I did physics research for over 10 years, and clinical medical research for over 25 years. I have reviewed physics papers (as assistant editor of a physics journal) and medical papers, especially for the Annals of Internal Medicine. As a physics reviewer, I could often suggest revisions that would make the paper publishable, but as a medical reviewer I found this to be impossible. During my 10 year tenure as a reviewer in my medical field, I would estimate that I rejected 90% of the papers I reviewed, usually for lack of scientific rigor, and my negative review was never overridden by the article being published in a medical journal of similar significance.
There are various problems with scientific rigor in medical journals, but the most serious is their improper use of statistics, followed by lack of reproducibility, i.e. other researchers cannot replicate the results. In science, this is usually due to fraud (black ink spots placed on mice) or self-delusion (N-rays in France), but in medicine it is usually a sign that the first result was not entirely correct. I always tell my patients who rush in breathlessly with the latest report of medical research to wait for the second and confirming report. The second report often does not confirm the first. I also tell them to beware of medical studies that look for surrogate endpoints (lowering of blood pressure or cholesterol) rather than significant clinical endpoints(stroke, heart attack).
There are too many books, articles, and TV shows including some authored by doctors, that are studded with phrases such as "the evidence suggests", "it seems reasonable that", "past history shows" or all patients with or without condition X did or did not have disease Y. None of these statements contains a scientific truth, and such phrases would never appear in a physics or chemistry journal. A hard fact is rarely stated, such as that 500mg 2 x day of Vitamin C will lower your uric acid level by approximately 1.0 and thereby reduce your risk of a gout attack (this latter statement has been substantiated by research). We have very little good clinical evidence about many medical conditions, although it is almost universally agreed that antibiotics can kill bacteria and save lives, and that vaccinations are beneficial.
We still don't understand why only 10% of smokers get lung cancer (although we know with 100% certainty that all smokers will develop emphysema if they smoke long enough---40 pack years is usually sufficient). We don't understand why different patients with high blood pressure develop problems in different organs: stroke, kidney failure, heart attack. We don't understand why one alcoholic gets cirrhosis of the liver, one dies of hemorrhagic pancreatitis, and one gets the Korsakoff Syndrome. Similarly, we cannot predict which organ will fail in a patient with insulin-dependent diabetes, or if in fact any of them will.
The main problem, of course, is that each patient is an individual biochemical laboratory, and no two patients react the same way to any medical intervention. This is always true if the patient is on three or more drugs, since almost all pharmacological studies are done on patients on no drugs. (And no one knows how all the over-the-counter health foods interact with anything.) Many medical recommendations are based on three or fewer studies, while there are over 50 verifications of Bell's Inequality in quantum physics, and hundreds of measurements of the speed of light. Furthermore the results of a medical study apply only statistically, in that not everyone is cured of strep throat by penicillin, and some people with strep throat recover without any antibiotic at all. If I were responsible for the treatment of 1,000,000 patients, I would have no hesitation in making certain recommendations, but if I am recommending treatment for just one person, I am never 100% certain if the treatment (a) will work, and (b) is necessary.
In a previous blog I carefully reviewed the mathematical and statistical flaws inherent in all meta-analyses, so let me just say here that every result suggested by any meta-analysis should be verified by double-blinded random testing, despite the rapidity with which the media trumpet the results of the study.
I should also mention the problem of confounding conditions. When we do a clinical intervention study, we try to make the treated and control patients physiologically as similar as possible. When we do not, we come to the false conclusion that coffee drinkers suffer more heart attacks than do non-drinkers, until it was realized that coffee drinkers also smoke more cigarettes than the non-drinkers. We still have conflicting studies on whether tall people live longer or shorter lives than short people, and are similarly lacking in knowledge about righties versus lefties. (But I do wonder why all left-handed tennis players seem to have a natural topspin on their forehand on television.) Many men gleefully reported to their wives and significant others the one study that seemed to indicate that frequent ejaculations had a protective effect against prostate cancer, but many fewer people and organizations trumpet the many studies that show that mild alcohol ingestion is protective against heart attacks, and the fact that NO study has shown that mild alcohol ingestion contributes to heart attacks.
And please ignore all studies reported at all medical conferences. Until these studies have been written up, reviewed and then published, there is no way for anyone to verify their accuracy. And beware doubly of the placebo effect: In the 1950's, before we had ethical treatment review boards, 12 patients with angina had open heart surgery (I will not name the surgeon or the institution). 6 patients had the "real" surgery, and the other 6 had "sham" surgery, in that they only had their sternum (chest) split open, and then were wired shut again without anything being done to their hearts. 4 out of 6 in each group had their anginal pain and symptoms relieved.
What I am trying to say is that doctors overstate the degree of medical certainty behind many of their medical prescriptions and suggestions. Remember that before 1973 homosexuality was a psychiatric disorder, and in the new DSM-V manual you will find that narcissism will no longer be one. (Although I expect that if a drug company develops a medicine to treat narcissism it will quickly become a disease again.)
Finally, if your internet searches seem to indicate that some doctor or institution has a "special" treatment for a disease, please remember that all doctors want to cure their patients, and many would not mind becoming famous. If someone had a new cure for lung cancer, or rheumatoid arthritis, it would not be kept secret, and doctors throughout the world would know about it. There is one case of medical secrecy in history: A family of French Huguenot doctors, the Chamberlens fled to England in the 16th century. One of them invented obstetrical forceps to aid with difficult births. (Remember that C-sections were almost uniformly fatal in those days.) They became famous for their work with difficult deliveries, and they kept the existence of obstetrical forceps secret for over 150 years. I do not think that this would be possible now.
