I own on it

I got to roughly halfway at 31.2 miles in 6:40 feeling great and running well. I felt I could run 14 hours and set that as my goal. I suspect that the accuracy of the mileage from here on in was off. Put it this way, I paid for 62.2 miles and I more than got my money’s worth as it would take me nearly 10 hours to do the 2nd half of the race, despite feeling like I was still running well. Certainly the information about mileage between aid stations reported on the race web site and what the aid station volunteers told me didn’t jibe, although the 2nd half of the course was much tougher.

I ran the downhills and walked the uphills from here on in strongly. On the flats I’d run some, but then kick a rock which hurt like hell and walk a bit. I stopped the 2nd time at Bald Mountain to eat a grilled cheese sandwich (delicious!) and someone passed me in the aid station (Tom should get a kick out of this). I was feeling fine, but making only slow progress. I was enjoying it though and not too worried. As night fell, it was so foggy, my headlamp didn’t work very well, but luckily I had a small handheld with me. All day it had been overcast and sometimes foggy, but it was almost ghostly at night. The rocks were slippery all day and on the downhill from Bald Mountain to Slacks I was pretty terrified on some of the steep rocky sections. The last section seemed to take forever, but finally I was on the last road stretch and finished. 16:33 which is much slower than I wanted, but that was more the course and conditions than anything I did.

Post-race: I ate some lasagna and went back to my hotel for a much needed shower. I turned down the temperature in my room as I sleep better in the cool air. Suddenly, I started experiencing strong, whole body shivers that I couldn’t control. Very weird. I dove beneath all the covers until I warmed up, then turned the temperature back up.
I slept okay, until 5:30 when the old guy next door started yelling into his cell phone. There were 2 buses of senior citizens staying in the hotel and my room was right across from the elevator. They all wanted to get to breakfast when it opened at 6, so I had no hope of getting back to sleep. I ate a ton after the buses departed at 7, then drove out to pick up my drop bags. Unfortunately, they were already gone, so I lost a light, a pair of shoes and a shirt L. (I don’t really care, but the drop bag wasn’t there when I finished and then was gone by 8 am, so they didn’t really give you much chance to claim your stuff).

The website says there were 29 finishers out of 71 entrants and I was 16th or 17th. But before the race, they only listed 55 starters and I suspect there were some no shows.. Given the weather, it’s hard to believe 16 people signed up for the 100k the day before (I want to meet those people if they exist, talk about tough). I didn’t have a great race, but my effort was solid and I was glad I persevered to finish. I must admit, I’m not a huge fan of rocky trail and so may focus on “easier” races in the future. The hills didn’t seem so bad to me as I was able to walk strongly up all of them and run down all but the patch from Bald Mountain to Slacks in the dark at the end (and maybe a few other patches). The website claims there is 16,000 feet of climb and descent but I find that hard to believe (my calculation is that would be an average 10% grade and very little of the course seemed that steep to me). With the conditions however (and I didn’t even talk about the mud and significant portions of the course where the trail was now a stream) it was by far the toughest course I’ve done, much worse than Western States. Massanutten (which I‘ve paced part of) was tougher, but this would be a good race for anyone wanting to do Massanutten. Apparently they redid the GEER course in 2007 and made it much tougher. I’d recommend this race (good aid, very well marked) but be ready for lots of rocks. To put it in perspective they had 80 people sign up to run a ½ marathon on parts of the course (mostly trail, but not to the top of Bald Mountain we did 3 times) and the winner took 2:10!

Western States Tips, or go and get your buckle

2008-02-03T11:17:00.000-05:00

With all the applicants and the apparently imminent demise of the 2-time loser rule, you may only get one shot at Western States, so here are some tips on getting that silver buckle.
I made it in 2007 after just breaking 28 hours 4 years earlier (race report and pictures)

Pre Race
1. Get in. This is rapidly becoming be the hardest part
2. Pick a year with little snow and good weather. 2007 was great for this. If global warming is real I think we’ll see less snow, but hotter temperatures. Of course the temperature on 1 day in June is going to be more variable that the snow over an entire winter
3. Train hard. I think you know this one
4. Get the rest of your life in order. Unless you are independently wealthy without family. training is going to impact the rest of your life. I let some things at work go and assured my family I’d have more time after the race. I also made the commitment to get up at 4:30 on Tuesdays and Thursdays to run 11 miles before getting home to get my kids up from school. I also got up that early or earlier on Saturdays when I had long runs, so I wasn’t gone the whole day. Your situation will vary but it is important to realize the effect training will have on the rest of your life.
5. Don’t overemphasize total miles. I think this is not the best metric for your training. Think about what runs you want to get in (long runs; back to backs, hill work; speed, etc) and focus on that, not the totals. Last year’s winner , Hal Koerner noted he only ran about 70 miles per week as opposed to 100 previously. I only ran about 50 miles per week on average, but that was usually in 4 runs/week with a good long run every 2-3 weeks. I cross-trained the equivalent of another 20-30 miles a week
6. Don’t overrace. Koerner also noted this was different about his training for 2007. I didn’t run a single race in 2007 before WS. I would have done some if they were convenient, but for me it was better to do long runs at home rather than travel to and from a race.
7. Take care of yourself. As you ramp up your training you have to be very careful about fueling and hydrating. As an example, if I am not training hard and I run 7 miles on a Tuesday morning, my next workout might not be until Wednesday or even Thursday so I might shower and get my kids up and dressed before I eat or drank, maybe 45 minutes, knowing I have lots of time to catch up on fueling and hydration. 2 months out from WS, I might run 11.5 on Tuesday morning, then lift and do a walking workout on the treadmill after work and a rowing workout Wednesday morning. In that case, I MUST drink and eat right after I finish my run. Then during the day, I have to keep up on hydration and make sure to have a snack before going to the gym. Similarly, I can’t afford to stay up watching TV or whatever; I need to make sure to get my rest. As training picks up your margin of error decreases.
8. Keep up with little things like stretching and ankle strength.
9. Be strong. I really felt strength work helped me, particularly late in the race. The ups and (especially) downs will be very tough on your quads and it is hard for running alone to prepare you for that, especially if you don’t regularly train on tough trail There are a lot of different opinions about what the best strength work for ultrarunners is, and I’m not sure it is the same for everyone. I’m big and come from a background of lots of lifting, so for me, 2 about half hour sessions a week focusing on lunges, pull-ups and dips was perfect, but other stuff might work just as well. The last few months before WS I cut back to 20 minute sessions and focused on maintaining my strength. Some people like to cut back to once a week, but I get too sore that way.
10. Have at least one cross-training activity. It is good to be able to get a good workout on days you want to stay off your legs, and you WILL have some minor injuries that will keep you from running. Having a cross-training activity will allow you to still workout while you recover. If you haven’t doing a specific activity I think it is hard to jump in and get a really good workout. I rowed in college and have a good rowing machine so that was good for me (and helped my quads) but I don’t think the actual activity is as important as having something you can do besides running.
The Course
11. Be ready for a tough course. If you just read the ULTRA list, you get the impression this is a pretty easy course with a few tough climbs. This is not true, unless you run primarily on technical single track. The first 1/2 of the race is at altitude and this will affect your performance. There are several very difficult climbs (the start, to Robinson Flat in the new/old course, and of course the canyons). Parts of the trail are moderately technical and even the dirt road parts mostly are rocky enough you need to pay attention. I saw one race report where they said that the course just never lets up, and I think that is apt. It isn’t at super high altitude, isn’t super-technical, etc, but it is NOT easy. If you don’t believe me, ask Greg Crowther.
12. Know the course. If possible go to the training weekend or do runs on the course. I never actually did this, but I thought the course knowledge I gained the first time I ran really helped me the second time. If nothing else, go to the course description meeting a few days before the race. It helps to know, for example, that after you top out Emigrant Pass you hit some single-track, and that it is a steady uphill to the aid station at Ford’s Bar. I think the benefit is both physical and mental
13. Be a good walker. Unless you are going to finish in the top 10 or so you are going to walk a lot on the uphills. I estimate I walked 40-50% of the course and still got under 24 hours. If you are going to spend that much time walking you need to practice it. I like practicing walking on a treadmill so I can get long, sustained climbs. My two favorite workouts were an hour at 15% grade and 4.0mph and successive miles at 15%/4.0 mph, 12%/4.3mph, 9%/4.6mph, 6%/5.0mph and 3%/5.5mph. If you lived where there were long hills, you could do some good hikes. If you think you don’t need to train to walk well, read this account of a winner of Angeles Crest where he talks about hikes as part of his training
14. Be a good downhill runner. It is a net downhill course and if you can run fast on the downs you can gain a lot of time. None of it is horribly technical but there are rocks and roots and some of the steeper downs can make you nervous (think Last Chance to Deadwood Canyon). See Crowther again.

RACE DAY
15. Don’t go out too fast. The desire to get ahead of 24 hour pace is strong, but you have to be careful with the altitude early in the race. Let the race come to you.
16. Don’t obsess about the 24 hour pace, especially early on. The times they post at aid stations (and are on the website) are really rough approximations. For example, between Duncan Canyon and Last Change is 5 trail miles. Not hard trail, but not all downhill and not super easy. Following the 24 hour “pace” you have to run this in 45 minutes . It is easy to get too worried about losing or gaining 5 or 10 minutes between stations. Focus more on running well but staying within yourself. There is time to be made up late in the course if you are running well. Also, note that 24 hour pace accounts for you slowing down as the race goes on, it gets dark, etc as well as for variations in course diffculty.
17. Get in and out of aid stations. My pacer said after the race I actually took more than 24 hours to run the course, but spent negative 28 minutes in aid stations! Get what you need but don’t waste time. If you have a crew and a chair it is easy to sit an extra five minutes, but you may wish you had those 5 minutes back at the end. If you don’t believe me check out Matt Carpenter's account of his record run at Leadville:

In reviewing tapes of previous LT100s (the 1994 race with Herrera and Trason is an epic on par with any Hollywood production) I was amazed by the amount of time runners of all abilities spent in the aid stations. Bottom line, 5 minutes at an aid station means having to run 30 seconds a mile faster over the next 10 miles just to break even. Impossible!

