The first fact to realize about insanity is that it is a culturally defined disease, in the sense that the culture and/or society decide what "normal" is. If something is sufficiently unusual and uncommon, and not explicable by reason or understood as having a well-defined cause, then society will often label the action as evidence of an "unsound mind". For instance, until the American Psychiatric Society voted (and not by 100% to zero) that homosexuality was not a mental disease, homosexuals were often "treated" by psychiatrists. Similarly, in the 1950's and 1960's, if a Russian citizen claimed that communism was not the best political system, he was often classified as schizophrenic, confined to a mental hospital, and treated with Thorazine and other anti-psychotics. In the Southern USA before 1860, if a black slave wanted to run away, he was often labeled as "crazy because of 'escapitis'", because why would he try to run away if he were not insane.
You also cannot "prove" that you are sane. It generally takes the testimony of two psychiatrists who have examined you to certify that you are insane or not insane. The default assumption is that you are sane, unless a judge requires you to prove you are sane before he will let you stand trial. Of course, the psychiatrists are themselves culturally bound, so that an American who attempts suicide is considered to have a mental problem, while a Japanese who attempts hari-kari is not, and probably everyone who sees Shakespeare's "Julius Caesar" understands Brutus' suicide. If you saw and spoke with the image of your dead grandmother, you might be considered insane, unless you were a teenage girl from a Latin American culture, where such such events can occur on or near her fifteenth birthday.
Then we come to the insanity defense. I am not commenting pro or con on its use, but how can you decide today that someone was insane two years, ago, if he/she were not examined at that time. However, most doctors will label a person as having a drinking problem, if the patient has drinks more on a daily basis than does the doctor. Similarly, as I tell my residents time and time again, all prescribing is a negotiating process, so if a hospitalized patient refuses to take a prescribed medicine, this is not grounds for a psychiatric consult.
One problem that occurs frequently is with people who hear voices or see images and claim that such sensations came from God. Clearly one cannot "prove" by any logical process that they were not, any more than they can prove that they were. There is a condition called the "Jerusalem Syndrome", wherein pious Christians and Jews are so overcome with the holiness of Jerusalem when they land at Lod airport that they become instantly convinced that they are the Jewish or Christian Messiah. There is a ward of Jerusalem Hospital that has permanently set aside beds for members of this group. Bernadette of Lourdes and Joan of Arc had difficulty convincing the authorities that they were divinely inspired while Abraham had no difficulty believing that the Lord commanded him to sacrifice his son, nor did Joseph Smith have difficulty believing in the Angel Moroni. Since religion is part of every culture, ideations that might otherwise be considered manifestations of paranoia are acceptable when they occur in a religious context.
In Salem, Massachusetts, women were judicially killed for being witches. Such behavior is not condoned now in the United States. However, there is a mental condition that occurs in males from Asia (especially Japan) as well as males in West Africa: They become convinced that their penis is shrinking and being pulled up and vanishing inside their bodies. Some men even go so far as to tie weights with ropes to their penises to arrest this process. However, in Africa, this belief is considered as evidence that a witch has placed a curse on you, and the immediate cure is to kill the witch. This has occurred, and the males involved are never prosecuted. I might observe in all societies it seems that only female witches are executed, and never male warlocks.
I would like to close this blog with a comment on free will. Most of us believe that we have free will, but most psychiatrists do not so believe. They believe that we are bound up in childhood problems, and try to solve them in the adult world in which we live. We try to resolve the unsolved problems of childhood and therefore (they believe) we marry the person who is most similar to the parent with whom we had the most problems.
This raises the question/problem of how much free will any of us have if we are still trying to solve childhood problems as an adult, since we never recognize the displacement 1nvolved in the battle(s). Since the justice system can only function logically and properly and fairly if we all have free will, that is precisely the default belief of all justice systems. Therefore you are responsible for all of actions, unless you can prove that you are not. To have any justice system function, it must be assumed, incorrectly or not, that you are legally responsible for 100% of your actions; this is the same assumption we make on Voting Day, as well as when we choose members of a jury.
Sunday, December 6, 2009
Tuesday, November 17, 2009
Mammograms, Zetia/Vytorin, Proscar,Folic Acid
I have received many phone calls from my patients and e-mails from readers on my bloglist about 3 different reports about medical research results: an article in the NY Times by Gina Kolata(Proscar), a report from a cardiac conference(Zetia/Vytorin), and recommendations from a medical study group (mammograms). I received no inquiries about an article in Lancet (folic acid), but I guess few people read British medical journals, even though Lancet antedates both NEJM and JAMA, and their letters to the editor are invaluable. My comments on these are probably applicable to many reports of medical results, and I leave it to my readers to evaluate any such reports.
First, some general comments. In many areas of non-precise science (I am therefore excluding mathematics, chemistry and physics) when recommendations are made, there is both a majority report/recommendation, and a minority report. However, in medicine, except as a rebuttal to a journal article (e.g. the discussion in Lancet as to whether or not reducing total salt in the diet saves lives) we never see the minority report. I doubt that 20 doctors (or 20 anyones) ever agree 100% on a committee report, and it would be nice to see the minority report (cf. the arguments about global warming) so we can try to make our own decision. Furthermore, most refereed journal articles require the authors to make the source data available on request, but this does not happen with medical committee recommendations, so we have no way to judge how they arrived at their recommendations, or what compromises were made (e.g. how did the government first decide that total cholesterol levels should be below 240?). Was it the same way that Congress decided on 27.5% as the oil depletion allowance, i.e. a compromise?
The recent recommendations on the starting age and frequency of mammograms are a case in point. There was no minority report, and the data on which the recommendations were made are not available. I only fear that HMO's will seize on this report to pay for fewer mammograms, as Medicare once did. I have never had a problem with ordering a test for a patient even if I was absolutely certain the result would be negative, because the patient's peace of mind is important to me.
There is absolutely no way to know for a given individual how often a mammogram should be done (why not every 6 months to detect fast-growing cancers?), or at what age the mammograms should start. I also have some 90 year old women who have never had a mammogram, and have never had breast cancer, and so far they are right as well.