Friday, February 4, 2011
Monday, January 31, 2011
Preventing Hypertensive Stroke
This blog is rather short, because the basic facets and results are quite clear. The biggest risk factor for stroke in the general public is high blood pressure. The first anti-hypertensive to conclusively demonstrate a reduction in stroke risk was thiazide diuretics. They apparently work by lowering the total amount of salt in the body. We also know that thiazide diuretics are synergistic with every other anti-hypertensive medicine, in that diuretics potentiate the effect of every other hypertensive treatment. In fact, if you are on two anti-hypertensive drugs, one of them should be a diuretic, unless you have some very unusual medical condition.
So the message of this blog is that diuretics prevent strokes. I raise this point because recent medical studies have been trumpeted in the newspapers as being more effective or more potent than thiazides in lowering blood pressure. But the question to ask your doctor is if this new and "better" anti-hypertensive treatment has been shown to lower the risk of stroke. If it hasn't, then either ask him to add a diuretic, or see a specialist in hypertension, to see if yours is a special case.
This is a small example of substituting an endpoint for a clinical result. We have seen similar problems in whether or not lowering cholesterol prevents heart attacks, or if lowering CPR is beneficial. To use my favorite analogy, just because you have a better "tool" for returning the arrow over the elevator to the lobby than simply pushing the lobby button, it doesn't mean that your tool will get the elevator down any faster.
So the message of this blog is that diuretics prevent strokes. I raise this point because recent medical studies have been trumpeted in the newspapers as being more effective or more potent than thiazides in lowering blood pressure. But the question to ask your doctor is if this new and "better" anti-hypertensive treatment has been shown to lower the risk of stroke. If it hasn't, then either ask him to add a diuretic, or see a specialist in hypertension, to see if yours is a special case.
This is a small example of substituting an endpoint for a clinical result. We have seen similar problems in whether or not lowering cholesterol prevents heart attacks, or if lowering CPR is beneficial. To use my favorite analogy, just because you have a better "tool" for returning the arrow over the elevator to the lobby than simply pushing the lobby button, it doesn't mean that your tool will get the elevator down any faster.
Tuesday, January 18, 2011
Helping Patients to Improve Their Health ?
There has been a lot of press and discussion about how giving patients more information about their health and healthy habits in general will improve their health, but I have never seen much evidence of this. In fact, a recent 13-month study of Taco Bell, which posts the calorie count of each item in its menu, showed that customers did not decrease their total caloric intake. It's somewhat similar to smokers smoking a greater number of low-nicotine cigarettes to get the same total nicotine effect, or people eating more of a low calorie food. I also can't see how having all their electronic medical records will give them healthier habits.
Every adult knows (or at least is told by his doctor and government authorities) that he/she can become healthier by stopping smoking, losing weight, and exercising, with very little effect on their habits. In all my years of practice I have never been able (even with the help of a nutritionist) to get any overweight new onset diabetic patient to lose weight, even after I told them that the loss of 20 pounds would probably reverse their diabetes. In fact the only patients I have ever seen voluntarily and efficiently lose weight is men after their first heart attack. The heart attack removes their denial that they could ever get seriously ill. Most of them immediately go on a diet whose major component is eating fish 7 days a week. This works, but after 6 months I have to check their blood for toxic mercury levels. The only healthy habit my patients willingly follow is that of having a glass of wine daily, fish oil twice a day, and dark chocolate. This is probably because two of the three taste pretty good, and none of it seems like real medicine.
The basic problem is that the human brain seems to be geared to avoid a life-threatening problem only if it is perceived to be imminent, i.e. to occur in the next 10 seconds, but not if the threat is 10 or 20 years in the future. So not every driver belts in, every cigarette smoker (and they know cigarettes are also called "coffin nails") intellectually believes that cigarettes may be dangerous, but also believes that the particular cigarette being smoked at this minute will not be lethal. Every adult understands the dangers of unprotected sex, but 25% of my college student patients (male or female) have unprotected sex at least once during college, usually when they are having sex with someone who is not their usual partner.
When I am medical ward attending, I poll my residents to see how many of them actually finished the prescribed number of days for their last antibiotic prescription, and the answer is always fewer than 75% of them. I then ask them to sit down and talk with the next ward patient who refuses a test or a prescription and try to understand their reasons and motives, rather than immediately call for a psychiatry consult. Similarly, I have regular patients who have never had a mammogram, a colonoscope, a flu vaccine, etc. However, I can usually get them to take a tetanus shot every 10 years after I explain that tetanus is usually fatal. (The same applies to yellow fever vaccine, but not always to malaria prophylaxis.)
Many patients also try to appear healthier than they are. I usually have my diabetic patients initially do fingerstick sugars fasting in the AM and 2 hours after dinner in the PM 3 times a week. Once the HgbA1C blood test became available (for you non-doctor readers, this is a measure of the average blood sugar for the previous 3 months) it was immediately evident that most diabetic patients either wrote down a lower number for their blood sugar than the test showed, or kept on re-doing the test until they came up with a number they liked.
We all have patients that try to reduce (on their own) the amount of blood pressure or asthma medicine that they take, because they think that the more medicine they take, the sicker they must be. I explain that the important aim is to achieve control of the problem, and it is not sensible to expose themselves to the possible side effects of any medicine unless they take enough medicine to achieve our mutual goal. Sometimes they will skip some of the medicine and not tell me, hoping that it will not show up on my examination.