As someone once said about WS “I had a chair to sit in, to; at the FINISH”
18. You’ll hear “the race starts at Foresthill” and in many ways it is true. If you look at the historical splits, lots of sub-24 finishers make up time from there to the river, and the course gets much easier after Green Gate. You have to get to Foresthill in good shape.
19. Use the light you have. My pacer, Tom Watson, told me coming out of Foresthill that we had 2 1/2 hours of daylight left and we should make the best use of it. As it gets dark you will slow down, so really push that last few hours.
Mental tips
20. Go for it. This may be your only shot and 24 hours isn’t very long. Don’t give up on your race mid-way because you are tired or hurting. Back off a little and
21. Have confidence. My biggest worry was that at some point I just wouldn’t be able to tough it out: I’d be on or near 24 hour pace but wouldn’t be able to push through to the finish. As it went, I remember distinctly getting to Foresthill at 6:35 or so and thinking “I’ll do whatever it takes to make it.” All those early mornings and long runs are strengthening your mentally as well as physically.

Now go and get your buckle.

Pittsburgh Indoor Sprints Rowing Race Report

2008-02-03T09:50:00.001-05:00

I led for only 200 meters, but fortunately they were the last 200.

I put down 6:50 as my estimated time 3 weeks ago, but after some short workouts at higher rates (strokes per minute) I figured I could go significantly under that, maybe even 6:40 if everything went perfectly. The 6:50 left me as second seed of 11 racers. The guy in first had put down 6:47 and won the race last year in about that time.

I got to the race just about 45 minutes prior to the race, expecting maybe a few dozen people. Instead there were several hundred, including a lot of rowers from local colleges.
I started my warmup about 30 minutes prior to race time, as we were supposed to be ready 10-15 minutes early.

10 minutes prior to race time we got to get on the race ergs. It was weird as we were facing the bleachers with lots of people just 10 feet away. The others were continuing to warm up, but I stuck to my plan and just waited for the start once I got the drag factor set. Kipp, the guy seeded first is actually smaller than me. I figured if it was close, I should be able to use my size and strength to beat him over the last 300 meters or so. The monitors were cool. In addition to the usual info about meters left and pace, it showed what place you were in, and how far you were behind the leader as well as the guys immediately ahead of and behind you.

Soon enough we started. Searching the web there seemed to be 2 basic race strategies. One is to take a few hard strokes to get started and then immediately settle into your goal pace. The other is to use your adrenaline the first 20 strokes or so to get ahead of your goal, then settle into a pace just slightly slower than your goal and try to make up any deficit in the last few hundeed meters. I figured I’d take 3 fast strokes to get going, 10 hard strokes, then take the next 10 to settle down to 1:40-1:41 per 500 meter pace.

Apparently, there is a 3rd popular strategy, which is to go all out the first 500m and try to hold on. This turns out to be as effective in rowing as in running, which is to say not very.

I was at 1:36-1:38 my first 10 strokes then settled down to 1:40 to 1:41. My rate was only 30 strokes per minutes, a bit slower than I’d planned, but I felt strong and like I was rowing within myself so I didn’t push it (in general, rowing the same pace at a lower rate is a bit less tiring). Some guy named Storm took it out incredibly hard. By the 500 meter mark I was 29 meters (about 6 seconds) behind him and in 4th overall. Holy Cow. I had promised myself I’d row my race, so I stuck with my pace and let the race come to me. By 700 meters down, I was in 3rd, still 29 meters behind this Storm guy and 9 meters (maybe 2 seconds) behind Kip, who was seeded first. Storm all of sudden starts coming back to us, no surprise. By 1000 meters I’ve almost caught him but was still 9 meters back of Kipp. At halfway my average pace is about 1:40.6 or 3:21.2 for 1000 meters

With 900 meters to go, I decide to try and make a move. I push my rate up a bit and aim for 1:39-1:40 instead of 1:400-1:41. No dice. Kipp is tough and I’m getting nowhere. Storm has exploded (how painful must his last 1000 have been?) and I’m 20 meters or so up on 3nd. I’m thinking I’ve got second wrapped up but it isn’t looking good for winning.

But I keep pushing, and by 600m to go the lead is 8m. Not much but maybe there is a chink in his armor. I had planned to start my sprint at 600 to go, but I’ve pushed so hard already, I don’t have much more. By 500 to go though, I’m hitting 1:39s consistently and the lead is 6 or 7 meters. I’m redlining here with the rate up to 32-33 and slowly moving back. At 300 I’m 3 meters down but moving through him. The spectators realized it is a hell of a race and start to really cheer. At 200, we are even, but I’ve pushed the pace down to 1:37 and he is, in retrospect, dying. With 10 strokes to go (100 meters) I have to back off a touch (to 1:38-1:39) and my last 2 strokes are 1:40 and 1:41 as my tank is empty. But Kipp has crashed. I finish in 6:39.3, the fastest I’ve rowed since college. Kipp is like 6:42, so I put some distance up on him in the last strokes, winning by maybe 10 meters.

Oh did that hurt. I just slide up and down for 30 seconds or so as the rest of the racers finish. That may be the hardest I’ve EVER pushed myself over a shortish distance. After a minute or 2 everyone else is done and we get up to make way for the next race. After walking around for a couple minutes I have to sit down just to catch my breath. Wheww.

Epilogue: All that air going in and out of my lungs gives the sensation that you’ve burned your windpipe and lungs. I coughed up a storm the next 2 hours and am still coughing up some phlegm 12 hours later.

In retrospect, this was a fine race. I stuck with my race plan even as others went out too fast. I held my pace and managed to row through everyone for the win. The fact I tired just a wee bit at the end shows how much I’d already given. I might have gone just a bit faster if I’d taken it out faster, but given this was my first (and perhaps last) race like this, I think a bit slow was better than too fast. Just ask Storm

Western States Pictures

2007-10-03T16:06:00.000-04:00

Thanks to Tom Watson, pacer extrordinaire, for these. If you click (or maybe double click on them) you'll see bigger versions.
This is the view from the start.
The first climb takes you up over the shoulder on the left of the mountain dead ahead (at least that is how I remember it).
When you arrive in Squaw Valley and see what this climb looks like, it tends to have a sphincter tightening effect.

Second is the plaque on a rock near the start.

Third is a picture of the start. It nicely captures the feeling you get: it's dark, there are 400 runners, lights and a huge sense of anticipation

Me at Robinson Flat, doing something

Some nice views of the high country, taken by Tom so presumably somewhere around Robinson Flat.

My ace crew (Isabel and Colin) waiting at Michigan Bluff (I think). Remember CREW = Cranky runner, endless waiting.

I even stopped for a picture (I hate to waste time in aid stations)

Tom, resting up before his big night. He looks innocent here, but there is a dark side to him! Seriously, he was invaluble in pushing me those last 38 miles.

Crossing the finish line. I love this picture as it sort of sums up how I felt at the end. I was just a small part of an enormous undertaking. I have this as the background on my desktop at work. I also like that dark sky

Getting my finishing medal from Tim Twietmeyer. This was his first "off" year after doing the race 25 consecutive times under 24 hours, including several wins. Incredible.

Getting my belt buckle (gingerly) with Adrianne in the foreground

One Hundred Miles, One (very long) Day

2007-07-21T09:49:00.000-04:00

It used to seem to me, That my life ran on too fast
And I had to take it slowly, Just to make the good parts last
But when you’re born to run, It’s so hard to just slow down
So don’t be surprised to see me, Back in that bright part of town
-Steve Windwood

Executive summary: 23:42:06. One Hundred Miles, One Day. A dream come true. Silver Buckle. The race of a lifetime, probably. I think sub-24 at Western States is very hard and yet attainable to runners of average talent like myself. People think the course isn’t that difficult, but it features rocky trail, altitude, lots of ups and downs and heat. It is MUCH tougher than the “easier” 100s I’ve done (Umstead, Vermont and Arkansas). Those of us from the east seem to have particular difficulty with this race.

The hairs on your arm will stand up; with the terror in each sip and in each sup;
Will you partake of that last offered cup, Or fade away, into the potter’s ground?
-Johnny Cash

Prologue: I had early success in my ultra career despite what most would consider minimal mileage (I ran sub-22 hours at Umstead, my first 100, on 100-130 mile months). That came to a crashing halt my first time at Western States in 2004. The altitude did a number on me and for a while it looked like I wouldn’t even finish. I rallied as the trail dropped and finished under 28 hours. It remains the race I’m proudest of, because of how I persevered under adversity. I wanted to come back; not so much to redeem myself but to see what I could do on a good day.

I didn’t apply for 2004 because I was relocating from Boston to Pittsburgh and knew I couldn’t spare the time for the race. I lost in the lottery for 2005 and 2006, so knew I was in for 2007 (I had conveniently qualified for both the 2006 and 2007 lotteries at Arkansas Traveler in 2005). But a new problems appeared: my knee hurt whenever I ran. I had hurt it playing basketball in college and had ACL replacement in medical school. More worrisome was that they had had to remove all the cartilage on the inner part of the joint, the cartilage that serves to cushion the impact between upper and lower leg bones. I had always been careful about mileage and for many years had not run on consecutive days. But for some reason it got a lot worse all of a sudden. By October, I was fat, out-of-shape and couldn’t run at all.

