Category Archives: General Health

Surgery as Placebo

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A recent summary by 538 website details how surgery can be a powerful placebo: Surgery Is One Hell of a Placebo

Here’s an excerpt:

“expectations matter, and we know they matter because of a bizarre research technique called sham surgery. In these fake operations, patients are led to believe that they are having a real surgical procedure…

A 2014 review of 53 trials that compared elective surgical procedures to placebos found that sham surgeries provided some benefit in 74 percent of the trials and worked as well as the real deal in about half.1 Consider the middle-aged guy going in for surgery to treat his knee pain. Arthroscopic knee surgery has been a common orthopedic procedure in the United States, with about 692,000 of them performed in 2010,2 but the procedure has proven no better than a sham when done to address degenerative wear and tear, particularly on the meniscus…

Even without a robust placebo effect, an ineffective surgery may seemhelpful. Chronic pain often peaks and wanes, which means that if a patient sought treatment when the pain was at its worst, the improvement of symptoms after surgery could be the result of a condition’s natural course, rather than the treatment. That softening of symptoms from an extreme measure of pain is an example of the statistical concept of regression to the mean.

My take: Both with medicine and surgery, sometimes improvement occurs even when the treatment itself is not effective.

Dupont Forest, NC

“Sell by”/Expiration Dates for Medications

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A recent NPR story/ProPublica research reiterates the fact that many medications remain potent long after their expiration dates: That Drug Expiration Date May be More Myth Than Fact

Here’s an excerpt:

Tossing such drugs when they expire is doubly hard. One pharmacist at Newton-Wellesley Hospital outside Boston said the 240-bed facility is able to return some expired drugs for credit, but had to destroy about $200,000 worth last year. A commentary in the journal Mayo Clinic Proceedings cited similar losses at the nearby Tufts Medical Center. Play that out at hospitals across the country and the tab is significant: about $800 million per year. And that doesn’t include the costs of expired drugs at long-term care pharmacies, retail pharmacies and in consumer medicine cabinets…

Pharmacists and researchers say there is no economic “win” for drug companies to investigate further. They ring up more sales when medications are tossed as “expired” by hospitals, retail pharmacies and consumers despite retaining their safety and effectiveness…

Whatever the solution, the drug industry will need to be spurred in order to change, says Hussain, the former FDA scientist. “The FDA will have to take the lead for a solution to emerge,” he says. “We are throwing away products that are certainly stable, and we need to do something about it.”

My take: Don’t expect any action on this issue anytime soon.  At the very least, this will may persuade some family members not to throw away some medications that are likely still effective.

“March of Science”

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A fascinating commentary (“The March of Science –The True Story”  L Rosenbaum NEJM 2017;377: 188-91) discuss issues regarding mistrust of science in this age of ‘alternative facts.”

Here are some key points:

  • “Nutrition science may be the area that provides the most ammunition for distrust, given the combination of uncertainty, public interest, and powerful preferences. Indeed, skepticism of most nutrition science is warranted, given the often insurmountable challenges of controlled, blinded experimentation…The confluence of these factors..often invoked to condemn the scientific process more generally: Why should I believe you people when you people are always changing your minds?”
  • “Remarkable gains in human longevity are just one manifestation of science’s success–but….’No one wants to hear about the plane that lands.'”
  • There has been a shift “in the tone of public discussions of science.” Instead of someone being “wrong,” they are now “corrupt” or “evil.”
  • Due to potential for condemnation, there is fear of “venturing into the fray” which “means that the public hears far more from science’s critics than its champions. This imbalance contributes to “science is broken” narratives ranging from claims about the pervasiveness of medical error to the insistence that benefits of our treatments are always overhyped.
  • Changing the narrative: “we have to learn to tell stories that emphasize that what makes science right is the enduring capacity to admit we are wrong. Such is the slow, imperfect march of science.”

My take: Widespread skepticism and confirmation bias have the potential to disrupt highly effective medical treatments by confusing them for those that are unproven.

Related blog posts:

Dupont Forest, NC

 

Understanding the Health Care Fight

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From Axios: This is what Washington has been fighting about

An excerpt:

Every time you hear the Trump administration or Congress fight about rising Affordable Care Act premiums, or what will happen to people with pre-existing conditions, just remember — we’re talking about issues that affect 7 percent of the population. That’s how many people are in the individual health insurance market, or the “non-group” market…

But when you hear about those sky-high rate hikes because of “Obamacare,” chances are, they’re not your sky-high rate hikes — unless you happen to be in that market…

The spending limits that have been proposed for Medicaid really do matter, and they affect a larger group — 20 percent of the population. 