In line with the above, patients with unhealthy habits know that their habits are unhealthy, and that their refusal to alter their habits is illogical. It is precisely because their behavior is not logical that telling them more than once or twice to change their habits is non-productive, and only causes bad feelings on the part of the advisor or advisee or both. Confrontation never works in such situations. The only exception I have ever seen is when an alcoholic man's boss tells him to go and dry out for 30 days or else he will lose his job, the man dries out and stops drinking. This is because his job is intimately entwined with his ego.
This subject will be continued in a future blog.
Every adult knows (or at least is told by his doctor and government authorities) that he/she can become healthier by stopping smoking, losing weight, and exercising, with very little effect on their habits. In all my years of practice I have never been able (even with the help of a nutritionist) to get any overweight new onset diabetic patient to lose weight, even after I told them that the loss of 20 pounds would probably reverse their diabetes. In fact the only patients I have ever seen voluntarily and efficiently lose weight is men after their first heart attack. The heart attack removes their denial that they could ever get seriously ill. Most of them immediately go on a diet whose major component is eating fish 7 days a week. This works, but after 6 months I have to check their blood for toxic mercury levels. The only healthy habit my patients willingly follow is that of having a glass of wine daily, fish oil twice a day, and dark chocolate. This is probably because two of the three taste pretty good, and none of it seems like real medicine.
The basic problem is that the human brain seems to be geared to avoid a life-threatening problem only if it is perceived to be imminent, i.e. to occur in the next 10 seconds, but not if the threat is 10 or 20 years in the future. So not every driver belts in, every cigarette smoker (and they know cigarettes are also called "coffin nails") intellectually believes that cigarettes may be dangerous, but also believes that the particular cigarette being smoked at this minute will not be lethal. Every adult understands the dangers of unprotected sex, but 25% of my college student patients (male or female) have unprotected sex at least once during college, usually when they are having sex with someone who is not their usual partner.
When I am medical ward attending, I poll my residents to see how many of them actually finished the prescribed number of days for their last antibiotic prescription, and the answer is always fewer than 75% of them. I then ask them to sit down and talk with the next ward patient who refuses a test or a prescription and try to understand their reasons and motives, rather than immediately call for a psychiatry consult. Similarly, I have regular patients who have never had a mammogram, a colonoscope, a flu vaccine, etc. However, I can usually get them to take a tetanus shot every 10 years after I explain that tetanus is usually fatal. (The same applies to yellow fever vaccine, but not always to malaria prophylaxis.)
Many patients also try to appear healthier than they are. I usually have my diabetic patients initially do fingerstick sugars fasting in the AM and 2 hours after dinner in the PM 3 times a week. Once the HgbA1C blood test became available (for you non-doctor readers, this is a measure of the average blood sugar for the previous 3 months) it was immediately evident that most diabetic patients either wrote down a lower number for their blood sugar than the test showed, or kept on re-doing the test until they came up with a number they liked.
We all have patients that try to reduce (on their own) the amount of blood pressure or asthma medicine that they take, because they think that the more medicine they take, the sicker they must be. I explain that the important aim is to achieve control of the problem, and it is not sensible to expose themselves to the possible side effects of any medicine unless they take enough medicine to achieve our mutual goal. Sometimes they will skip some of the medicine and not tell me, hoping that it will not show up on my examination.
In line with the above, patients with unhealthy habits know that their habits are unhealthy, and that their refusal to alter their habits is illogical. It is precisely because their behavior is not logical that telling them more than once or twice to change their habits is non-productive, and only causes bad feelings on the part of the advisor or advisee or both. Confrontation never works in such situations. The only exception I have ever seen is when an alcoholic man's boss tells him to go and dry out for 30 days or else he will lose his job, the man dries out and stops drinking. This is because his job is intimately entwined with his ego.
This subject will be continued in a future blog.
Saturday, January 15, 2011
Urine Drug Tests
I have not read any articles recently about urine drug tests, so I thought I might discuss it here. A useful article with many excellent references was written by Karen Moeller, in the Mayo Clinic Proceedings: www.mayoclinicproceedings.com/content/83/1/66.full. If you are an old-timer such as myself, you probably remember the Yippie Handbook: "Steal This Urine Test".
The problem for the tester is the existence of false negative tests, and of course the problem for the testee is false positive tests. As a compromise, all tests have a cutoff, above which the test is considered positive. The urine tests are almost always a screen by immunoassay for either the parent drug or a metabolite. Since, as we shall see, many OTC as well as Rx drugs can give a false positive for various "drugs of abuse" (a technical term comprising amphetamines, cannabinoids, opiates, cocaine, and phencyclidine), for legal purposes any positive screening urine drug tests must be confirmed by gas chromatography-mass spectroscopy. The immuno screening test is used because it is rapid, not labor intensive, and cheap, much in the same way that the VDRL test is used to screen for syphilis, and the FTA to confirm it. As an example of the problem with a false positive screening test, since Lyme Disease is caused by a spirochete, just as syphilis is, many patients with Lyme disease will test positive on a blood screening test for syphilis.
One immediate problem occurs with the amphetamine assay. There are 2 chiral isomers of methamphetamine: d-methamphetamine and l-methamphetamine. The (d) and (l) prefixes stand for (dextro) and (levo) respectively. The d-isomer if dissolved in water will rotate the plane of polarization of polarized light to the Right, and the l-isomer will rotate it to the Left. Louis Pasteur showed over 100 years ago that (almost always) chemical syntheses make an equal amount of the (d) and (l) isomer, but animal enzymes will usually act on one and not the other (he used tartaric acid for this demonstration). Thus your body usually uses only d-sugar isomers (hence dextrose), and the 8 essential amino acids for protein synthesis are all l-isomers. In fact if you were fed only d-amino acids by IV, you would starve to death.