I went to a local sports medicine specialist. On the way out, a colleague mentioned that he was known for not telling runners to stop running. Sounds good, I thought. He took one look at my X-ray and said “you’ve got to stop running on that knee.” Uggh. I pouted for a couple days, but my friend Dave Fish mentioned how many people he’d run with who’d been told they’d have to stop. The doc had gone on to give me some advice on what to do if I ignored his initial advice, mostly focusing on strengthening the quads and hamstrings, which had atrophied.

I decided to give it a shot. A former collegiate oarsman, I knew rowing would strengthen the quads, so I started rowing like a madman on my Concept II. I eased back into running with a few laps on a decrepit cinder track near my house. I also restarted strength work, which I had let slip. This combination worked wonders and my knee felt better. I put in >1000 miles preceding the race in 2007, rowed another 300, and did lots of uphill walking on the treadmill and strength work. I worked up to 2 difficult walking workouts (1hour at 4 miles per hour and 15% grade and successive miles at 4.0 mph/15% grade, 4.3/12%, 4.6/9%, 5.0/6% and 5.5/3%). I also built up to 2x20 dips and 2x10 pullups as well as 2x15 lunges (each leg) holding 35 lbs dumbbells in each hand.

Despite the knee issues, I started running the day after my long runs. Several times after doing 30-35 trail miles on Saturday, I’d do 10-12 miles with a running group. Having previously trained exclusively by myself, I found it much easier to get through runs on tired legs with company. On non-long run weekends, I tried to keep up with the faster runners in the group on the uphills, which helped my speed. My weight dropped from 212 in October to the 180s in June. I’d weigh in at 187, 16 lbs. lighter than 4 years previous.

My left hamstring bothered me sometimes during speed work, so I got less of that in than I’d have liked. Amazingly, I was able to back off early and not miss a ton of training, rather than trying to train through and getting really hurt. Must be the wisdom of years. My knee felt as good as it had post-surgery and it bothered me almost not-at-all the last few months.

Given my family and job responsibilities, I knew this was the best 100 mile shape I’d ever be in.

PRERACE: After attending my in-laws 50tth anniversary in Vegas the weekend prior to the race; we arrived at our condo on Monday night. We did fun stuff around the area (Donner Party museum, rafting on the Truckee, etc.). If you are ever in Reno go to Eclipse Pizza, run by my friend Dave Fish, for the best pizza and salads I’ve ever had. Get the apple goat-cheese salad. It’s awesome.

My wife commented on how relaxed I seemed. I figured I had trained as hard as I could, given my professional and personal life, so what was there to be nervous about. My ace pacer, Tom Watson, arrived Thursday night. On Friday they told us the course would be free of snow and the highs might only be in the 80s. The stars were starting to align…

“He who races the clock has an opponent who knows no casualty”

GAMEDAY: I gave my kids a kiss before I left. My daughter, usually a heavy sleeper, woke up and said “Daddy, I like the brass buckle better, because it looks likes gold!” Hmm

The hype seemed less than 4 years ago, but that was probably more me than anything external. I walked up the big hill at the start running only a few flatter sections. By the top there were lots of people both ahead of and behind me and I was about 54m, right on 24 hour time. This year I was able to run in the high country, which was beautiful with wildflowers, and snow free. I pushed a little harder than I should of, wanting not to get behind 24 hour pace. This was a mistake, but not a fatal one. The “new/old” course was much tougher and I was really feeling the altitude on the climb to Robinson Flat. I arrived there a few minutes ahead of 24 hour pace, but knew I was working too hard. I decided to forget about sub-24 and the buckle and just run comfortably. It was a great decision. From there to Last Chance I just ran along, enjoying myself out on the trail. I was keeping up on my nutrition and hydration, taking a Succeed cap every hour and a gel every 25-30 minutes.

I ran hard on the downhill (and faceplanted) out of Last Chance and then climbed steadily up to Devil’s Thumb. 4 years ago I had started to feel better in this section and passed about 20 people on both the way down and up. This year I only passed a couple, but I did it in 1:15, which is quick. As I was heading down toward the cemetery, another runner, I think Keith Straw, caught up to me. I was still just running my race, but he was confident we’d make sub-24, going on about how this was the toughest cut-off and all we had to do was keep moving. I didn’t get too caught up in it, but I started to think I had a shot. He had to stop to get a rock out of his shoe and I didn’t see him again until the end. I fell again heading down to El Dorado but had a good climb to Michigan Bluff. I saw my family there, which was nice, but didn’t spend much time in aid stations all day. At Foresthill, I saw my friend and colleague Geoff Kurland who was the M.D. at the aid staion and Dave Fish and his girlfriend, who were working, and Tom and my family as well. Still in an out in 2 minutes.

I left about 6:35; by this point I was ~25 minutes ahead of 24 hour pace and starting to believe. I told Tom to push me as hard as necessary to get there on time. This was totally unnecessary as Tom had no mercy.. The trail from Foresthill to the River is mostly downhill (but rolling) and mostly runnable, with less rocks than average for this course. Tom suggested using the remaining daylight, which I did, running a lot of the flats here. We didn’t need our lights until Ford’s Bar. The river seemed lower than 4 years ago, but was refreshing on my legs. I had fresh socks and shoes at the far side, but didn’t want to take the time to change. We were out by 10:20, forty minutes of cushion. The stretch from here to Auburn Lakes (and really Brown’s Bar) has lots of relatively flat, smooth, runnable trail, but my quads were so trashed I mostly walked the flats, but aggressively. I would shuffle the downhills (not really running, Tom would tell me, just letting gravity do some of the work). We did okay until slowing on the nasty downhill from Brown’s Bar and the subsequent climb up to Highway 49. We got there about 2:50, having lost about half our cushion, but still 20 minutes ahead of 24 hour pace and with >2 hours to go less than 7 miles. The math was definitely in my favor.

Tom “suggested” I run some of the downhill to No Hands “just to make sure.” After the 49 crossing there is about a mile mostly uphill until you turn and head down toward No Hands Bridge. At the turn there were a couple yahoos and a lot of Christmas lights to make sure you don’t miss the turn. The guys were pretty boisterous and were yelling for us “Go get your buckle” and “Silver” which fired me up. As we headed down toward No Hands there was a runner in front of me, just barely shuffling the down hills. It was almost funny how slowly he “ran.” And I couldn’t catch him. So I just shuffled along behind him. It was perhaps the ugliest running of my life; reminiscent of 8 months earlier when I had to take walking breaks on the cinder track. But run I did, and when we hit the bridge we had 80 minutes to do 3 miles and I knew I’d make it. The climb up to Auburn didn’t seem so bad and I liked the searchlights they had set up at the high school. I felt a lot better as we got closer and closer to the high school and gave Tom my pack and light before we hit the track. I have to say enjoyed running around the track knowing I’d made it and made my goal of sub-24. I’d dreamed of running around that track in the dark for 10 years and now I was finally doing it.

AFTERMATH: Boy was I tired! This was by far the hardest 24 hours of my life. I’d never run so much on tired quads or pushed so hard all day. My friend Damon Lease says that when he ran a sub-3 hour marathon he cared about his time every step of the way. I’m not sure my intensity was that high, but it was close.

But it was cold at the finish and I was worried about getting chilled. I had planned to get a massage but hadn’t really left any clothes or anything at the finish. Tom’s car was parked up above the grandstand so I had to hobble up that. A women watching commented “One last hill” as I staggered up. I laughed and said “they told me that 3 miles ago!”

We stood at the top watching the last sub-24 finishers come in. I was glad to see Keith Straw, who had gotten me fired up back at Last Chance make it in under the wire. I broke down a little as I thought of all the work I’d done, and how I’d dreamed of this. I was also a little bit down as I hadn’t really thought I ran that well. I went out too fast and didn’t finish strong. I made some mental errors like forgetting to get gels at some aid stations and not realizing I had Succeed caps and naproxen with me the last 30 miles. It seemed like a hundred people passed me in the last 20 miles.. I knew there’d be a lot of silver buckles given out with the conditions as they were, so I hadn’t worried at all about that during the race, but wished I’d run a little stronger at the end.

Tom and I drove to our hotel, which was 20 minutes away. It was a big hotel and we were the room farthest away from the entrance. My wife commented the hall must look like another 100 miles to me. I had a few blisters but I’ve had worse. But when I got in the shower, I started hyperventilating and getting dizzy so I had to sit down in the tub, no easy feat. By the time I finished the free breakfast at our hotel had started, so Tom and I went down. I ate about 4000 calories.

We slept a few hours (note to self and others: when feet are blistered post race, pulling the sheets and blankets all the way out from under the mattress makes it much more comfortable). The awards ceremony was mercifully short. Any disappointment I had felt about my race was gone by the time I hobbled up to get my buckle. It really was a dream come true. All those runners who passed me look fit! I apologized to my daughter for getting the silver one, but she replied “now you have one of each!” We ate at In and Out Burger (another 4000 calories) and headed back to the hotel for more sleep.

I took the red-eye home on Monday night and could feel my legs swelling the whole way. By midway on the flight the skin over my feet and ankles was stretched tight and I was getting a bit worried. Once I got home (and fought rush hour traffic) and put my feet up for a few hours, they got a lot better. The hyper-soreness in my quads passed in two days, although even two week later I feel the healing microtears whenever I get into or out of a chair. I strained the tendon on the front of my right calf and that took 10 days to head. I’ve done a few easy runs the last week and my cardiovascular system feels great, but my legs feel dead.