Diarrhea Mortality Improving

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A  recent story from NPR indicates that globally diarrhea deaths are on the decline, ~30%, from 2005-2015.  In wealthy countries, there has been a mild increase, likely related to Clostridium difficile infection and the use of antibiotics.  The article cautions that data from some parts of the world are questionable due to upheaval.

Full Link: A Good News Story About Diarrhea -With One Surprising Exception

An excerpt:

An infection by E. coli, Cryptosporidium, Shigella or rotavirus, and the resulting diarrhea, is often a death sentence in much of the world. In 2005, about 1.6 million people died from diarrhea-related diseases, and roughly 770,000 of them were kids under 5. But that number has been steadily dropping, as a new study points out…

Published this month in The Lancet, the study shows diarrhea-related deaths have declined about 20 percent from 2005 to 2015 for all ages to 1.3 million people, and 35 percent for children under 5 to about 500,000 children during the same time period.

NEJM: Senate Effort to Scale Back Health Care Coverage

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This is a concise summary on the potential effects of the U.S. Senate’s efforts to ‘repeal and replace’ Obamacare: from NEJM: Health, Wealth, and the U.S. Senate

Here’s an excerpt:

The Better Care Reconciliation Act (BCRA), as the U.S. Senate calls the health care bill released by a small working group of Republican senators last week, is not designed to lead to better care for Americans. Like the House bill that was passed in early May, the American Health Care Act (AHCA), it would actually do the opposite: reduce the number of people with health insurance by about 22 million, raise insurance costs for millions more, and give states the option to allow insurers to omit coverage for many critical health care services so that patients with costly illnesses, preexisting or otherwise, would be substantially underinsured and saddled with choking out-of-pocket payments — all with predictably devastating effects on the health and lives of Americans. What would get “better” under the BCRA is the tax bill faced by wealthy individuals, which would be reduced by hundreds of billions of dollars over the next decade — about $5,000 per year for families making over $200,000 per year and $50,000 or more for those making over $1 million, according to analysis of the AHCA, which included a similar set of tax provisions.1 We believe that that trade-off is not one to which we — physicians, patients, or American society — should be reconciled.

Related blog post: Five Reasons Why Medical Groups Oppose the Senate’s AHCA

St. Vitus Cathedral, Prague

 

Little Evidence to Support Dietary Intervention in Autism Spectrum Disorders

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Thanks to Kipp Ellsworth Twitter feed for reference:  Nutritional and Dietary Interventions for Autism Spectrum Disorder: A Systematic Review N Sathe Pediatrics 2017; vol 139.

Abstract:

CONTEXT: Children with autism spectrum disorder (ASD) frequently use special diets or receive nutritional supplements to treat ASD symptoms.

OBJECTIVES: Our objective was to evaluate the effectiveness and safety of dietary interventions or nutritional supplements in ASD.

DATA SOURCES: Databases, including Medline and PsycINFO.

STUDY SELECTION: Two investigators independently screened studies against predetermined criteria.

DATA EXTRACTION: One investigator extracted data with review by a second investigator. Investigators independently assessed the risk of bias and strength of evidence (SOE) (ie, confidence in the estimate of effects).

RESULTS: Nineteen randomized controlled trials (RCTs), 4 with a low risk of bias, evaluated supplements or variations of the gluten/casein-free diet and other dietary approaches. Populations, interventions, and outcomes varied. Ω-3 supplementation did not affect challenging behaviors and was associated with minimal harms (low SOE). Two RCTs of different digestive enzymes reported mixed effects on symptom severity (insufficient SOE). Studies of other supplements (methyl B12, levocarnitine) reported some improvements in symptom severity (insufficient SOE). Studies evaluating gluten/casein-free diets reported some parent-rated improvements in communication and challenging behaviors; however, data were inadequate to make conclusions about the body of evidence (insufficient SOE). Studies of gluten- or casein-containing challenge foods reported no effects on behavior or gastrointestinal symptoms with challenge foods (insufficient SOE); 1 RCT reported no effects of camel’s milk on ASD severity (insufficient SOE). Harms were disparate.

LIMITATIONS: Studies were small and short-term, and there were few fully categorized populations or concomitant interventions.

CONCLUSIONS: There is little evidence to support the use of nutritional supplements or dietary therapies for children with ASD.