Now even gas chromatography is not sensitive enough to distinguish between d-methamphetamine and l-amphetamine. The d-isomer works as a CNS stimulant and produces euphoria, and the l-isomer produces peripheral vasoconstriction, and thereby relieves cold symptoms. Of course the OTC drugs used for cold symptomd such as pseudoephedrine, phenylephrine, and phenylpropanolamine will produce false positive tests. Most stimulant drugs used for ADD (such as Ritalin) and most diet drugs (such as phentermine) will also produce a false positive test. More amazingly, the following are some of the Rx drugs that will give a false positive methamphetamine urine screening test: Amantadine (used for the flu and for Parkinson's Disease), Wellbutrin (buproprion), Zantac (ranitidine), Trazodone, Desipramine, Trimipramine, Labetolol (for blood pressure), Chlorpromazine, and Isoxsuprine.
False positive tests for cannabinoids (marijuana metabolites) can be produced by Efavirenz (an anti-viral used to treat AIDS patients), ANY of the NSAIDS ( Motrin, Alleve, Celebrex, etc.), Tolmetin, and any of the proton-pump inhibitors (Nexium, Prevacid, omeprazole, etc.).
False positive tests for phencyclidine ("Angel Dust") can be produced by Effexor (venlafaxine), Tramadol,, Advil/Motrin/Ibuprofen, Robitussin DM (dextromethorphan), Benadryl (diphenhydramine), Doxylamine, Imipramine, and Ketamine.
False positive tests for opiates: Robitussin DM (again!), Benadryl (also again), poppy seeds, quinine, Rifampin (used to treat TB, and also occasionally added to the Rx for severe staph infections), and ALL of the quinolones (Cipro, Levaquin, etc.).
As far as is known, no OTC or Rx drug produces a false positive test for cocaine, unless the Rx itself contains cocaine.
For completeness, I should add the length of time that drugs of abuse can be detected in the urine:
Amphetamine---48 hrs., Barbiturates----short acting---24 hrs, long acting (e.g. phenobarb)---3 weeks, benzodiazepams-----short acting (e.g. Ativan/lorazepam)---3 days, long acting (Valium/diazepam)---30 days(!), cocaine metabolites----2 to 4 days, Phencyclidine---8 days, Marijuana---once---3 days, 4 x a week---5-7 days, daily use---10-15 days, long term heavy smoker---more than 30 days.
I should also mention that some urine tests also use indirect testing methods, such as testing for the presence of a diuretic, which was taken by the testee in order to dilute his/her urine and cause a false positive test. If your company wants to see if you are a smoker, they will test your urine for the presence of cotinine, a metabolite of nicotine. Unfortunately, many vegetables such as tomatoes contain a high concentration of cotinine naturally, so if you are a true vegan, you may have a "true" false positive test for tobacco use, in the sense that the chemical is really in your urine, but was only derived from your diet.
BTW, the ingestion of ethyl alcohol will produce a positive urine test for 7-12 hours.
The problem for the tester is the existence of false negative tests, and of course the problem for the testee is false positive tests. As a compromise, all tests have a cutoff, above which the test is considered positive. The urine tests are almost always a screen by immunoassay for either the parent drug or a metabolite. Since, as we shall see, many OTC as well as Rx drugs can give a false positive for various "drugs of abuse" (a technical term comprising amphetamines, cannabinoids, opiates, cocaine, and phencyclidine), for legal purposes any positive screening urine drug tests must be confirmed by gas chromatography-mass spectroscopy. The immuno screening test is used because it is rapid, not labor intensive, and cheap, much in the same way that the VDRL test is used to screen for syphilis, and the FTA to confirm it. As an example of the problem with a false positive screening test, since Lyme Disease is caused by a spirochete, just as syphilis is, many patients with Lyme disease will test positive on a blood screening test for syphilis.
One immediate problem occurs with the amphetamine assay. There are 2 chiral isomers of methamphetamine: d-methamphetamine and l-methamphetamine. The (d) and (l) prefixes stand for (dextro) and (levo) respectively. The d-isomer if dissolved in water will rotate the plane of polarization of polarized light to the Right, and the l-isomer will rotate it to the Left. Louis Pasteur showed over 100 years ago that (almost always) chemical syntheses make an equal amount of the (d) and (l) isomer, but animal enzymes will usually act on one and not the other (he used tartaric acid for this demonstration). Thus your body usually uses only d-sugar isomers (hence dextrose), and the 8 essential amino acids for protein synthesis are all l-isomers. In fact if you were fed only d-amino acids by IV, you would starve to death.
Now even gas chromatography is not sensitive enough to distinguish between d-methamphetamine and l-amphetamine. The d-isomer works as a CNS stimulant and produces euphoria, and the l-isomer produces peripheral vasoconstriction, and thereby relieves cold symptoms. Of course the OTC drugs used for cold symptomd such as pseudoephedrine, phenylephrine, and phenylpropanolamine will produce false positive tests. Most stimulant drugs used for ADD (such as Ritalin) and most diet drugs (such as phentermine) will also produce a false positive test. More amazingly, the following are some of the Rx drugs that will give a false positive methamphetamine urine screening test: Amantadine (used for the flu and for Parkinson's Disease), Wellbutrin (buproprion), Zantac (ranitidine), Trazodone, Desipramine, Trimipramine, Labetolol (for blood pressure), Chlorpromazine, and Isoxsuprine.