Huge thanks to Adrianne, my wife, and my kids Colin and Isabel for putting up with all the training time; to my Sunday morning running buddies for helping me make it through the back-to-backs and making me faster, especially Todd Green for inviting me and Alex Sax for organizing. The volunteers and organizers of this race are awesome. Early on I was frustrated and upon arriving at an aid station with my bottles still 1/2 full told the volunteers I didn’t need any more fluid. As I was grabbing a gel, a volunteer came up and nicely told me it was 6 miles to the next aid station and I should reconsider. I did and he nicely filled up my bottles, which were dry by the time I got to the next one. Things like that set this race apart. Above all thanks to my pacer Tom Watson. He pushed me hard, which is exactly what I needed, although I may not have appreciated it so much at the time. Maybe I make sub-24 without him, but I’m not sure; in any case it would have been a lot closer.

4 weeks later, I’m still basking in the glow of my finish. I still can’t quite believe I did it. I feel like I’ve been outed as an ultrarunner, though. Most people can’t really comprehend ultrarunning, so I don’t talk about it much. But thanks to friends and an article in the Pittsburgh paper, people I barely know are congratulating me and asking me all sorts of questions. My 15 minutes of fame I guess.

My legs are still healing but I’m doing some good runs. I’m trying to take it easy and heal it up and just enjoy my accomplishment. With some perspective, I realize the silver buckle and sub-24 aren’t really of much importance. But to pick a goal like this and work my butt off to achieve it; to come back from injury, those are things to be proud of. After the race, I told Tom I wouldn’t try WS again for at least 10 years, but now I’m not sure. It is a spectacular race with incredible support. I’m already asking my wife if I can apply next year….

Stop Smoking!

2006-07-14T17:42:00.000-04:00

If this doesn't curb your cigarette habit, nothing will.

all those bumps are individual metastases of this long-time smokers lung cancer.

Lovely

physicians and unions

2006-07-14T16:50:00.000-04:00

Why I'll never join a doctor's union:

The death of a patient in Goettingen, central Germany, is being blamed on weeks of strikes by doctors demanding better pay and conditions. The physicians involved assert that the patient's care was not compromised but a manslaughter inquiry is underway....

Doctors at the University Hospital in Goettingen, central Germany, were in their 13th week of strikes when the 57-year-old patient, named only as Elke S for legal reasons, suffered a fatal heart attack. She had been scheduled to have an intracardiac catheter fitted on June 2, but the operation was put back a week because of the protests, even though poor results were recorded when an electrocardiogram was carried out. The patient died 2 days later on June 4 after her condition worsened at home.

From the latest Lancet, probably no free text. I think by choosing to be a physician you have to put care of patients above your personal interests.

Intelligent design

2006-05-31T15:51:00.000-04:00

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?

2006-05-24T13:44:00.000-04:00

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

2006-05-24T13:25:00.000-04:00

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

2006-05-21T16:55:00.000-04:00

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

2006-05-21T16:49:00.000-04:00

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

2006-05-21T16:42:00.000-04:00

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

2006-05-18T08:39:00.000-04:00

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

2006-05-15T11:14:00.000-04:00

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

2006-05-14T14:07:00.000-04:00

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

2006-05-14T13:15:00.000-04:00

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

2006-05-06T19:34:00.000-04:00

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

2006-05-05T08:15:00.000-04:00

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

2006-05-04T13:19:00.000-04:00

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!

2006-05-04T09:01:00.000-04:00

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)

TGN1412

2006-04-20T16:03:00.000-04:00

It was apparently the medicine itself, not a contaminant that caused the horrific reactions to TGN1412:

A preliminary investigation of a UK trial in which six healthy volunteers became critically ill said this was probably due to effects of the drug in humans not predicted by animal studies. But the report stopped short of questioning how the study was carried out.

The investigation into the phase I trial of the monoclonal antibody TGN1412, carried out by the Medicines and Healthcare Products Regulatory Agency (MHRA), the body that approves clinical trials in England, said the trial was run according to the agreed protocol, using the correct dose. It also found no evidence of a manufacturing problem or contamination of the product given to the trial volunteers.

One problem with animal testing for monoclonal antibodies against human proteins is that they are likely to be much more potent in humans than animals since they are specifically engineered for high affinity for a human protein and may have little or no binding to the homologous animal protein. This is unlike more classic small molecules which are likely to have similar potencies in animals and humans.

Living longer

2006-04-20T15:34:00.000-04:00

Death rates in the United Stares are plummeting, according to the National Center for Health Statistics; and the discrepancy between the races is closing. Looking at the figure, I'd estimate an 8-10% reduction in age-adjusted death rates since 2000. I blame George Bush.

Seriously, I'm glad I didn't write an article like this one, suggesting that mortality rates were likely to increase due to the increase in obesity.

UPDATE: missed link fixed, thanks to Flea

Medical professionals and the death penalty

2006-04-16T14:17:00.000-04:00

Atul Gawande has a very thoughtful piece about the involvement of doctors and nurses in carrying out death sentences. I can't really do it justice here, but it is well written and describes pretty graphically how the process can go wrong:

Gas chambers proved no better: asphyxiation from cyanide gas,which prevents cells from using oxygen by inactivating cytochrome oxidase, took even longer than death by hanging, and the public revolted at the vision of suffocating prisoners fighting for air and then seizing as the hypoxia worsened. In Arizona, in 1992, for example, the asphyxiation of triple murderer Donald Harding took 11 minutes, and the sight was so horrifying that reporters began crying, the attorney general vomited, and the prison warden announced he would resign if forced to conduct another such execution.

And the full text is free, so read it all. Most fascinating are his interviews with 4 doctors and a nurse who have participated in executions. Most are furtive, unwilling to be identified, but the final doc is not what you'd expect:

Dr. D is a 45-year-old emergency physician. He is also a volunteer medical director for a shelter for abused children. He works to reduce homelessness. He opposes the death penalty because he regards it as inhumane, immoral, and pointless. And he has participated in six executions so far.

Dr D, who is actually Dr. Carlo Musso, argues that a death sentence is like state-imposed terminal cancer. The doctor needs to keep the patient from suffering unnecessarily, whateve the cause of death.

As Gawande notes, there are problems with this position, not least of which is that doctors involved in executions remain anonymous in a way oncologists and pain specialists don't. But Gawande's view, that execution should be legal, but medical professionals not involved, and if that makes it humane, then it should be unconstitutional and illegal is more than a little convoluted. Gawande also makes much of the American Medical Association's code of ethics which prohibits almost all participation by physicians in executions. But the AMA is, in my view, nothing more than a lobbying organization for physicians. I don't belong to it and don't feel in any way bound by it's views. For example, the AMA code of ethics contains the following pearl:

Ethical medical practice thrives best under free market conditions when prospective patients have adequate information and opportunity to choose freely between and among competing physicians and alternate systems of medical care.

which would shock many of my colleagues who advocate for a single-payer system. And while I disagree with them, I wouldn't accuse them of being "unethical" for advocating for their beliefs, whatever the AMA code of ethics say. More powerfully, of course, right and wrong are not determined by majority vote, as I've discussed before and Gawande also notes.

My own feelings are, alas, muddled. I weakly support the death penalty as the only fitting punishment for some crimes. But I also wonder if all the negative aspects of executions (and let's be honest, that is what they are; "capital punishment" is just a euphamism), are worth it. Personally, I don't have problems with medical professionals participating in executions, if society has determined that they should occur.

My first thought is that I would participate in an execution, but if I actually faced that possibility I'd have to consider the issues more deeply. It seems a bit inconsistent to be pro-execution, but not want to be involved yourself.

Life is good

2006-04-15T19:27:00.000-04:00

I am sitting on my patio, enjoying a glass of Pinot Noir and the great view. The weather is nearly perfect (I could use a long-sleeve T-shirt instead of my short-sleeve one along with shorts, but a fleece would be too cold) and the mosquitos haven't arrived yet (for the year), and blogging via wireless.

I live in an urban area with fairly large single family homes situated on a hill side and I am picking up 3 separate wireless connections (of course I'm using my own, which is password protected).

I mananged to take my kids to Buildabear for their Easter treat, get a lot of work done in the garden, do our laundry for the week as well as a load of dishes and work-out, which isn't too bad for one day. Our taxes are done and I'm getting a pretty big refund which is poor planning, but better than having to write a big check. Adrianne is cooking pork-chops for dinner. I may be old, slow and broken-down, but I'm enjoying these few minutes!

I'm also trying to send good vibes to my friend Ollie, who must be about halfway throught the McNaughton 100 mile race right about now

Happy Easter, Passover, or just a happy spring (I guess it is fall "down under") weekend to all Dr. Andy readers.

UPDATE:

Cool HIV fact

2006-04-14T14:44:00.000-04:00

that I learned from the item immediately preceeding this one.

How fast does HIV mutate?

The global sequence diversity of influenza, another variable RNA virus, during a pandemic is lower than the diversity of viruses observed within a single HIV-infected individual

So there is more variability between the HIV viruses in a single infected person than among all the different influenza viruses circulating all over the world. That's fast.

Quote from this review of HIV; original article here.

Experiment of nature

2006-04-14T14:24:00.000-04:00

Some experiments you just have to be in the right place at the right time. Such is the case in this study in which 2 identical twins got infected with the same strain of HIV at the same time by sharing needles. They routinely shared needles with each other, but shared only once with someone else and both contracted HIV from that incident.

Because the twin brothers share the same immune system genes, including the MHC genes which are responsible for presenting peptides from infectious agents to the all-important T-cells, they should have very similar initial responses to infection.

It is known that HIV mutates rapidly, allowing it to stay one step ahead of the immune response (from commentary accompanying article):

Recent longitudinal studies of early HIV infection have shown that strain-specific neutralizing antibodies are elicited in response to the virus. When these antibodies reach a critical threshold (a matter of weeks), a resistant virus emerges. Eventually, a neutralizing antibody response to this virus develops and a new resistant virus emerges. Apparently, the virus always stays one step ahead of the evolving neutralizing antibody response.