Related blog post: Gluten-free, Casein-free -No improvement in Autism

Bayeux, France

Camp Oasis 2017: Don’t Tell Me the Sky’s the Limit

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For many years, our group has helped out at Camp Oasis, a week-long camp for children with inflammatory bowel disease.  Among our physicians, Dr. Larry Saripkin has devoted more time than anyone else for about 15 years and he does such a great job. Over the years, our nurses and many other office staff have participated as well. Here are a couple photos from this year’s camp:

 

Don’t Tell Me the Sky’s the Limit When There are Footsteps on the Moon!  –one of many painted rocks

Ft Yargo State Park (location of Camp Oasis)

POWER — Practice Guide on Obesity and Weight Management, Education, and Resources

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Recently, the American Gastroenterological Association (AGA) has published a large amount of information regarding obesity and the potential role for gastroenterologists.  In addition to publishing an entire Special Issue supplement of Gastroenterology (152: (7): 1635-1801, the AGA has published a “white paper” (Clin Gastroenterol Hepatol 2017; 15: 631-49).  The AGA has also addressed coding issues and episodic care issues: Clin Gastroenterol Hepatol 2017; 15: 650-64.

Some useful points from these articles:

  • “Severe obesity [as classified by] the American Heart Association…BMI>120% of the 95% for age and sex or a BMI ≥35” (“class 2 obesity in adults”) Class 3 obesity is BMI >140% of 95% for age and sex or a BMI ≥40.
  • Intensive lifestyle interventions ‘average weight losses of up to 8 kg in 6 months’ but maintaining weight loss has been a challenge. “However, both the DPP and Look AHEAD have shown that weight loss, followed by substantial weight regain, was associated with greater improvements in health than not having lost weight at all.”
  • Good idea to review medications that affect weight.  Medications associated with weight gain include antidiabetics, some antihypertensives (eg. nadolol, propranolol), antidepressants (eg. lithium, mirtazapine, SSRIs, tricyclic antidepressants), antipsychotics (clozapine, olanzapine, quetiapine, risperdione), some antieleptics (carbamazepine, gabapentin, pregabalin, valproic acid), 1st generation antihistamines and glucocorticoids.
  • Is there a best diet? On this topic, the authors (pg 1749 of supplement): “there appears to be little weight loss advantage or difference in metabolic health outcomes between dietary approaches and improvements in health are relative to degrees of weight loss.  Caloric restriction is the fundamental premise of every successful weight loss strategy, whether that is achieved by lowering fat or carbohydrate, fasting, or using meal replacements...the best diet ultimately is the one you can stick to long enough“

The information available in these publications are overlapping and cannot be summarized adequately in a short post.  The white paper, in particular, does an excellent job of summarizing the reasons for obesity, the steps a clinician should take, identification of comorbidities, management (diet, exercise, pharmacologic agents, endoscopic therapies, and surgery), and outcomes.

My take (borrowed from the authors):  “obesity is possibly the greatest health care issue of our day…Although lifestyle changes, including an individualized reduced-calorie diet and physical activity, are the cornerstones of treatment, new medications and bariatric endoscopic therapies and surgery can be effective tools.”

Related blog posts:

Mural Near Sullivan’s Island

 

NPR: Handshake-Free Zones to Decrease Spreading Germs

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NPR recently detailed a study to reduce germs by implementing a handshake-free zone at a neonatal intensive care unit.

Here’s the link: Handshake-Free Zones Target Spread of Germs

An excerpt:

In a survey of staff and family members about the experience, Sklansky and his colleagues found that establishing handshake-free zones does reduce the frequency of handshakes. And most health care workers support the idea.

The findings were published in the American Journal of Infection Control. The survey didn’t determine whether avoiding handshakes actually reduced the rate of infections, but Sklansky hopes to answer that question in a future study.

The formal experiment is now over, but the signs in the NICUs remain. And doctors and nurses still discourage handshakes.

It’s is an effective way to decrease the spread of germs, says Maureen Shawn Kennedy, editor-in-chief of the American Journal of Nursing…

Although there is no data to prove that reducing handshakes limits hospital infections, one study showed that bumping fists was more hygienic than shaking hands.

However, some infectious disease specialists believe health care workers don’t need to stop shaking hands. They just need to scrub better.

“The problem isn’t the handshake: It’s the hand-shaker,” says Herbert L. Fred, a Houston physician and associate editor of the Texas Heart Institute Journal.

In a 2015 editorial he urged doctors to ensure their hands are clean before touching patients. After all, he wrote, “If we ban the handshake, we might as well ban the physical examination. Both practices can spread germs,” — if you don’t wash your hands properly.

My take: The bigger message of this article is that hand hygiene needs to be improved to decrease the spread of infections.  I doubt stopping handshakes will be particularly helpful.

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Musee d’Orsay