The article about men not taking Proscar even though men on Proscar have a lower incidence of prostate cancer did not properly emphasize the fact that if prostate cancer does occur when a man is taking Proscar it is much more aggressive, and has a higher Gleason score. On the other hand, taking both Proscar and Flomax decreases a man's probability of needing a TURP of the prostate to relieve blockage caused by a growing prostate. Also, some men do not like taking Proscar because it diminishes the amount of fluid in the ejaculate by at least 50%, and these men do not enjoy the different sensation, because their orgasms are therefore shorter. Why not just say that men who do not take Proscar are "pharmacologically autonomous"?
Both Zetia and Vytorin decrease cholesterol, which is all the FDA required them to do. Studies on other statins as well as on Niacin showed that lowering cholesterol by these chemicals reduced the risk of second heart attacks and strokes, as well as the risk of first heart attacks. (I have never seen a study on diet, lower cholesterol, and heart attacks.) The FDA then assumed that any chemical lowering of cholesterol was beneficial, as does the entire medical establishment.
The study of Zetia/Vytorin showed that they did not cause regression of the narrowing of the intima of a major artery. However, this is a secondary surrogate marker for strokes and heart attacks. If heart attacks are caused by rupture of plaque (as many cardiologists believe) then stabilizing the plaque (are statins anti-inflammatory as aspirin is?) is more important than the lumen diameter, after a certain narrowing. No one has shown that lowering the cholesterol with Zetia or Vytorin does NOT reduce the risk of heart attack or stroke, just as no one has shown that intimal regression is a valid surrogate for MI's and CVA's.
The latest issue of Lancet reported a large study that showed that fortifying the diet with folic acid, which successfully lowered neural tube defects in infants, INCREASED the risk of cancer. I wonder what the USA and FDA will do with this study. It certainly should be repeated. But studies showing that vitamin ingestion can cause problems rarely make headlines in America. Maybe we should revise the recent recommendations which raised the RDA for folate from 0.4mg to 0.8mg?
Thought for the month: Why does the full moon appear larger when it rises in the East than it does when it is directly overhead?
First, some general comments. In many areas of non-precise science (I am therefore excluding mathematics, chemistry and physics) when recommendations are made, there is both a majority report/recommendation, and a minority report. However, in medicine, except as a rebuttal to a journal article (e.g. the discussion in Lancet as to whether or not reducing total salt in the diet saves lives) we never see the minority report. I doubt that 20 doctors (or 20 anyones) ever agree 100% on a committee report, and it would be nice to see the minority report (cf. the arguments about global warming) so we can try to make our own decision. Furthermore, most refereed journal articles require the authors to make the source data available on request, but this does not happen with medical committee recommendations, so we have no way to judge how they arrived at their recommendations, or what compromises were made (e.g. how did the government first decide that total cholesterol levels should be below 240?). Was it the same way that Congress decided on 27.5% as the oil depletion allowance, i.e. a compromise?
The recent recommendations on the starting age and frequency of mammograms are a case in point. There was no minority report, and the data on which the recommendations were made are not available. I only fear that HMO's will seize on this report to pay for fewer mammograms, as Medicare once did. I have never had a problem with ordering a test for a patient even if I was absolutely certain the result would be negative, because the patient's peace of mind is important to me.
There is absolutely no way to know for a given individual how often a mammogram should be done (why not every 6 months to detect fast-growing cancers?), or at what age the mammograms should start. I also have some 90 year old women who have never had a mammogram, and have never had breast cancer, and so far they are right as well.
The article about men not taking Proscar even though men on Proscar have a lower incidence of prostate cancer did not properly emphasize the fact that if prostate cancer does occur when a man is taking Proscar it is much more aggressive, and has a higher Gleason score. On the other hand, taking both Proscar and Flomax decreases a man's probability of needing a TURP of the prostate to relieve blockage caused by a growing prostate. Also, some men do not like taking Proscar because it diminishes the amount of fluid in the ejaculate by at least 50%, and these men do not enjoy the different sensation, because their orgasms are therefore shorter. Why not just say that men who do not take Proscar are "pharmacologically autonomous"?
Both Zetia and Vytorin decrease cholesterol, which is all the FDA required them to do. Studies on other statins as well as on Niacin showed that lowering cholesterol by these chemicals reduced the risk of second heart attacks and strokes, as well as the risk of first heart attacks. (I have never seen a study on diet, lower cholesterol, and heart attacks.) The FDA then assumed that any chemical lowering of cholesterol was beneficial, as does the entire medical establishment.
The study of Zetia/Vytorin showed that they did not cause regression of the narrowing of the intima of a major artery. However, this is a secondary surrogate marker for strokes and heart attacks. If heart attacks are caused by rupture of plaque (as many cardiologists believe) then stabilizing the plaque (are statins anti-inflammatory as aspirin is?) is more important than the lumen diameter, after a certain narrowing. No one has shown that lowering the cholesterol with Zetia or Vytorin does NOT reduce the risk of heart attack or stroke, just as no one has shown that intimal regression is a valid surrogate for MI's and CVA's.
The latest issue of Lancet reported a large study that showed that fortifying the diet with folic acid, which successfully lowered neural tube defects in infants, INCREASED the risk of cancer. I wonder what the USA and FDA will do with this study. It certainly should be repeated. But studies showing that vitamin ingestion can cause problems rarely make headlines in America. Maybe we should revise the recent recommendations which raised the RDA for folate from 0.4mg to 0.8mg?
Thought for the month: Why does the full moon appear larger when it rises in the East than it does when it is directly overhead?
Monday, November 16, 2009
Universal Health Care: What it Should Contain
Many patients and friends have asked me during the past months what I would like to see in universal health care. I only want a system that is best for my patients, and takes the least paperwork time for me. Any system, of course, will always pay less for thinking than for doing (i.e. operating) because it is difficult to measure thinking. I defer the question of outcome measurements to another blog.
1) We already have socialized medicine, and it is called Medicare and the VA Hospitals, and none of the users of the systems seems very much dissatisfied with it. And, in fact, middle-class parents paying to put their children thru college, etc., would find it difficult if not impossible to provide dollar for medical dollar coverage for their elderly parents, as they would have to do without Medicare.