The twin brothers, who were followed for 3 years, until one died of an overdose, had remarkably similar immune responses to the virus. And the pattern of viral mutations was similar as well, suggesting that the interacton of virus and immune system over time may be more predictable that previously thought. This might aid development of an effective vaccine.

Incredibily, a similar pair of twins were the subject of a report in the Journal of Virology published in December. This pair were infected by a single blood donor while babies. They followed a remarkably similar clinical course, developing symptoms of HIV infection at age 7, progressing to severe disease at 17 and then improving with initiation of HAART (highly active anti-retroviral therapy). By that point however, their immune responses to the virus had diverged signficantly. The cytotoxic T cells response had more differences than commonalities.

Since both sets of twins were infected by the same virus at the same time this suggests that the initial interaction of virus and immune system is predictable (as the first set of twins had very similar responses) but diverge over time, probably just by chance. This suggests any effort to target immunity based on knowledge of viral and host immune factors needs to happend soon after infection.

Moderate drinking

2006-04-14T13:58:00.000-04:00

may not actually be good for you.

It has generally been accepted that moderate drinking was good for you, based on the fact that epidemiological studies demonstrated decreased death rates for those who drank some alcohol compared to those who abstained. The benefit is seen largely in decreased rates of cardiovascular disease; this finding has biologic plausability as alcohol consumption raises levels of HDL, the so-called good cholesterol.

The exact definitions of moderate drinking and the minimum amount of alcohol needed to gain this protection haven't been 100% clear. 2-3 drinks/day would be the upper limit of "moderate" and some studies have suggested even a drink or two per week confers the observed benefit, although this is controversial.

A new meta-analysis of these studies suggests most have a serious flaw: they incorrectly group those who have quit drinking alcohol in with those who never partook. Because people quite for reasons including illness, aging and the need to take medicines which interact with alcohol, this may lead to bias. Specifically, buy grouping sick or old patients into the group of abstainers it may incorrectly show a benefit to alcohol consumption.

I don't have access to the new article, which was published in the journal Addiction Research and Treatment, so what I now is from this BMJ new item, which isn't free full text:

The researchers, from the University of California at San Francisco and the University of British Columbia, said that most of the 54 prospective studies were flawed as they included as abstainers people who had reduced or stopped drinking, which people often do because of ageing or ill health. Abstainers thus seemed to be less healthy than light drinkers and had a higher risk of death.

After considering 57 variables the researchers found just seven of the studies to be free of error and to include long term abstainers. Analysis of these studies showed no reduction in mortality among moderate drinkers in comparison with abstainers. Only studies containing the "abstainer error" showed protection against death with moderate drinking

So I guess my wine consumption may not be good for my health after-all and the reticence of doctors to encourage alcohol consumption by their patients may have been well-advised. At least the methodologically sound studies didn't show any harm from moderate drinking.

Support free speech

2006-04-14T12:22:00.000-04:00

and don't buy from Borders

When I got up to the counter the dreadlocked hippie asked, "If I found everything I was looking for?" I explained that I had not and asked where I could find a copy of the magazine “Free Inquiry”. He was confused I explained why it wasn’t there his manager started hovering behind him he explained that I must be mistaken I assured him I was not. Then I said, “I won’t be purchasing these books today because your company has decided not support free speech.”

Hat tip Ace of Spades. Note I don't necessarily agree with other views expressed in the linked vignette.

Bingo odds

2006-04-09T11:34:00.000-04:00

My kid's school PTA had a bingo event to raise money Friday night. I volunteered to call numbers. In my first game, I went 16 numbers without getting an I (for bingo novices, there are 75 letters, divided into 5 letter groups; 1-15 ar B, 16-30 are I, etc.) So I wondered what the odds of that are.

Mathematically inclined readers may want to pause here to work this out for themselves, if they haven't already figured it out.

You might think the odds would be (60/75)^n where n is the number of balls drawn. This would be correct if balls were replaced during the game, but once a ball is drawn it is out for the remainder of the game.

So the odds are (60/75)(59/74)...depending on how many numbers are drawn.

This can be expressed using the factorial function where 5!=5x4x3x2x1 as

odds = (60!/(60-n)!)/(75!/(75-n)!). Plugging in 16 (or setting up a spreadsheet so you can see how the odds change with varying n) I get about a 1.75% chance, which is unusual but not exactly shocking; even at 20 draws you have a >0.5% or 1 in 200 chance of this happening (and this doesn't take into account that there are 5 groupings of numbers)

I also calculated the odds while replacing balls and at lower numbers it doesn't change the odds as much as I'd have guessed: 2.8% and 1.15% at 16 and 20 draws, respectively.

More info on this kind of problem here. Nerdy readers may wish to work out the problem of what the odds of completely filling there bingo cards (24 spaces+free space) for a given number of draws.

One funny note. My second game calling "four corners" I mistakenly called out the I, N, G numbers not realizing those were of no use. I was quickly reprimanded by a grandmother looking type who obviously had a lot more bingo experience than I.

UPDATE: fixed formulas (removing errant 1- at start) per Ollies comments. Note to self: you know math professor is regular reader; proofread future math posts closely

Updates

2006-04-09T10:21:00.000-04:00

I've updated my blogroll with a few more medical blogs as well as the blogs of some friends. I try to stay out of politics but both Blueollie and Freerangeathlete are primarily political but from very different perspectives, with a bit of running (or in Ollie's case walking) thrown in. Tom and Ollie are ultrarunning friends. Check out Jason's Photography Space for amazing ~~pictures~~ photographs. Jason is also an MD, a former colleague, but focuses on other interests in his blogging. Funny how that works.

I find it interesting that my relatively small blogroll now contains 2 female general surgeons, a female urologist and a male pediatrician. Given the respective dominance of males in surgery and females in peds, this is surprising. I'll speculate that bloggers are less conventional types, more willing to go against convention.

I don't mean to keep my blogroll "exclusive" but am always finding something else to do rather than update it. So if you feel "left out" just email me and I'll put you on with my next update (which could be a while)

Absolute versus relative poverty

2006-04-08T08:21:00.000-04:00

You often hear how well off the poor are in the US:

Overall, the typical American defined as poor by the government has a car, air conditioning, a refrigerator, a stove, a clothes washer and dryer, and a microwave. He has two color televisions, cable or satellite TV reception, a VCR or DVD player, and a stereo.

Yet this absolute affluence (in the face of relative poverty) doesn't seem to translate into health and well-being. According to a recent commentary in JAMA (no free full text) by Michael Marmot:

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.

The article goes on to demonstrate that simple explanations such as poor diet or sedentary life style don't explain the entire discrepency and that a health effect of status (as opposed to income) exists in every society studied and at every level of status. For example

In egalitarian Sweden, Erikson showed that individuals with a PhD have lower mortality than those with a master’s degree, who have lower mortality than those with a bachelor’s degree, and so on down the educational hierarchy. “Greater poverty,” or material deprivation, is not a helpful answer to the question of why someone with a master’s degree should have higher mortality than someone with a PhD.

While omnipresent, the status effect is more pronounced in some societies (e.g. the United States) than others (Sweden). Marmot proposes some reasons (stress, social participation) but there doesn't seem to be much data backing those up.

Here's a research idea for an enterprising epidemiologist. There seems to be a trend toward US citizens retiring in Mexico, where the cost-of-living is lower. My hypothesis is that the higher social status middle income US retirees in Mexico enjoy should lead to better health and longer lives compared to similar retirees who remain in the US despite similar or decreaseds access to quality medical care in Mexico. Call it status arbitrage.

The Shangri-la diet

2006-04-07T14:21:00.000-04:00

I blogged about this when it was featured in the Freakonomics section of the NYTimes magazine (that column can be found here). Now, Seth Roberts, a professor of psychology, has a book coming out about his unusual diet.

Briefly, Roberts used himself as a lab rat and tried a variety of diets to try and lose weight. He hypothesized that the body has a "setpoint" which is the weight it thinks it should way. If you weigh more than your setpoint, you will not feel hungry or want to eat much. If you weigh less, you'll obsess about food and tend to eat more. This concept has considerable empirical support and explains why while many dieters succesfully lose weight, so few can keep it off: will power or an unusual diet works for a while but it is very difficult to keep it up.

Based on his experience drinking unusual sugared sodas while on vacation, Roberts hypothesized that regular intake of a small numbers of calories with no flavor (or, it turns out, just sweetness) would reset the setpoint allowing him to lose weight. Depending on whether you believe the NYTimes article or the book he lost somewhere between 30 and 40 pounds over a period of 3 months, by taking in a few hundred calories as either extralight (and therefore almost flavorless) olive oil or water sweetened with fructose. Otherwise he ate what he wished, but he found he didn't have much an appetite.

He believes that other light oils like canola or table sugar (sucrose) in water work just as well. He cut down the number of calories taken in this way once he got thin enough and has managed to keep the weight off.

The extent of the empirical evidence is his weight loss and that some friends have also lost weight this way. No animal trials, no human trials, nothing. He does quote a few commentors on blogs who had initial succes with the diet after the Freakanomics feature. I'd have a lot more faith that this would work if there were more data. He quotes a bunch of animal research that has some relevance to his theory but no direct tests of this diet. (The Penguin site does note that "fformal clinical trials will soon be under way" whatever that means; the skeptic in me wonders if the trials aren't working so they are getting the book out before it becomes clear this method doesn't work for most people).

The theory underlying the diet, which seems to be that taking in bland calories signals scarcity while taking in lots of familiar, highly flavored foods signals abundance doesn't seem very intuitive to me; lab mice and rats along with many other animals stay thin on chow. In fact, in his extra credit chapter which gives other tips for losing weight is sometimes self-contradictory, simultaneously advocating eating a variety of unusually flavored foods and eating bland food like cottage cheese. He does rail against fast food as too many calories that taste the same everytime.