False positive tests for cannabinoids (marijuana metabolites) can be produced by Efavirenz (an anti-viral used to treat AIDS patients), ANY of the NSAIDS ( Motrin, Alleve, Celebrex, etc.), Tolmetin, and any of the proton-pump inhibitors (Nexium, Prevacid, omeprazole, etc.).
False positive tests for phencyclidine ("Angel Dust") can be produced by Effexor (venlafaxine), Tramadol,, Advil/Motrin/Ibuprofen, Robitussin DM (dextromethorphan), Benadryl (diphenhydramine), Doxylamine, Imipramine, and Ketamine.
False positive tests for opiates: Robitussin DM (again!), Benadryl (also again), poppy seeds, quinine, Rifampin (used to treat TB, and also occasionally added to the Rx for severe staph infections), and ALL of the quinolones (Cipro, Levaquin, etc.).
As far as is known, no OTC or Rx drug produces a false positive test for cocaine, unless the Rx itself contains cocaine.
For completeness, I should add the length of time that drugs of abuse can be detected in the urine:
Amphetamine---48 hrs., Barbiturates----short acting---24 hrs, long acting (e.g. phenobarb)---3 weeks, benzodiazepams-----short acting (e.g. Ativan/lorazepam)---3 days, long acting (Valium/diazepam)---30 days(!), cocaine metabolites----2 to 4 days, Phencyclidine---8 days, Marijuana---once---3 days, 4 x a week---5-7 days, daily use---10-15 days, long term heavy smoker---more than 30 days.
I should also mention that some urine tests also use indirect testing methods, such as testing for the presence of a diuretic, which was taken by the testee in order to dilute his/her urine and cause a false positive test. If your company wants to see if you are a smoker, they will test your urine for the presence of cotinine, a metabolite of nicotine. Unfortunately, many vegetables such as tomatoes contain a high concentration of cotinine naturally, so if you are a true vegan, you may have a "true" false positive test for tobacco use, in the sense that the chemical is really in your urine, but was only derived from your diet.
BTW, the ingestion of ethyl alcohol will produce a positive urine test for 7-12 hours.
Wednesday, January 5, 2011
Weight loss (#3)
I think it is time to describe how to lose weight as simply as possible, and to examine how to apply these results to everyday life. From a biophysical viewpoint, if the energy input (calories) is less than the energy expended in daily motion and metabolism, we will lose weight. It is also important to remember that it takes metabolic energy to digest, process, and burn or store food, so that although fat contains 9 calories/gm, carbohydrates contain 5 cal/gm, and the average protein 4.5 cal/gm, the energy yield of each is less than this, because of the metabolic work that must be performed to make it useful to the body. Don't forget that, for instance, swallowing and peristalsis both use muscles, and these muscles require energy to function.
Again, if you ingest fewer calories than your daily expenditure, you will lose weight (and probably feel hungry throughout the process). The only painless way to lose weight is by cigarette smoking, and we deduce this from inverse data: Everyone who stops smoking gains about 10 to 15 pounds the first year, and women usually gain more than men. From this we infer that smoking not only assuages hunger, but raises our metabolic rate. And it has to be smoking, because the use of nicotine gum or patches does not lead to weight loss.
I might here mention that as far as I can see, antidepressants do not invariably lead to weight gain. Rather, depressed patients usually become vegetative, and lose interest in eating, sleeping, exercise and sex. As they become less depressed by the use of medicine, all their appetites increase.
I should also mention that most women find it impossible to lose the last 5 pounds they put on after they become pregnant and give birth. I am convinced (without any supportive evidence) that there is a permanent endocrine/metabolic change in their bodies.
Now, how can we ensure losing weight? The only method that always works (and cures adult onset diabetes as well, secondary to its enforced weight loss) is gastric banding or gastric bypass. The operation works by severely restricting the part of the stomach that can receive food at a given feeding. The patient's eating habits do not change, but if too much food is eaten at one sitting, the stomach pain is excruciating, so that patients learn to eat much, much less, and typically lose 100-150 pounds. On rare occasions, liver failure occurs 6 months to 2 years after the bypass surgery, and the failure is reversed by reversing the surgery. I have had 3 such patient, and since their fundamental eating habits were never changed, they quickly ballooned up to their previous weights.
I should also mention that between the ages of 25 and 75, your metabolic rate decreases by the equivalent of 3 to 4 pounds per year, so to paraphrase what the Red Queen told Alice in Wonderland you have to run faster or eat less each year just to maintain your current weight.
There is no evidence that posting the calories next to a food choice enables people to lose weight. All it does is spoil the pleasure of eating a hot dog at a ballpark, because you really don't want to know how many calories you are eating when you are eating for fun. It requires a lot of mental discipline to lose weight, and the human brain is not geared to avoid problems 10 years down the road, but only the dangers that are 10 seconds away. (Just as a cigarette smoker knows that cigarettes are dangerous, but feels confident that the particular cigarette he is about to smoke will not kill him.) I have told countless adult-onset diabetic patients that if they lost 10 to 20 pounds they would no longer have elevated sugars and I could stop their diabetic medicine. In all my years of practice not one has ever achieved this, even after being referred to an endocrinologist and a nutritionist.
Insofar as carbohydrates are concerned, it is wise to avoid foods with a high glycemic index. If you are dieting you should NEVER eat white potatoes or any bread (bread is really composed of "useless" calories, and white bread is the worst). It is OK to eat pasta, but never have seconds. Rice is the safest carbohydrate to eat to lose weight. In fact, many civilian captives of the Japanese in their prison camps during WWII lost a goodly amount of weight, and their diabetes went away. Before insulin, the standard nutritional treatment for diabetes was to limit the carbohydrates eaten to just rice. I should also mention here that in paleontologic excavations, skeletons from 9000B.C. when man was a hunter-gatherer show no evidence of tooth decay, but as soon as man started to cultivate carbohydrates, the later skeletons showed caries.