2) You are allowed (by law) to keep your same cell phone number for life, if you want to, and don't have to change it every time you switch carriers. But when you are transferred from HMO A to HMO B because your company got a better premium deal from the second company,you suddenly have to scurry around and find a new internist, gynecologist, pediatrician, and any other specialist you are seeing. This is manifestly unfair, inefficient, and disrupts the smooth flow of medical care-taking. It's one thing if a patient chooses to leave a doctor, but to be forced to leave a doctor is unconscionable and stressful. And what if you are a Cigna patient but the world's expert is an Oxford surgeon? Then you have to pay his full bill, with no insurance deduction. You should be able to KEEP THE SAME FAMILY DOCTOR FOR LIFE!
3) Many patients are tied to their jobs thru their health insurance. If they stop working or switch their jobs, their wife and children may not be covered, or there may be very special coverage available only while they work for this particular company.
4) A minor point: why does the family coverage for your children stop when they are 23 years old?
4) A stronger point: If you and your wife both have paid premiums for a $100K fire policy on your house, and it burns down, you both get paid $100K., because you each have a policy. But if you and you wife both have paid medical premiums for a family policy, and you get a heart attack,you can only collect doctor and hospital bills from one of your policies. This means the other one was invalidated for this case, and all the premiums (10, 20 30 years' worth)are sheer profit for the company. Why should this be? It's like reverse double-dipping,only this time your pockets are the ones being directly dipped into.
5) I should not have to waste my time calling up for permission for MRI's. I don't have to do it for MCR, but most HMO's want me to expose a patient to cancer-causing Xrays of a CT exam before they allow an MRI, or I have to spend a lot of time (my least fungible recourse) convincing them otherwise.
6) I could also save time if I didn't have to call the drug management company to explain why the drug I chose for my patient is preferable to their chosen (and cheaper) drug. They don't know the patients. (Actually, must drug stores and wholesalers make a greater per cent profit on generics than brand names, because no one outside the field knows how cheap it is to make a generic.)
7) They should not make Electronic Medical Records mandatory until they have proved that they save money, or at least patient morbidity. There has been no clear evidence of this yet.All I know is that in the "good old days" I could admit a patient and write a set of orders with pen and paper in 5 minutes. Now with filling out the matrix in the computer form in the sequence of questions they ask me (e.g. what is my patient's flu vaccine status, a fact I always put down in my admitting note) punching in my date of birth xx-xx-xxxx (not a code) just more information collected, so all doctors tend to be born on 11-11-1911) it takes me at least 25 minutes to admit a patient. This is not progress, but more on the EMR on another blog.Sometimes when I get tired of all the pettifogging, if it is my personal patient, I just put down patient refuses".
In summary: keep the same doctor for life, and also solve the problem of who will pay for abortions, because as long as we have both men and women, married or unmarried, we will have unwanted pregnancies,
1) We already have socialized medicine, and it is called Medicare and the VA Hospitals, and none of the users of the systems seems very much dissatisfied with it. And, in fact, middle-class parents paying to put their children thru college, etc., would find it difficult if not impossible to provide dollar for medical dollar coverage for their elderly parents, as they would have to do without Medicare.
2) You are allowed (by law) to keep your same cell phone number for life, if you want to, and don't have to change it every time you switch carriers. But when you are transferred from HMO A to HMO B because your company got a better premium deal from the second company,you suddenly have to scurry around and find a new internist, gynecologist, pediatrician, and any other specialist you are seeing. This is manifestly unfair, inefficient, and disrupts the smooth flow of medical care-taking. It's one thing if a patient chooses to leave a doctor, but to be forced to leave a doctor is unconscionable and stressful. And what if you are a Cigna patient but the world's expert is an Oxford surgeon? Then you have to pay his full bill, with no insurance deduction. You should be able to KEEP THE SAME FAMILY DOCTOR FOR LIFE!
3) Many patients are tied to their jobs thru their health insurance. If they stop working or switch their jobs, their wife and children may not be covered, or there may be very special coverage available only while they work for this particular company.
4) A minor point: why does the family coverage for your children stop when they are 23 years old?
4) A stronger point: If you and your wife both have paid premiums for a $100K fire policy on your house, and it burns down, you both get paid $100K., because you each have a policy. But if you and you wife both have paid medical premiums for a family policy, and you get a heart attack,you can only collect doctor and hospital bills from one of your policies. This means the other one was invalidated for this case, and all the premiums (10, 20 30 years' worth)are sheer profit for the company. Why should this be? It's like reverse double-dipping,only this time your pockets are the ones being directly dipped into.
5) I should not have to waste my time calling up for permission for MRI's. I don't have to do it for MCR, but most HMO's want me to expose a patient to cancer-causing Xrays of a CT exam before they allow an MRI, or I have to spend a lot of time (my least fungible recourse) convincing them otherwise.
6) I could also save time if I didn't have to call the drug management company to explain why the drug I chose for my patient is preferable to their chosen (and cheaper) drug. They don't know the patients. (Actually, must drug stores and wholesalers make a greater per cent profit on generics than brand names, because no one outside the field knows how cheap it is to make a generic.)
7) They should not make Electronic Medical Records mandatory until they have proved that they save money, or at least patient morbidity. There has been no clear evidence of this yet.All I know is that in the "good old days" I could admit a patient and write a set of orders with pen and paper in 5 minutes. Now with filling out the matrix in the computer form in the sequence of questions they ask me (e.g. what is my patient's flu vaccine status, a fact I always put down in my admitting note) punching in my date of birth xx-xx-xxxx (not a code) just more information collected, so all doctors tend to be born on 11-11-1911) it takes me at least 25 minutes to admit a patient. This is not progress, but more on the EMR on another blog.Sometimes when I get tired of all the pettifogging, if it is my personal patient, I just put down patient refuses".