Besides the anecdotal nature of his success, the book feels as though it was thrown together in a hurry to capitalize on the media exposure he was getting (I think he also appeared on Good Morning America or elsewhere). It is 176 pages, but the information could have fit in half that number. Like the proverbial term paper, they seem to have used every trick to make it longer: small pages, big margins, etc.

Finally, Roberts seems to have an unusual relationship to food and eating. One of the benefits he sees in the diet is the time he saves. He currently eats only one small meal a day, and doesn't seem to miss the rest. I can remember a number of great meals I've eaten, but if Roberts has similar memories, he doesn't share them in the book.

I love food and I love eating. I'm pretty sure I'd abandon any diet where I only had appetite for one small meal a day, and I'd miss the pleasure of eating tasty food if I was so limited. I don't sense Roberts has even considered that. I suspect that even if people lose weight on this diet, they'll gain it back as they either grow tired of plain oil and sugar water or miss the experience of eating.

That said, it seems to work. I'm never shy about trying a preposterous new diet and I could always lose a few lbs. so I've given this one a shot for the last week. I haven't been regularly checking my weight, but the decreased appetitie is noticeable. I fill up on much less food than typically, although still much more than Roberts eats. I should note than I'm big, exercise a lot and usually eat quite a bit. Now I'd say that a reasonable portion is enough for me, but I still eat three good meals a day.

The drinking sugar water or oil isn't too bad, although to avoid establishing taste-calorie connections in your brain you have to not take in anything flavored (food, drink, even brushing your teeth seems to count) for an hour before or after, which means you have to plan a bit.

Of course, every diet works at the start. I'll keep Dr. Andy readers updated about how I'm able to keep this up overtime. You may remember I succesfully lost 15lbs by fasting one day a week. That diet works well but requires an enormous amount of willpower, going to be at night, having had no calories for 24 hours with a full refrigerator downstairs. If I ever decide to get really thin for a race, I may try combining the diets and fast a day a week except for some plain oil or sugar water.

FULL DISCLOSURE: The book is not out yet. Some publicist from Penguin emailed me to ask if I wanted a copy to review and I said yes. So I did get the book free, but I have no other financial interest. I suspect Dr. Roberts will soon be a wealthy man, whether or not his experience turns out to be generally applicable.

UPDATE: follow my weight loss here.

TGN1412 update

2006-04-06T18:40:00.000-04:00

One of the two men left critically ill by a phase I trial of a new monoclonal antibody almost two weeks ago is improving, says the latest statement released by the hospital caring for him.

Which sounds like good news. Still no word on what exactly what went so horribly wrong

The power of prayer

2006-03-31T08:29:00.000-05:00

Does praying for a sick person's recovery do any good? In the largest scientific test of its kind, heart surgery patients showed no benefit when strangers prayed for their recovery.

And patients who knew they were being prayed for had a slightly higher rate of complications. The researchers could only guess why.

Several scientists questioned the concept of the study. Science "is not designed to study the supernatural," said Dr. Harold G. Koenig, director of the Center for Spirituality, Theology and Health at the Duke University Medical Center.

Honestly, my first reaction to this is what a waste of $2.4 million (and parenthetically, how expensive has biomedical research become? They randomized 1800 patients to be prayed for or not and it cost 2.4 million? I wonder how much they paid the prayers?). Abstract of original article is here(no free full text).

Hopefully, further research funding can concentrate on interventions likely to actually, you know, benefit patients. I don't mean to disparage prayer and religion (especially given that I attend church regularly), but I agree with this editorial that describes prayer as

widely practiced . . . with no plausible mechanism

at least biologically. I don't think you are going to learn much about divine intervention doing clinical research

Doctors telling all

2006-03-30T16:48:00.000-05:00

Should physicians reveal how they are paid? A new study suggests disclosing this information increases trust:

Disclosing how physicians are compensated may increase patient loyalty, and does not appear to undermine patients' trust in their doctors, a new study shows.

"This study suggests that regulators, policy makers, and physician groups themselves should renew their consideration of disclosure as an instrument to advance the best interests of patients and physicians," Dr. Steven D. Pearson of Harvard Medical School in Boston and colleagues conclude.

Sounds good, and I agree that patients should have access to the information.

An important caveat is that all the doctors in the study were paid by a combination of salary and bonus with the bonus based on a rather nebulous formula, so these doctors weren't conflicted in giving impartial advice. Patients who learned their surgeon derived 80% of income from operating might be less trusting of his or her advice to undergo an operation; of course, in the global scheme that is probably a good thing.

Project retrains prostitutes as caretakers

2006-03-30T16:35:00.000-05:00

A new project in Germany is retraining prostitutes to become care workers for elderly people.

The state of North Rhine-Westphalia is using {euro}1m (£0.7m; $1.2m) of local and European Union money to try to get sex trade workers off the street and into care homes

Seems like a good idea; I wonder if they could get Viagra to sponsor it. This quote from Rita Kuehn, one of the people behind the scheme is even better.

She believes that prostitutes make excellent carers as they have "good people skills, aren't easily disgusted, and have zero fear of physical contact."

"These characteristics can set former prostitutes apart from trainee nurses," she said

She added, "However, nursing home bosses will have to be discreet so that elderly men don't try to get more than they are paying for."

Three good days in NYC

2006-03-28T18:21:00.000-05:00

I'm back from a brief mini-vacation in NYC.

Here are some of the highlights

1. Visitng Liberty and Ellis islands. I was completely against this, figuring it would be too crowded and touristy. It was, we waited more than an hour for a ferry. And the Statue of Liberty was cool, but not that cool. Ellis island, however, was awesome. It's been converted to an immigration musuem which was fabulous. It is hard to imagine giving up everything where you are to come to a new country sight unseen. And kids and wives often followed with just a train ticket pinned to their coats to direct them where they were going.

My favorite was asking my kids the questions the examiners asked the immigrants. I asked my son if he was a polygamist. He didn't know what that meant, so I asked if he wanted to have more than 1 wife. "Not at this time" he replied.

2. The NY Public Library. Beautiful building, free and the map collection room is great. For a time it was believed California was an island, disconnected from the rest of North America. The main reading room is also wonderful

3. Ice skating at Rockefeller center. A Mastercard moment: you can't believe the price, but my daughter's smile was priceless

4. The Lion King. Tremendous, especially the costumes and sets. I thought it would be smarmy Disney, but it was wonderful. Yesterday, I mentioned that I'd seen it to one of my pateint's parents who is a theatre professional and she said she'd cried during the show because it was so wonderful. Appropriate for almost anyone (Isabel, who is 5 sat throught it, mesmerized)

5. The Intrepid. A converted aircraft carrier with lots of planes, helicopters, etc. including a Concorde. My son loved it and it had lots I was interested in as well+

6. American Museum of Natural History. This was okay but overrun by schoolkids and the "space show" was not much better than what you can see for free elsewhere (like the Carnegie Science Center in Pittsburgh).

7. Books on tape. We drove the 6+ hours both way and listened to Harry Potter and the Order of the Phoenix. It makes the time fly, yet doesn't really distract you from driving

Another reason

2006-03-21T16:19:00.000-05:00

not to marry your cousin, especially if you are already a member of an inbred population:

In a sky blue bedroom they share but rarely leave, a young sister and brother lie in twin beds that swallow up their small motionless bodies, victims of a genetic disease so rare it does not even have a name.

Grand Rounds 2:26

2006-03-21T11:10:00.000-05:00

is here

No symptoms, no asthma

2006-03-20T06:57:00.000-05:00

It is widely recognized (at least by physicians and scientists) that asthma is a chronic disease. In a simplified view, ongoing inflammation in the lung underlies contraction of smooth muscle which causes symtpoms. Blocking or treating the underlying inflammation, by means such as allergen avoidance and use of inhaled steroids, helps prevent exacerbations triggered by things like exercise, viral infections and exposure to allergens (think cat).

Patients, however, may not share this view, believing instead that they only have asthma when they are having symptoms. Thus one of the hardest things asthma doctors face is convincing patients (or thier parents) that they need medicine everyday when they only have symptoms intermittently. Even when we think we've explained ourselves, patients often returns saying they stopped the medicine because they were all better.

Halm et al. have now shown just how prevalent that belief can be; more than 1/2 of patients HOSPITALIZED with asthma at Mt. Sinai in New York City believe that they only have asthma when they have symptoms. This even though 1/4 of the sample has been intubated for an asthma exacerbation in the past.

This helps explain why many patients are resistant to use of daily controller medications to prevent asthma flares.

They authors identify the question "Do you think you have asthma all of the time, or only when you are having symptoms?" as an effective means of identifying patients who need further education.

My only criticism of the study is that it doesn't tell us much about the level of persistent symptoms the patients have. If you have symptoms most or all days, which many of these patients presumably do, the idea that you only have asthma when you have symptoms may not be relevant. The authors do show that among patients with daily symptoms, the "no symptoms, no asthma" belief is less common.

2 more deaths with mifepristone

2006-03-17T14:53:00.000-05:00

The FDA has issued an alert to medical providers that an additional two deaths coinciding with use of mifepristone to induce abortion. Previously, 4 women died of overwhelming infection with an unusual bacteria Clostridium sordellii but it isn't clear yet what the cause of death in the additional cases was.

Not good

2006-03-17T09:03:00.000-05:00

Not good at all

Four men left seriously ill after taking part in a drug trial have regained consciousness, say doctors.

Another two are in a critical condition and under sedation but have shown early signs of responding to treatment, said Dr Ganesh Suntharalingam.

The men suffered multiple organ failure within hours of taking the TGN1412 drug at a research unit based at Northwick Park Hospital in north-west London.

TGN1412 is an antibody that blocks a key molecule on the surface of T-cells called CD-28, thereby causing changes in the immune system which can apparently be either pro or anti-inflammatory (as evidenced by it being studied for both cancer and rheumatoid arthritis).