So how do we lose weight? I am ignoring exercise for the time being, except to note that most college graduates gain weight the first year they are working, because instead of running all over the campus and up and down stairs, they are sitting behind a desk for 8 to 10 hours each day. Again, we have to eat less, and exercise portion control. I don't believe in special diets, because few patients can keep them up forever, and it is easier to lose weight on diets that you like. I tell my patients no white potatoes or white bread, to weigh themselves on Sunday, and to re-weigh themselves the next Sunday. If no weight has been lost, I tell them to eat smaller portions any way they choose to, and to weigh themselves again the following Sunday. Repeat the process until weight is lost, and then maintain that diet with those portions. The weight loss always plateaus, because the brain is persnickety and loves the status quo, so as you lose weight, the body's metabolic rate decreases, so it becomes harder and harder to continue the weight loss. (Don't worry, the same thing happens in reverse as well: if you gain weight, the body's metabolic rate increases.) The main fact to remember is that you burn fat most readily when you feel hungry, and your liver usually has a 6 hour supply of glycogen, or animal starch. So if you feel hungry after dinner, you will start to burn fat in 6 hours, but if you don't feel hungry you start to burn fat 6 hours after you do feel hungry. So the best way to ensure fat loss is to feel hungry all the time, which most people cannot do.
The most successful at losing weight are marathoners and other long-distance runners, and anorectics. So at the extremes, both hard exercise and not eating will help you to lose weight. This shows that weight loss is definitely achievable, but no one knows how to motivate people to lose weight, any more than we know how to motivate them to stop smoking or drinking. I don't know if the dieters or the smoke-enders know themselves how or why they changed their habits.
I do think that daily exercise is part of weight loss. When I was young, we all ate "junk food" Bonbons, Dots, Chuckles, Banana splits Milky Way, Twizzlers, etc, but we ran around playing games in the school yard for 3 hours each day until dinner, and all day Saturday and Sunday. Today's children have after-school studies, practice, scheduled play dates, etc, so they have less of a chance to burn off the calories they ate. I assume they have the same food appetites that we did, so how can they lose weight without exercise? I should also mention that weight loss is especially problematic for poorer people, because protein is always more expensive than carbohydrates.
One final point: Why don't adults say to themselves "Hey, I should lose some weight" the first time their pants waists increase from 30 to 32 inches or their dress size increases from 6 to 8? Until we can answer that question I don't think we will ever solve the problem of how to help people lose weight.
And we all like ice cream because it's components are that of mother's milk: sugar and fat!
Again, if you ingest fewer calories than your daily expenditure, you will lose weight (and probably feel hungry throughout the process). The only painless way to lose weight is by cigarette smoking, and we deduce this from inverse data: Everyone who stops smoking gains about 10 to 15 pounds the first year, and women usually gain more than men. From this we infer that smoking not only assuages hunger, but raises our metabolic rate. And it has to be smoking, because the use of nicotine gum or patches does not lead to weight loss.
I might here mention that as far as I can see, antidepressants do not invariably lead to weight gain. Rather, depressed patients usually become vegetative, and lose interest in eating, sleeping, exercise and sex. As they become less depressed by the use of medicine, all their appetites increase.
I should also mention that most women find it impossible to lose the last 5 pounds they put on after they become pregnant and give birth. I am convinced (without any supportive evidence) that there is a permanent endocrine/metabolic change in their bodies.
Now, how can we ensure losing weight? The only method that always works (and cures adult onset diabetes as well, secondary to its enforced weight loss) is gastric banding or gastric bypass. The operation works by severely restricting the part of the stomach that can receive food at a given feeding. The patient's eating habits do not change, but if too much food is eaten at one sitting, the stomach pain is excruciating, so that patients learn to eat much, much less, and typically lose 100-150 pounds. On rare occasions, liver failure occurs 6 months to 2 years after the bypass surgery, and the failure is reversed by reversing the surgery. I have had 3 such patient, and since their fundamental eating habits were never changed, they quickly ballooned up to their previous weights.
I should also mention that between the ages of 25 and 75, your metabolic rate decreases by the equivalent of 3 to 4 pounds per year, so to paraphrase what the Red Queen told Alice in Wonderland you have to run faster or eat less each year just to maintain your current weight.
There is no evidence that posting the calories next to a food choice enables people to lose weight. All it does is spoil the pleasure of eating a hot dog at a ballpark, because you really don't want to know how many calories you are eating when you are eating for fun. It requires a lot of mental discipline to lose weight, and the human brain is not geared to avoid problems 10 years down the road, but only the dangers that are 10 seconds away. (Just as a cigarette smoker knows that cigarettes are dangerous, but feels confident that the particular cigarette he is about to smoke will not kill him.) I have told countless adult-onset diabetic patients that if they lost 10 to 20 pounds they would no longer have elevated sugars and I could stop their diabetic medicine. In all my years of practice not one has ever achieved this, even after being referred to an endocrinologist and a nutritionist.