In summary: keep the same doctor for life, and also solve the problem of who will pay for abortions, because as long as we have both men and women, married or unmarried, we will have unwanted pregnancies,
Friday, October 23, 2009
Stress and Somaticism
I have often noticed how stress wears my patients down, and causes multiple somatic symptoms. If the mind is unhappy and/or stressed, it will always make the body hurt. If you are fortunate, the discomfort induced by stress is always the same: IBS, headache, low back pain, etc., so that you can use the physical symptom as a signal to you that you are under stress, and try to abort a full-blown attack of pain by minimizing or avoiding the stress. I am most concerned that the brain will get so used to pain that the pain circuit becomes self-perpetuating, as it can in post-herpetic neuralgia. It is more difficult to reduce or eliminate the stress when the stress is due to a dysfunctional relationship. I look for situations that can produce stress in my patients' minds by asking a few simple questions at their first exam and at annual physicals: what do you do that you most dislike doing? when was your last vacation? do you look forward to coming home at the end of the day? do you look forward to going to work?
I have found that a frequent cause of stress is due to living with a person with a character disorder, whose view of the world is impervious to logic, manners, or sensitivity. Often the patient is unaware of how permanent the dysfunctional situation is. The most severe case of this is in the borderline personality. I recall that psychiatry attendings would comment that they would never allow first year residents to treat borderlines, because they invariably sabotage their treatment, which can trigger unresolved anger in the therapist.
As I was preparing this blog, I received an e-mail which described what it was like to live with a borderline personality. I think the writer described the household situation extremely well. I am therefore posting the link here, in the hopes that you all will click on it:
http://www.bpl411.org/walkingoneggshells.html
The title of the article is "Walking on Eggshells", and this phrase is a perfect analogy to what life is like when you live with a person with a borderline personality disorder. (I personally think that these borderlines have a tremendous amount of unrecognized anger, but that is for another blog.)
I have found that a frequent cause of stress is due to living with a person with a character disorder, whose view of the world is impervious to logic, manners, or sensitivity. Often the patient is unaware of how permanent the dysfunctional situation is. The most severe case of this is in the borderline personality. I recall that psychiatry attendings would comment that they would never allow first year residents to treat borderlines, because they invariably sabotage their treatment, which can trigger unresolved anger in the therapist.
As I was preparing this blog, I received an e-mail which described what it was like to live with a borderline personality. I think the writer described the household situation extremely well. I am therefore posting the link here, in the hopes that you all will click on it:
http://www.bpl411.org/walkingoneggshells.html
The title of the article is "Walking on Eggshells", and this phrase is a perfect analogy to what life is like when you live with a person with a borderline personality disorder. (I personally think that these borderlines have a tremendous amount of unrecognized anger, but that is for another blog.)
Monday, October 5, 2009
Screening Tests---Part I
This blog is the first of a staggered series in which screening tests will be discussed and analyzed. By a screening test, I mean a test done as part of a routine physical, perhaps suggested by the medical history. I define a useful screening test as one which detects a disease at such a time that medical treatment can cure the disease or prolong life.
Since one problem with screening tests is the occurrence of false positives, then either the screening test must be "very" sensitive (few false positives) or else the disease being tested for must have a "high" incidence. The definition of "very" and "high" depends on the disease, the doctor, the patient, the community, and the circumstances. We also would like the sensitive screening test to be able to be supplemented with a more precise test of high specificity (few false negatives). At the present,for instance,the Western Blot is the gold standard for the second test with both Lyme disease, and HIV/AIDS. (I should note parenthetically that the Blood Banks prefer tests of low sensitivity, since they do not want to risk transfusing infected blood.)
There are four reasons for doing screening tests (and again, I want to emphasize that I am NOT talking about diagnostic tests, where a disease is suspected).The reasons are:
a) To benefit the patient (obvious)
b) To benefit the patient's family (but then the patient must give informed consent, since the test will not benefit him directly)
c) To benefit society (again, the patient's consent is required)
d) The patient or a family member suggests it. In this case, it is vital to remember that NO DOCTOR EVER GOT SUED FOR DOING A TEST, but only for not doing one. It does no good to tell a jury that the odds of Leprosy were 1:10,000. If the patient asks for the nine-banded armadillo test, and you refuse, and the patient comes down with leprosy, then the jury will just see that the patient asked for a test, you refused, and he suffered preventable injury as a result.
I am not going to discuss the screening tests to be done on a female who plans to become pregnant, or who is pregnant, or a patient about to be immunosuppressed by steroids,or anti-cancer drugs, or organ transplant treatment, or asplenic patients, etc.
It goes without saying that before any test is done on a patient, he/she should know which tests you are ordering---kidney tests, liver tests, thyroid tests, etc.
Blood pressure---we know that treating high blood pressure (especially systolic) will help prevent strokes. Oddly enough, although there is an entity called hypertensive heart disease, there is not good data to show that lowering blood pressure prevents this.
CBC---detecting anemia leads to a search for the cause and treatment of both the anemia and the underlying cause. Detecting a persistently elevated or low white blood count or platelet count will generally lead to a bone marrow biopsy, which may yield a treatable disease on analysis.
BUN/Creat---elevated kidney tests leads to treatment of early kidney failure.
LFT---elevated liver tests and/or GGTP leads to testing for hepatitis, fatty infiltration of the liver, alcoholism, etc.
Uric acid---elevated in chronic alcoholism, and a warning of risk for gout.
PPD---for certain patients, a skin test for tuberculosis is appropriate.
VDRL---ditto for a screen for syphilis. Caveat: both syphilis and Lyme disease are caused by a spirochete, and Lyme disease is a common cause of a false positive syphilis test. The reflex test for syphilis is FTA-ABS, which turns positive when a patient has syphilis, and almost never reverts to negative. Second caveat: when doing a spinal tap for neurosyphilis, only do the VDRL; nobody knows what to do with a positive CSF FTA.
Stool for blood--- screens for CA of colon, but the most common cause of a positive stool for blood lies in esophageal or gastric irritation/ulceration. Over the age of 65, the cause for the positive stool is not found in 10% of the patients, even when angiodysplasia of the cecum is carefully looked for.
TFT---thyroid abnormality is very common in women, especially after pregnancy, and seems to follow in the female line.
25-OH Vitamin D---low values can contribute to osteoporosis, so females with osteoporosis (and probably those approaching menopause) should be tested.
PSA---as of now, there is no good evidence that treating prostate cancer saves lives, so this test is of doubtful use. Different medical groups recommend for (CA society, urologists) or against (Canadian Health Task Force, USPHS) it.