Usual protocol for new drugs is to administer them to healthy volunteers after extensive animal testing, which was apparently done in this case and showed no evidence of toxicity. Why the medicine caused such a violent reaction when given to humans is unclear, but it sounds like it was horrible.

I would not discount the possibility that the medication given was somehow adulterated. If not, it is probably just an example of very bad luck.

That said, why 6 people were given the medicine simultaneously is not clear. It would seem safer to give it to one at a time, so at least 5 of the 6 might have been spared. Additionally, the practice of testing new drugs first on healthy volunteers seems odd; wouldn't it make more sense to test it on someone suffering from one of the diseases for which the med is being studied? I know that might confuse the outcome as for some adverse outcomes it might be unclear whether it was the medicine or the underlying condition that was causitive. That said, at least the participants would have an incentive beyond money.

Ethics of conscientious objection

2006-03-15T16:03:00.000-05:00

In the February 4th British Medical Journal, one Julian Savulescu, director of the Oxford Uehiro Centre for Practical Ethics argues that there is little if any room for autonomy by physicians in deciding not to provide certian kinds of care

A doctors' conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources, which requires a reasonable conception of the patient's good and the patient's informed desires. If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors. Doctors should not offer partial medical services or partially discharge their obligations to care for their patients.

Certainly once can't accuse Savulescu of pulling punches.

I see a number of problems with this sort of reasoning, not least that the pool of potential physicians might be signficantly limitied if every medical school applicant had to be prepared to offer any medical service that was currently legal or might be legal in the future. I don't think breast augmentation should be illegal, but I don't see any problem with not doing them myself.

Now, in a letter responding to the original article, Vaughan Smith, powerfully points out the flaws in Sauvescu's "public servants must act in the public interest, not their own" line of reasoning:

Since visiting Auschwitz, I have grappled with the question of how I would have behaved as a doctor in Nazi Germany or Stalinist Russia. I hope I would have had the moral courage to refuse to participate in the various perversions of medicine that these regimes demanded—for example, respectively, eugenic "research" and psychiatric "treatment" of dissidents.

I hope, but not being a very courageous person, I'm not at all sure. My chances of behaving honourably would have been greatest if I had felt part of an independent medical profession with allegiance to something higher and more enduring than the regime of the day.

which puts it more eloquently than I ever could. And points our the obvious problem that what is "legal" can vary immensely from time to time and society to society. One can of course object that conscientious objection by physicians hasn't been very effective, but that is an entirely different issue. I suspect that Savulescu wouldn't be impressed with US physicians who participated in mistreatment and torture of prisoners at Abu Ghraib and Guantanomo because it was "legal."

Note that I'm pro-choice, although not necessarily pro-abortion. I don't currently face the issue commonly, but would refer any pregnant patient who desired an elective abortion to a qualified provider. So it's Savulescu's reasoning I object too.

Grand Rounds 2:25

2006-03-14T12:50:00.000-05:00

is here at Geeknurse. What a great name for a blog

Two girls named Sam

2006-03-12T19:46:00.000-05:00

This week's grand rounds at Geek Nurse will feature a "glass half-full/glass half-empty" theme. I don't generally try to post to conform to specific criteria, but I've been mulling over this post for some time.

The first Sam came to me while I was still in Boston. She had egg allergy. On her first bite of scrambled eggs at age 2 she had gotten classic symptoms of anaphylaxis: hives, swelling and shortness of breath. Her pediatrician had gotten the labs to prove that it was egg, prescribed an Epi-pen and told her parents to have her see an allergist. Her parents brought her all the way from New Hampshire. She was precocious, although I soon learned that some of that was that she was extremely small for her age, well under the 3rd percentile for both height and weight. Otherwise everything was straightforward.

I asked about her size, but the parents assured me neither they or her pediatrician were worried. As a specialist, you always face the question of how much to just focus on your area (her egg allergy) and how much to worry about other problems. With Sam apparently healthy and thriving, albeit small, and both parents and pediatrician seemingly on the ball and unconcerned, I figured there wasn't much to add.

I saw her several more times, before the parents told me they were moving back to Tennesee, where they were from. Two weeks after they moved I got a tearful call from the mother. Sam had been diagnosed with cystic fibrosis. Their new pediatrician was worried about her size and checked a sweat test, standard protocol for failure-to-thrive. Ouch. Massachusetts screens newborns for CF, so most kids I saw had already been screened; of course Sam wasn't from Massachusetts.

I still think about Sam frequently, still kick myself for not picking up her CF. From then on, I vowed I would do what I thought best for my patients, even if it meant stepping on a pediatrican's toes. Luckily, Sam saw a better doctor than me before any serious damage occurred.

The second Sam is the worst asthmatic I follow here in Pittsburgh. I first met her when she was 18 months and intubated in the ICU secondary to a horrible asthma exacerbation. She had coded in a small ER in a small town way north of Pittsburgh and been life-flighted in. They lived on a farm, far from good medical care.

She was lucky, the outside ED doc had intubated her quickly, she had avoided prolonged hypoxia and fully recovered. I saw her and started her on an aggressive regimen to control her asthma, but it didn't help much. She had two more hospitalizations that winter along with a couple more courses of oral steroids. 98% of asthmatics I can make better, if they take their medicines; Sam I couldn't. I tried treating her for gastroesophageal reflux, looked for sinustis, even though she was young but couldn't find anything. I sent her to pulmonary for a sort of "second opinion" but they didn't have any brilliant ideas, either. Sam's mom would call me when she was sick to get advice, and we'd discuss if she just needed to see the pediatrician or go to the hospital or even come straight to Pittsburgh. I was afraid she might have another horrible attack and die.

The parent's best friend was a chiropractor so they'd also take Sam there to get "adjustments." They claim it really helps, although I'm skeptical. I told them it is okay as long as they also give the medicines that really do help, which they do

A few weeks ago I realized I hadn't heard from Sam's mom in several months. I'd been wondering what had been up. So I called up mom, who told me she was doing great, and thanking me for making her better. I pointed out that Sam had mostly gotten better on her own, maybe with a little help from me. We see that sometimes; the young asthmatics get better as they get older, probably because the airways get a bit bigger, less prone to close off. Either way, we are both thrilled with how well she's doing and I sleep a little bit better at night, not so worried about getting awoken about Sam.

Bird flu miscellany

2006-03-09T20:58:00.000-05:00

Baxter has shown that it's plasma derived products (such as clotting factor for hemophiliacs and IVIG for patients with immune deficiency) are safe from avian flu. Given that the properties of the avian flu aren't significantly different from the usual influenza virus, at least in a chemical sense. Still good news for patients who depend on these products, particularly given how many hemophiliacs got HIV.

Also, Britian has announced it will reserved the avian flu vaccination for health care workers. This may sound unfair, but given how hard it will be to keep the health care system working in case of a pandemic, it makes sense. Hopefully, others can stay home and avoid exposure, but health workers will be needed to care for patients.

Kissing and peanut allergy

2006-03-09T20:42:00.000-05:00

I missed this while I was away, but apparently Christina Desforges didn't actually die of peanut allergy.

A 15-year-old Canadian girl with a peanut allergy did not die because of kissing her boyfriend who had eaten peanut butter, a coroner has ruled.

But Saguenay coroner Michel Miron did not reveal why Christina Desforges died last November because he has yet to make his final report.

According to another article, she died of cerebral anoxia or lack of oxygen to the brain. I hate to speculate, but there was recently a tragic case in Pittsburgh where a pediatrician's son died of asphyxia. Apparently, some kids play a game called "knock out" where they strangle themselves near the point of passing out to get a high as bloodflow returns. I'm tempted to make fun of this as natural selection at work, but I'm sure many of us did things as teenagers that seem crazy in retrospect.

As I pointed out at the time, the timing of the death would have suggested that very little peanut protein was left in the boyfriend's mouth. At the AAAAI meeting I just got back from, a group presented a study of how long saliva contains peanut protein:

The new study, presented at the American Academy of Allergy, Asthma and Immunology's annual meeting in Miami Beach, involved 10 people and found that the peanut allergen was detectable in a majority of subjects after eating but left the saliva after several hours.

This seems like reasonable advice, although I'd consider avoiding peanut altogether. So as of now there are again no documented cases of deaths from food allergies after kissing.

Brokeback marriages

2006-03-08T19:20:00.000-05:00

On the whole these are not marriages of convenience or cynical efforts to create cover. Gay and bisexual men continue to marry for complex reasons, many impelled not only by discrimination, but also by wishful thinking, the layered ambiguities of sexual love and authentic affection.

"These men genuinely love their wives," said Joe Kort, a clinical social worker in Royal Oak, Mich., who has counseled hundreds of gay married men, including a minority who stay in their marriages. Many, he said, considered themselves heterosexual men with homosexual urges that they hoped to confine to private fantasy life.

This will sound terrible, but I'd recommend that women ask prospective husbands what kind of porn they look at (or sneak around and figure it out themselves). I suspect that most of the gay men who get married look at gay porn, much as they want to believe they can have a successful heterosexual marriage.

Back

2006-03-08T19:00:00.000-05:00

I'm back from Miami. I have some good posts coming, but without easy free full text access to most journals at home, you'll just have to wait. My flight didn't arrive until 11:30PM last night so I didn't get into bed until after 1. Spent the day revising dictations, following up labs and phone calls etc. But now I'll be set tomorrow.

A couple notes. One while I find David Irving deplorable, putting him in jail is preposterous. As my former neighbor, Jeff Jacoby puts it:

But as a matter of law and public policy, Irving's sentence is deplorable. The opinions he expressed are vile, and his arguments about the Holocaust are ludicrous. But governments have no business criminalizing opinions and arguments, not even those that are vile or ludicrous. . . . . But free societies do not throw people in prison for giving offensive speeches or spouting historical lies.