Insofar as carbohydrates are concerned, it is wise to avoid foods with a high glycemic index. If you are dieting you should NEVER eat white potatoes or any bread (bread is really composed of "useless" calories, and white bread is the worst). It is OK to eat pasta, but never have seconds. Rice is the safest carbohydrate to eat to lose weight. In fact, many civilian captives of the Japanese in their prison camps during WWII lost a goodly amount of weight, and their diabetes went away. Before insulin, the standard nutritional treatment for diabetes was to limit the carbohydrates eaten to just rice. I should also mention here that in paleontologic excavations, skeletons from 9000B.C. when man was a hunter-gatherer show no evidence of tooth decay, but as soon as man started to cultivate carbohydrates, the later skeletons showed caries.
So how do we lose weight? I am ignoring exercise for the time being, except to note that most college graduates gain weight the first year they are working, because instead of running all over the campus and up and down stairs, they are sitting behind a desk for 8 to 10 hours each day. Again, we have to eat less, and exercise portion control. I don't believe in special diets, because few patients can keep them up forever, and it is easier to lose weight on diets that you like. I tell my patients no white potatoes or white bread, to weigh themselves on Sunday, and to re-weigh themselves the next Sunday. If no weight has been lost, I tell them to eat smaller portions any way they choose to, and to weigh themselves again the following Sunday. Repeat the process until weight is lost, and then maintain that diet with those portions. The weight loss always plateaus, because the brain is persnickety and loves the status quo, so as you lose weight, the body's metabolic rate decreases, so it becomes harder and harder to continue the weight loss. (Don't worry, the same thing happens in reverse as well: if you gain weight, the body's metabolic rate increases.) The main fact to remember is that you burn fat most readily when you feel hungry, and your liver usually has a 6 hour supply of glycogen, or animal starch. So if you feel hungry after dinner, you will start to burn fat in 6 hours, but if you don't feel hungry you start to burn fat 6 hours after you do feel hungry. So the best way to ensure fat loss is to feel hungry all the time, which most people cannot do.
The most successful at losing weight are marathoners and other long-distance runners, and anorectics. So at the extremes, both hard exercise and not eating will help you to lose weight. This shows that weight loss is definitely achievable, but no one knows how to motivate people to lose weight, any more than we know how to motivate them to stop smoking or drinking. I don't know if the dieters or the smoke-enders know themselves how or why they changed their habits.
I do think that daily exercise is part of weight loss. When I was young, we all ate "junk food" Bonbons, Dots, Chuckles, Banana splits Milky Way, Twizzlers, etc, but we ran around playing games in the school yard for 3 hours each day until dinner, and all day Saturday and Sunday. Today's children have after-school studies, practice, scheduled play dates, etc, so they have less of a chance to burn off the calories they ate. I assume they have the same food appetites that we did, so how can they lose weight without exercise? I should also mention that weight loss is especially problematic for poorer people, because protein is always more expensive than carbohydrates.
One final point: Why don't adults say to themselves "Hey, I should lose some weight" the first time their pants waists increase from 30 to 32 inches or their dress size increases from 6 to 8? Until we can answer that question I don't think we will ever solve the problem of how to help people lose weight.
And we all like ice cream because it's components are that of mother's milk: sugar and fat!
Saturday, December 18, 2010
Robotic Surgery
There has been a flood of people requesting robotic surgery, especially men with prostate cancer, and I fear that they are not aware of all the pertinent facts. These men seem to think that robotic surgery is superior (i.e. more curative), and therefore have greater disappointment when the cancer returns. I have certain biases against robotic surgery, both medical and economic, and I would like to explain these to you, with reference to both general (open) and laparoscopic ("mini") surgery.
First some background, and an explanation of what robotic surgery really entails. The first surgery, of course, was "regular" surgery, which left a long scar because the surgeon needs adequate exposure to visualize the surgical field and its surroundings, and thereby minimize the chance of transecting the common bile duct during gall bladder surgery, etc. The need for adequate field of view was drilled into the heads of all surgical residents. The result for cholecystectomies was usually a long (8 to 12 inch) scar under and parallel to the lowest right rib, and a 10 day recovery period in the hospital. The surgery was almost always done after a severe gallbladder attack, with the idea of preventing a second severe attack and possible ascending cholangitis.
Laparoscopic surgery typically involves only four small incisions in the abdomen, each no longer than an inch. Lights and a TV camera are inserted, and the surgeon then directly manipulates his/her instruments to remove the gall bladder. They have gotten so skilled at this that last year a surgeon removed a gall bladder through the superior vaginal wall (!), leaving no abdominal scar whatsoever. In addition, because of minimal incisional tissue damage, the time in the hospital after a laparoscopic cholecystectomy was reduced from ten to three days, and now it may be as little as two. Therefore there is less trauma and faster healing than under the old method, and it was thought that with fewer days in the hospital, the nationwide annual cost of cholecystectomies would decrease. Unfortunately, as shown by an article in NEJM 10-15 years ago, this was not the case. The surgery was so "easy" that satisfied patients informed their friends, and more and more patients with asymptomatic gall stones elected to have the laparoscopic cholecystectomy. The overall result was that the annual total cost of gall bladder surgery increased in the United States.
Now we come to robotic surgery. It is essential to remember that the FDA does NOT have to clear or approve of any new surgical technique, unless a medical device (artificial hip, heart valve) is implanted. If I wanted to drill a hole in your head to let the "evil humors" escape,, and you were agreeable, then it is a go.
If I wanted to remove your gall bladder through an endoscope, it is also a go. In robotic surgery, several things are true that are not true for laparoscopic surgery:
(1) There is an extra $3,000 added to the cost of the surgery,---$1500 for the instruments that have to be disposed, and $1500 to amortize the cost of the equipment. Whether or not Medicare or your HMNO will pay the extra expense is a separate question.