Fe/TIBC/ferritin---I test all menstruating females and vegetarians. ? if you should test everyone else once to screen for hemochromatosis.
Vitamin B-12----test vegetarians, Nordics, Latin Americans, and patients over 50.
Cholesterol/triglycerides/LDL----screen, and then discuss results with patient. there are no hard and fast rules for treatment, or, if there are, they change every three years. More about cholesterol in a future blog.
U/A----tremendous screen for many diseases. You can even use it to screen for diabetes.
Glucose---Enormous argument in literature about how intensively to treat diabetes, and the benefits thereof, but a patient with diabetes needs other special medical treatment, and needs to be made aware if it. Back it up with HgbA1C.
HgbA1C---probably the most efficient screen for diabetes.
CRP---as a complement to cholesterol panel---every other year a paper says that screening is beneficial, or is not beneficial. Flip a coin. Patients expect it now, so I do it.
ESR---a useful screen for inflammatory processes, e.g. bacterial infection, TB, CA, certain arthritidies. Very useful in the ER, since a normal ESR (and it does rise with age---10-20 for men, 10-30 for women, and then maybe 5 points every 10 years) raises the probability of a viral process. Over 100 means a serious process is going on.
Testosterone---serum and free---baseline it at age 50. Both men and women may need supplementation as they get older.
Blood test for pregnancy---on all hospital admissions and ER visits.
HIV/AIDS--screen and Western Blot follow-up on positives. For appropriate patients. Remember that there are reports in the literature that the Flu Vaccine can lead to a false positive screening test for HIV for 4 to 8 weeks after vaccination, but not a false positive Western Blot. I once had five fraternity brothers in December come to me, all of whom gave blood in a college blood drive, and all of whom had false positive HIV screens one month after flu vaccine.
Lyme disease---only when I suspect it, or the patient is unusually insistent. Reasoning is too involved to go into here.
Tissue Transglutaminase IgA (celiac screen) and lactose intolerance screen---really should be part of a work-up for every patient with Irritable Bowel Syndrome, as well as a stool for Giardia antigen. (I know, this is diagnostic, not screening per se, but no logical system is totally complete, according to Godel.)
Hg+---If a patient eats pelagic fish three or more times a week, I check the blood mercury level.
Blood type---useless. The hospital would never believe the patient's memory, and would re-type and cross-match before transfusion.
Sometimes a patient comes in who has had unprotected sex, or who is about to start with a new sexual partner, and wants to be tested for "everything". I always tell them to help their country by donating a unit of blood, and the blood bank will routinely screen for "everything" (e.g. Hepatitis A,B, and C, syphilis, AIDS, West Nile Virus, etc.) I also comment that the next insurance company that requests a copy of his/her medical records may wonder why tests for "everything" were done, and raise the premium.
I have deliberately not mentioned mammograms, EKG's, stress tests, Ca++/CT scans, USG of carotid arteries, etc. They will be discussed in a future blog.
If you know of a blood test you use for your screening that I have not mentioned, please e-mail it to me as a blog comment, so everyone can see it when it is posted. Feel free to use a pseudonmyn if you prefer. I promise to comment on all posts.
Since one problem with screening tests is the occurrence of false positives, then either the screening test must be "very" sensitive (few false positives) or else the disease being tested for must have a "high" incidence. The definition of "very" and "high" depends on the disease, the doctor, the patient, the community, and the circumstances. We also would like the sensitive screening test to be able to be supplemented with a more precise test of high specificity (few false negatives). At the present,for instance,the Western Blot is the gold standard for the second test with both Lyme disease, and HIV/AIDS. (I should note parenthetically that the Blood Banks prefer tests of low sensitivity, since they do not want to risk transfusing infected blood.)
There are four reasons for doing screening tests (and again, I want to emphasize that I am NOT talking about diagnostic tests, where a disease is suspected).The reasons are:
a) To benefit the patient (obvious)
b) To benefit the patient's family (but then the patient must give informed consent, since the test will not benefit him directly)
c) To benefit society (again, the patient's consent is required)
d) The patient or a family member suggests it. In this case, it is vital to remember that NO DOCTOR EVER GOT SUED FOR DOING A TEST, but only for not doing one. It does no good to tell a jury that the odds of Leprosy were 1:10,000. If the patient asks for the nine-banded armadillo test, and you refuse, and the patient comes down with leprosy, then the jury will just see that the patient asked for a test, you refused, and he suffered preventable injury as a result.
I am not going to discuss the screening tests to be done on a female who plans to become pregnant, or who is pregnant, or a patient about to be immunosuppressed by steroids,or anti-cancer drugs, or organ transplant treatment, or asplenic patients, etc.
It goes without saying that before any test is done on a patient, he/she should know which tests you are ordering---kidney tests, liver tests, thyroid tests, etc.
Blood pressure---we know that treating high blood pressure (especially systolic) will help prevent strokes. Oddly enough, although there is an entity called hypertensive heart disease, there is not good data to show that lowering blood pressure prevents this.
CBC---detecting anemia leads to a search for the cause and treatment of both the anemia and the underlying cause. Detecting a persistently elevated or low white blood count or platelet count will generally lead to a bone marrow biopsy, which may yield a treatable disease on analysis.
BUN/Creat---elevated kidney tests leads to treatment of early kidney failure.
LFT---elevated liver tests and/or GGTP leads to testing for hepatitis, fatty infiltration of the liver, alcoholism, etc.
Uric acid---elevated in chronic alcoholism, and a warning of risk for gout.
PPD---for certain patients, a skin test for tuberculosis is appropriate.
VDRL---ditto for a screen for syphilis. Caveat: both syphilis and Lyme disease are caused by a spirochete, and Lyme disease is a common cause of a false positive syphilis test. The reflex test for syphilis is FTA-ABS, which turns positive when a patient has syphilis, and almost never reverts to negative. Second caveat: when doing a spinal tap for neurosyphilis, only do the VDRL; nobody knows what to do with a positive CSF FTA.