Well said.

More trivially, I was glad to see Trader Joe's make the NYTimes today. Allegedly they are coming to Pittsburgh this fall, which should greatly improve my wife's opinion of the city. The only downside is that whenever I go there, everyone thinks I work there (I like to wear Hawaiian shirts).

It can always get worse

2006-03-03T05:34:00.000-05:00

or so we told ourselves during residency. That said, I hope not to have many more weeks like this one.

First, I realized that the protocol I've been working on was the WRONG VERSION. I'm not sure how exactly this happened (either the sponsor sent us the wrong one or my boss didn't pass on the correct one to me) and in any case I get a large share of the blame for not paying more attention and noting that the title was different.

Then yesterday someone from outside my section contacted me about a handout I'd spent a fair amount of time working on, saying her section wanted to do something similar and could she look at ours. 4 hours later she e-mailed back saying our sucked (in slightly different words) and she couldn't believe we were using it. Funny, I didn't remember asking her opinion.

For whatever reason this really pissed me off. I'm not sure why. I didn't even originate the handout, I just adapted it. I did spend a fair amount of time on it, not least sitting through meetings endless discussing it.

Luckily, I think, I'm currently in the Pittsburgh Airport surrounded by college students heading to Spring Break, waiting for my flight to Miami. Not vacation, but the annual allergy meetings, which will at least give me some time to read, relax and decompress.

Misleading graphs

2006-03-02T14:16:00.000-05:00

I want to call attention to a graph I published yesterday (source here) showing the relationship between asphalt use in Finland and asthma rates.

There is something very misleading, even wrong, about this graph: the asthma rate is plotted for 20 years longer than asphalt use. This causes several problems.

1. It tricks you into thinking that the asthma/ashphalt correlation has gone on much longer than it really has.

2. It makes the correlation look much tighter. Cover up the area of the graph from 1990 on and the dip in asphalt use between 1980 and 1990 is much more prominent.

Why would you ever present data like this? I can think of no reason to continue graphing one variable and not the other, especially for a period taking up 1/4 of the whole graph. The relationship is a good one without the extra data and this just blows your credibility in the eyes of a careful reader. I also can't help but wonder what asphalt use really was in 1995 and 2000. Maybe it plateaued?

Eat dirt, prevent asthma!

2006-03-01T17:12:00.000-05:00

Why have asthma and other allergic diseases gotten so much worse in the last 50 years? No one knows for sure. A leading hypothesis is called the “hygiene hypothesis,” which states that we are too clean. Initially the idea was that we got fewer infections than we used to before immunizations, antibiotics, antimicrobial soaps and gels, etc. However, studies haven’t been able to show, for example, that kids who get antibiotics earlier or more frequently are more likely to get allergic diseases than those that don’t

A new modification of the hypothesis suggests that it isn’t lack of exposure to microorganisms that cause infections that is the problems, but lack of exposure to harmless bacteria and fungi, particularly those that live in the ground. Studies clearly show that growing up on a farm is protective against allergies (as shown in the first graph) and that the more rural the environment the better.

One problem is that measuring the extent of urbanization is difficult. Now, 2 Finnish researchers writing in this month’s Journal of Allergy and Clinical Immunology have come up with a good proxy, use of asphalt. As this graph shows, the increase in asthma in Finland closely parallels use of asphalt.

So if you want to avoid asthma, allergies, etc. eat dirt.

UPDATE: added link to original article. Link to criticism of second graph as misleading.

Ultrawalking

2006-02-28T11:17:00.000-05:00

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

2006-02-28T11:10:00.000-05:00

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

Clergy and evolution

2006-02-26T17:58:00.000-05:00

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

2006-02-25T08:25:00.000-05:00

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?

2006-02-24T15:21:00.000-05:00

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

2006-02-24T12:55:00.000-05:00

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

2006-02-24T05:36:00.000-05:00

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

2006-02-23T05:26:00.000-05:00

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

2006-02-22T13:44:00.001-05:00

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

2006-02-22T12:10:00.000-05:00

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

2006-02-21T06:00:00.000-05:00

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

2006-02-19T15:38:00.000-05:00

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

2006-02-18T20:06:00.000-05:00

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

2006-02-17T09:22:00.000-05:00

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

2006-02-17T08:24:00.000-05:00

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

2006-02-16T08:43:00.000-05:00

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

2006-02-15T16:48:00.000-05:00

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

2006-02-15T08:19:00.000-05:00

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

2006-02-14T09:38:00.000-05:00

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

2006-02-14T06:13:00.000-05:00

is here. Very creative format

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

A good day

2006-02-13T14:15:00.000-05:00

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

2006-02-13T14:12:00.000-05:00

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

2006-02-12T09:07:00.000-05:00

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

2006-02-11T20:31:00.000-05:00

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

2006-02-11T19:27:00.000-05:00

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

2006-02-10T12:32:00.000-05:00

is here at Science and Politics

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

The video case for universal healthcare

2006-02-10T12:27:00.000-05:00

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!

2006-02-10T11:34:00.000-05:00

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 documentsincreased risk of respiratory tract infection including pneumoniaand recurrent OM in children who were fully breastfed for 4vs 6 months. These findings support current recommendationsthat infants receive only breast milk for the first 6 monthsof 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

2006-02-10T06:12:00.000-05:00

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

2006-02-05T16:22:00.000-05:00

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

2006-02-03T18:44:00.000-05:00

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

2006-02-02T19:37:00.000-05:00

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

Oral allergy syndrome

2006-02-02T12:36:00.000-05:00

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?

2006-02-02T12:33:00.000-05:00

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.

US births

2006-01-28T10:54:00.000-05:00

I've been asking fellowship candidates the following question:

"There are approximately 300 million people in the United States. About how many babies are born each year?"

Answers so far have ranged from 20,000 to 100 million!

Absolutely no one knows the answer, which is available in this article or as the first commnent to this post.

Try to make an educated guess, then look to see the actual number.

Hint: it is somewhere between 20,000 and 100 million.

The case for intelligent design

2006-01-26T18:10:00.000-05:00

nicely summarized by a commentator on an earlier post of mine.

I think that what you have to say is just a bunch of CRAP!!! To you there may not be any info to prove the "theory" of intelligent design, but think again, its called a BIBLE!!!!! na durr!! look in it once in a while!! and FYI, if there gonna teach about the gay "theory" (which by the way is a load of crap also) of evolution in schools, then they should at least teach the truth, ABOUT GOD (intelligent design)!!!!!!!!

Oh yeah, this is the anoynomous person again (the first 1), and i have a couple more things to say....ur a freak!!!!! You may think that by saying this you aren't affending anyone, but think again.........YOU'RE OFFENDING ALL CHRISTIANS, which i happen to be!!!! so i suggest that you go to church and read the bible, although I don't think that will help your screwed up head!!!!! All you have said is lies!!!!!! EVOLUTION is NOT a theory, its a lie!!!!!!!

Surprisingly, this eloquent proponent of ID doesn't wish to be identified.

And to my anonymous commenter, I'd point out that I attend my church weekly and don't see any conflict between that and accepting evolution.

How to choose a specialty

2006-01-25T15:27:00.000-05:00

Good advice from Fat Doctor (hey that's her name for the blog, not mine):

You have to like going to work in the morning, enjoy the intellectual subject matter, like the type of people you work with, tolerate the lifestyle and be qualified to get into that residency. Otherwise it just won't work for you

Pretty good advice for life in general. I'd only add that if you are thinking of one of the more rigorous specialties, make sure about the lifestyle. I've met a lot of bitter surgeons who either left their program or would have done something different if they had it to do over again. It's not like they don't warn you it will be tough.

2006-01-25T08:57:00.000-05:00

A good article, by one of the best medical writers around, Peri Klass (no blog, but I guess when you have gigs with the New England Journal and New York Times you don't need one).

She talks about how hard it can be to separate the truly sick kid with meningitis or leukemia out from the sea of viral infections and worried moms.

I posted a similar experience here. I think one of the most important things for a pediatrician is being able to differentiate sick from non-sick kids. And by "sick" I mean really sick, not the flu. I have one more case I'll describe in the future, but when caring for the kid with a viral illness that was really leukemia, I wasn't smart enough to know right away that it was leukemia. I was, however, smart enough to know that something bad might be going on. In the midst of a busy night seeing "non-urgent" kids in the emergency room that was enough.

Grand Rounds 2:18

2006-01-24T06:22:00.000-05:00

is here.

The Will Rodgers effect

2006-01-21T19:50:00.000-05:00

My last post on ALL (Acute Lymphoblastic Leukemia) reminded me of an interesting statistical phenomenon referred to as the Will Rodgers effect: if you have divided a sample into two groups, one at higher probability of succesful outcome, changing the criteria in order to make more individuals members of the low success group will improve the outcomes of both groups. Obviously you could extend this to more than 2 groups.

As an example in leukemia, some patients are characterized as "high-risk" based on characteristics that make them less likely to be cured by standard therapy (age, T cell, high initial white blood cell count, etc). Changing the criteria so that more patients are characterized as high risk will improve survival in both groups, even as overall survival stays constant.

Leukemia

2006-01-21T19:39:00.000-05:00

This chart shows the incredbile progress that has been made against childhood leukemia, specifically acute lymphoblastic leukemia. So if your child is diagnosed with ALL today, she probably has a greater than 90% chance of cure. 40 years ago the chance was more like 10%.

Chart is from last week's NEJM. ALL is the success story in cancer. Progress in other cancers has obviously been less impressive. Still, the success rate in childhood ALL is so great that much current research focuses on identifying "low risk" patients who will be cured with less-intensive regimens that have fewer adverse effects.