Stool for blood--- screens for CA of colon, but the most common cause of a positive stool for blood lies in esophageal or gastric irritation/ulceration. Over the age of 65, the cause for the positive stool is not found in 10% of the patients, even when angiodysplasia of the cecum is carefully looked for.
TFT---thyroid abnormality is very common in women, especially after pregnancy, and seems to follow in the female line.
25-OH Vitamin D---low values can contribute to osteoporosis, so females with osteoporosis (and probably those approaching menopause) should be tested.
PSA---as of now, there is no good evidence that treating prostate cancer saves lives, so this test is of doubtful use. Different medical groups recommend for (CA society, urologists) or against (Canadian Health Task Force, USPHS) it.
Fe/TIBC/ferritin---I test all menstruating females and vegetarians. ? if you should test everyone else once to screen for hemochromatosis.
Vitamin B-12----test vegetarians, Nordics, Latin Americans, and patients over 50.
Cholesterol/triglycerides/LDL----screen, and then discuss results with patient. there are no hard and fast rules for treatment, or, if there are, they change every three years. More about cholesterol in a future blog.
U/A----tremendous screen for many diseases. You can even use it to screen for diabetes.
Glucose---Enormous argument in literature about how intensively to treat diabetes, and the benefits thereof, but a patient with diabetes needs other special medical treatment, and needs to be made aware if it. Back it up with HgbA1C.
HgbA1C---probably the most efficient screen for diabetes.
CRP---as a complement to cholesterol panel---every other year a paper says that screening is beneficial, or is not beneficial. Flip a coin. Patients expect it now, so I do it.
ESR---a useful screen for inflammatory processes, e.g. bacterial infection, TB, CA, certain arthritidies. Very useful in the ER, since a normal ESR (and it does rise with age---10-20 for men, 10-30 for women, and then maybe 5 points every 10 years) raises the probability of a viral process. Over 100 means a serious process is going on.
Testosterone---serum and free---baseline it at age 50. Both men and women may need supplementation as they get older.
Blood test for pregnancy---on all hospital admissions and ER visits.
HIV/AIDS--screen and Western Blot follow-up on positives. For appropriate patients. Remember that there are reports in the literature that the Flu Vaccine can lead to a false positive screening test for HIV for 4 to 8 weeks after vaccination, but not a false positive Western Blot. I once had five fraternity brothers in December come to me, all of whom gave blood in a college blood drive, and all of whom had false positive HIV screens one month after flu vaccine.
Lyme disease---only when I suspect it, or the patient is unusually insistent. Reasoning is too involved to go into here.
Tissue Transglutaminase IgA (celiac screen) and lactose intolerance screen---really should be part of a work-up for every patient with Irritable Bowel Syndrome, as well as a stool for Giardia antigen. (I know, this is diagnostic, not screening per se, but no logical system is totally complete, according to Godel.)
Hg+---If a patient eats pelagic fish three or more times a week, I check the blood mercury level.
Blood type---useless. The hospital would never believe the patient's memory, and would re-type and cross-match before transfusion.
Sometimes a patient comes in who has had unprotected sex, or who is about to start with a new sexual partner, and wants to be tested for "everything". I always tell them to help their country by donating a unit of blood, and the blood bank will routinely screen for "everything" (e.g. Hepatitis A,B, and C, syphilis, AIDS, West Nile Virus, etc.) I also comment that the next insurance company that requests a copy of his/her medical records may wonder why tests for "everything" were done, and raise the premium.
I have deliberately not mentioned mammograms, EKG's, stress tests, Ca++/CT scans, USG of carotid arteries, etc. They will be discussed in a future blog.
If you know of a blood test you use for your screening that I have not mentioned, please e-mail it to me as a blog comment, so everyone can see it when it is posted. Feel free to use a pseudonmyn if you prefer. I promise to comment on all posts.
Wednesday, September 16, 2009
The Obesity "Epidemic" and Nutrition
There has been a lot of talk and newsprint about the obesity "epidemic" that is occurring, but I feel that certain facts have been ignored, as well as certain principles of human behavior. Whenever patients tell me that doctors don't know much about human nutrition, I generally comment that neither does anybody else. There have been very few double-blinded studies about the effect of nutrition on human health and well-being, but that doesn't seem to stop people from being more certain about human nutrition than the facts will allow:
1) No one knows how many meals a human should eat each day: one, six, or whatever.
2) No one knows at what time of the day the largest meal should be eaten, (but if you eat within 2 hours of bedtime you increase your risk of reflux esophagitis).
3) If you eat only vegetables, you will die from pernicious anemia, aka vitamin B-12 deficiency, since vegetable cells contain NO vitamin B-12; vitamin B-12 is is needed for animal cell DNA synthesis, and not for vegetable DNA.
4) Nobody smiles in a vegetarian restaurant, but everyone looks ecstatic at a steak restaurant such as Peter Luger's.
5) The only vegetables that seem to benefit human health when added to the diet are alcohol (beer, wine or whiskey), dark chocolate, olive oil (the Mediterranean diet), and the bark of the willow (salicylic acid, which Bayer transformed into aspirin).
6) No one knows how much water/fluids a human should drink each day, but the general consensus is a minimum of 0.5 liters, since that is the urine volume required to excrete the products of oxidation in maximally concentrated urine.
7) In a hospital, the minimum IV should be D5/0.5NaCl with 20 meq of KCl at 125 cc/hr, and then adjust to the patient's condition.
8) Fat cells require cholesterol and preferentially absorb insulin, so if you are a diabetic or have a cholesterol problem, you should lose weight.
9) Cholesterol does not increase cholesterol, so egg yolks are OK, and, in fact, eggs have about the highest protein per gram of any food.
10) If you do not have high blood pressure and are not diabetic, then salt and sugar should cause you no problem.
11) Almost all my patients who on oral medicine for diabetes cannot/will not lose weight, even after I tell them that a 20m pound weight loss will probably (temporarily) cure their diabetes.
12) As you get older, your metabolism slows up, and your blood pressure, cholesterol and fasting blood sugar generally increase.
13) Most women find it impossible to lose the last 5 pounds necessary to get down to their pre-pregnancy weight.
14) Most men gain at least 10-15 pounds the first year they work or get married, in the first case from lack of exercise (8-10 hrs/day behind a desk), and in the second case from an increase in calories consumed at dinner.
15) Cigarette smoking increases your metabolism and decreases your appetite, so most men gain 10 pounds the first year they quit smoking and most women gain 15.
16) And this is key: The first pleasure all humans got was from being fed, either at their mother's breast or from a bottle. The first desire to be fulfilled was that created by hunger. Therefore, it feels good to eat, and it is difficult to deny yourself this fundamental pleasure and to feel hungry, which you must do in order to lose weight. The first time a woman's dress goes from size 6 to size 8, or a man's belt from 32" to 34", they rarely say "I must lose some weight". It has nothing to do with not knowing how many calories they are eating, or doctor-patient information, or lack of electronic medical records. Most patients don't care enough about how they look after gaining 10 pounds, or believe that there is enough increased health risk from added weight to lose the additional pounds. Men actually are less stressed by their appearance when overweight than are women: When a woman looks full face into a mirror, she sees the added weight that went to her hips, but when a man looks in a mirror the same way, he barely sees the added weight that went to his belly.Losing weight means being willing to suffer present pain for future gain, and the human brain is not geared to worry about the future, but rather to fasten the seatbelt 10 seconds before the car hits a brick wall. The same comment about future gain also holds true for exercise, but the average patient finds it much easier to exercise than to lose weight.
17) I also think the reason that almost all humans love ice cream is that it is rich in sugar and fat, just like mother's milk.
18) Don't you think that by the time he/she is 7 days old, a baby is addicted to sugar by Pavlovian conditioning: whenever he/she is hungry (or whatever is felt), this discomfort is assuaged by a warm sweet fluid, so that the baby associates warmth (chicken soup?) and sweets with a sense of comfort and well-being. It's difficult to see how an external message can easily overcome this dependence.
19) Final observation: based on my informal questioning of my patients, the majority of adults who loved chocolate ice cream as a child can curl their tongue (I can!), while the majority of patients who did not like chocolate ice cream cannot. I wonder what the genetic linkage is. I personally thought that my friends who preferred vanilla ice cream to chocolate could not have possibly tasted the same chocolate flavor that I did.
1) No one knows how many meals a human should eat each day: one, six, or whatever.
2) No one knows at what time of the day the largest meal should be eaten, (but if you eat within 2 hours of bedtime you increase your risk of reflux esophagitis).
3) If you eat only vegetables, you will die from pernicious anemia, aka vitamin B-12 deficiency, since vegetable cells contain NO vitamin B-12; vitamin B-12 is is needed for animal cell DNA synthesis, and not for vegetable DNA.
4) Nobody smiles in a vegetarian restaurant, but everyone looks ecstatic at a steak restaurant such as Peter Luger's.
5) The only vegetables that seem to benefit human health when added to the diet are alcohol (beer, wine or whiskey), dark chocolate, olive oil (the Mediterranean diet), and the bark of the willow (salicylic acid, which Bayer transformed into aspirin).
6) No one knows how much water/fluids a human should drink each day, but the general consensus is a minimum of 0.5 liters, since that is the urine volume required to excrete the products of oxidation in maximally concentrated urine.
7) In a hospital, the minimum IV should be D5/0.5NaCl with 20 meq of KCl at 125 cc/hr, and then adjust to the patient's condition.
8) Fat cells require cholesterol and preferentially absorb insulin, so if you are a diabetic or have a cholesterol problem, you should lose weight.
9) Cholesterol does not increase cholesterol, so egg yolks are OK, and, in fact, eggs have about the highest protein per gram of any food.
10) If you do not have high blood pressure and are not diabetic, then salt and sugar should cause you no problem.
11) Almost all my patients who on oral medicine for diabetes cannot/will not lose weight, even after I tell them that a 20m pound weight loss will probably (temporarily) cure their diabetes.
12) As you get older, your metabolism slows up, and your blood pressure, cholesterol and fasting blood sugar generally increase.
13) Most women find it impossible to lose the last 5 pounds necessary to get down to their pre-pregnancy weight.
14) Most men gain at least 10-15 pounds the first year they work or get married, in the first case from lack of exercise (8-10 hrs/day behind a desk), and in the second case from an increase in calories consumed at dinner.
15) Cigarette smoking increases your metabolism and decreases your appetite, so most men gain 10 pounds the first year they quit smoking and most women gain 15.
16) And this is key: The first pleasure all humans got was from being fed, either at their mother's breast or from a bottle. The first desire to be fulfilled was that created by hunger. Therefore, it feels good to eat, and it is difficult to deny yourself this fundamental pleasure and to feel hungry, which you must do in order to lose weight. The first time a woman's dress goes from size 6 to size 8, or a man's belt from 32" to 34", they rarely say "I must lose some weight". It has nothing to do with not knowing how many calories they are eating, or doctor-patient information, or lack of electronic medical records. Most patients don't care enough about how they look after gaining 10 pounds, or believe that there is enough increased health risk from added weight to lose the additional pounds. Men actually are less stressed by their appearance when overweight than are women: When a woman looks full face into a mirror, she sees the added weight that went to her hips, but when a man looks in a mirror the same way, he barely sees the added weight that went to his belly.Losing weight means being willing to suffer present pain for future gain, and the human brain is not geared to worry about the future, but rather to fasten the seatbelt 10 seconds before the car hits a brick wall. The same comment about future gain also holds true for exercise, but the average patient finds it much easier to exercise than to lose weight.
17) I also think the reason that almost all humans love ice cream is that it is rich in sugar and fat, just like mother's milk.
18) Don't you think that by the time he/she is 7 days old, a baby is addicted to sugar by Pavlovian conditioning: whenever he/she is hungry (or whatever is felt), this discomfort is assuaged by a warm sweet fluid, so that the baby associates warmth (chicken soup?) and sweets with a sense of comfort and well-being. It's difficult to see how an external message can easily overcome this dependence.
19) Final observation: based on my informal questioning of my patients, the majority of adults who loved chocolate ice cream as a child can curl their tongue (I can!), while the majority of patients who did not like chocolate ice cream cannot. I wonder what the genetic linkage is. I personally thought that my friends who preferred vanilla ice cream to chocolate could not have possibly tasted the same chocolate flavor that I did.
Saturday, September 5, 2009
Radiation, X-rays, Medicine, and Cancer
The question of the relationship between radiation, X-rays, cosmic rays, (radioactive) radon gas, and cancer is a murky one, and there are many unanswered questions. In some cases, exposure to radiation gives the patient an increased lifetime risk for cancer, and for reasons unknown to medical science, the risk for women is greater than the risk for men. Because of the very long time delays that can be involved (up to 45 years has been recorded), it would appear that radiation is a cancer potentiator, rather than a direct inducer.(But radiation itself can be an inducer for a cell that has already been potentiated.) In the cases (Hiroshima, Chernobyl) where a direct and short time correlation has been observed, it is probable that the intensity of the radiation is also important. We know that high energy, high intensity radiation is lethal to humans, and lower intensity radiation is lethal to cancer cells. We also know about radiation sickness. We have a rough idea of the lethal dose of radiation (which is different for alpha rays, beta rays, photons (gamma rays), neutrons, and cosmic radiation). We know how much radiation shielding astronauts need to keep them alive.
We do not know, and will never know, the LD50 dose for humans for any type of radiation. We cannot even measure human radiation exposure. The unit called the Sievert is used, but the Sievert depends on the type of radiation, the energy, and, most important of all, the amount of radiation energy absorbed by various tissues, and this latter term can only be estimated (and very poorly, at that) from animal studies. We also know that we are missing some scientific factor: The residents of Denver dwell 5,000 feet higher than the residents of NYC, and therefore have one mile less of atmospheric shielding from cosmic rays. How is it then that Denver residents do not have a significantly higher rate of cancer than do Manhattanites?
There was a recent article published in JAMA detailing the increased amount of radiation we are all getting over our lifetime from X-ray studies. In fact, the U.S. gov't has officially classified radiation as a carcinogen. Why is it then that no patient is ever given a release form to sign than delineates the estimated immediate and lifetime personal carcinogenic risk from the proposed X-ray study? (I once tried to generate and have my ER patients sign such a form, and I was immediately told by the chairmen of Radiology and Medicine to stop.)
Thirty years ago, when I was a physics professor, I started to do some experiments with a colleague of mine from Princeton. Since he had a joint appointment with Princeton Physics Dept. and the Princeton Plasma Physics Lab, which meant that he also worked on the Stellarator, our research was classified (and still is, for all I know). We then co-opted a physicist at Oak Ridge Nat'l Labs for good radioactive sources. We were trying to see if there is a minimum radiation dose below which there is NO cancer risk. The belief now as well as then was that there is not, and that there is no minimum safe dose of radiation. We were unable to come to a definite conclusion. We could not determine whether or not a certain straight line on a graph passed through the origin.
The universal fear of radiation is so great that MRI was initially called by its correct name NMR (Nuclear Magnetic Resonance), but NMR was changed to MRI so as to not scare patients away from the MRI. We could greatly decrease food poisoning and contamination with germs and bugs by subjecting wheat, fruit, etc., to killing levels of radiation, but again, the public is so fearful of the possible consequences of radiation that Congress has never passed a food-radiation enabling law, and we can therefore expect future lethal food outbreaks similar to the E. Coli in hamburgers. The one time we should have been fearful, we were not, and many women who licked camel's hair brushes to make a finer point before painting the numbers on a wristwatch with a radioactive chemical developed mouth and jaw cancers.
I guess this blog is written with mixed emotions, and no firm purpose. As a physicist I have the greatest respect for the dangers of radiation, and as a physician, I know its many beneficial uses. I wish we all knew more!
We do not know, and will never know, the LD50 dose for humans for any type of radiation. We cannot even measure human radiation exposure. The unit called the Sievert is used, but the Sievert depends on the type of radiation, the energy, and, most important of all, the amount of radiation energy absorbed by various tissues, and this latter term can only be estimated (and very poorly, at that) from animal studies. We also know that we are missing some scientific factor: The residents of Denver dwell 5,000 feet higher than the residents of NYC, and therefore have one mile less of atmospheric shielding from cosmic rays. How is it then that Denver residents do not have a significantly higher rate of cancer than do Manhattanites?
There was a recent article published in JAMA detailing the increased amount of radiation we are all getting over our lifetime from X-ray studies. In fact, the U.S. gov't has officially classified radiation as a carcinogen. Why is it then that no patient is ever given a release form to sign than delineates the estimated immediate and lifetime personal carcinogenic risk from the proposed X-ray study? (I once tried to generate and have my ER patients sign such a form, and I was immediately told by the chairmen of Radiology and Medicine to stop.)
Thirty years ago, when I was a physics professor, I started to do some experiments with a colleague of mine from Princeton. Since he had a joint appointment with Princeton Physics Dept. and the Princeton Plasma Physics Lab, which meant that he also worked on the Stellarator, our research was classified (and still is, for all I know). We then co-opted a physicist at Oak Ridge Nat'l Labs for good radioactive sources. We were trying to see if there is a minimum radiation dose below which there is NO cancer risk. The belief now as well as then was that there is not, and that there is no minimum safe dose of radiation. We were unable to come to a definite conclusion. We could not determine whether or not a certain straight line on a graph passed through the origin.
The universal fear of radiation is so great that MRI was initially called by its correct name NMR (Nuclear Magnetic Resonance), but NMR was changed to MRI so as to not scare patients away from the MRI. We could greatly decrease food poisoning and contamination with germs and bugs by subjecting wheat, fruit, etc., to killing levels of radiation, but again, the public is so fearful of the possible consequences of radiation that Congress has never passed a food-radiation enabling law, and we can therefore expect future lethal food outbreaks similar to the E. Coli in hamburgers. The one time we should have been fearful, we were not, and many women who licked camel's hair brushes to make a finer point before painting the numbers on a wristwatch with a radioactive chemical developed mouth and jaw cancers.
I guess this blog is written with mixed emotions, and no firm purpose. As a physicist I have the greatest respect for the dangers of radiation, and as a physician, I know its many beneficial uses. I wish we all knew more!
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