(2) There is no direct tactile feel by the surgeon on your organs. Even with laparoscopic surgery, the instruments are directly moved by his hands, and he can feel resistance, texture, etc. But in robotic surgery, he types in commands to a computer console, and the computer then moves the instruments. It is true that the computer has finer motions than human hands, but it has no "feel", and the patient also has to hope that the program was properly entered, not like the CT scans of the brain or the gamma-ray vs. electron beam treatment of tumors where the wrong button was pushed or the wrong program entered, and the patient's tissues were fried. So the robotic surgeon is deprived of tactile feedback.
(3) Most important of all: There is a sharp learning curve in robotic surgery, precisely because of the lack of tactile feedback. It has been estimated that it takes between 50 to 100 robotic operations on the prostate for the surgeon to become proficient enough so that the results and the time of robotic surgery equals that of non-robotic surgery. Skin-to-skin prostate surgery takes 2 to 2.5 hours, and the first time a surgeon uses the robot it can take 4.5 to 5.0 hours, and the depressive effect of anesthesia on your heart and lungs increases after 2.5 hours. Therefore, the first question you should ask any surgeon who wants to to robotic prostate or heart valve or any other critical surgery on you is : HOW MANY OF THESE ROBOTIC OPERATIONS HAVE YOU DONE? If the answer is fewer than 50, I, for one, would not let him/her touch me. It makes you wonder: Who "volunteered" to be the surgeon's first robotic surgery patient, and did the patient know that he/she was the first? Did the surgeon tell the patient?
First some background, and an explanation of what robotic surgery really entails. The first surgery, of course, was "regular" surgery, which left a long scar because the surgeon needs adequate exposure to visualize the surgical field and its surroundings, and thereby minimize the chance of transecting the common bile duct during gall bladder surgery, etc. The need for adequate field of view was drilled into the heads of all surgical residents. The result for cholecystectomies was usually a long (8 to 12 inch) scar under and parallel to the lowest right rib, and a 10 day recovery period in the hospital. The surgery was almost always done after a severe gallbladder attack, with the idea of preventing a second severe attack and possible ascending cholangitis.
Laparoscopic surgery typically involves only four small incisions in the abdomen, each no longer than an inch. Lights and a TV camera are inserted, and the surgeon then directly manipulates his/her instruments to remove the gall bladder. They have gotten so skilled at this that last year a surgeon removed a gall bladder through the superior vaginal wall (!), leaving no abdominal scar whatsoever. In addition, because of minimal incisional tissue damage, the time in the hospital after a laparoscopic cholecystectomy was reduced from ten to three days, and now it may be as little as two. Therefore there is less trauma and faster healing than under the old method, and it was thought that with fewer days in the hospital, the nationwide annual cost of cholecystectomies would decrease. Unfortunately, as shown by an article in NEJM 10-15 years ago, this was not the case. The surgery was so "easy" that satisfied patients informed their friends, and more and more patients with asymptomatic gall stones elected to have the laparoscopic cholecystectomy. The overall result was that the annual total cost of gall bladder surgery increased in the United States.
Now we come to robotic surgery. It is essential to remember that the FDA does NOT have to clear or approve of any new surgical technique, unless a medical device (artificial hip, heart valve) is implanted. If I wanted to drill a hole in your head to let the "evil humors" escape,, and you were agreeable, then it is a go.
If I wanted to remove your gall bladder through an endoscope, it is also a go. In robotic surgery, several things are true that are not true for laparoscopic surgery:
(1) There is an extra $3,000 added to the cost of the surgery,---$1500 for the instruments that have to be disposed, and $1500 to amortize the cost of the equipment. Whether or not Medicare or your HMNO will pay the extra expense is a separate question.
(2) There is no direct tactile feel by the surgeon on your organs. Even with laparoscopic surgery, the instruments are directly moved by his hands, and he can feel resistance, texture, etc. But in robotic surgery, he types in commands to a computer console, and the computer then moves the instruments. It is true that the computer has finer motions than human hands, but it has no "feel", and the patient also has to hope that the program was properly entered, not like the CT scans of the brain or the gamma-ray vs. electron beam treatment of tumors where the wrong button was pushed or the wrong program entered, and the patient's tissues were fried. So the robotic surgeon is deprived of tactile feedback.
(3) Most important of all: There is a sharp learning curve in robotic surgery, precisely because of the lack of tactile feedback. It has been estimated that it takes between 50 to 100 robotic operations on the prostate for the surgeon to become proficient enough so that the results and the time of robotic surgery equals that of non-robotic surgery. Skin-to-skin prostate surgery takes 2 to 2.5 hours, and the first time a surgeon uses the robot it can take 4.5 to 5.0 hours, and the depressive effect of anesthesia on your heart and lungs increases after 2.5 hours. Therefore, the first question you should ask any surgeon who wants to to robotic prostate or heart valve or any other critical surgery on you is : HOW MANY OF THESE ROBOTIC OPERATIONS HAVE YOU DONE? If the answer is fewer than 50, I, for one, would not let him/her touch me. It makes you wonder: Who "volunteered" to be the surgeon's first robotic surgery patient, and did the patient know that he/she was the first? Did the surgeon tell the patient?
Friday, December 10, 2010
Aspirin and Colon Cancer
There have been reports in the news lately about two different articles in medical journals: (1) whether daily aspirin use reduces the incidence of colon cancer, and (2) the expense and morbidity of robotic surgery as opposed to standard laparoscopic ("keyhole" or "mini") surgery. Since I am an internist and neither article will affect my practice or income, I feel can comment on them without bias (outside my usual inquisitorial examination of the evidence presented in research papers, a habit than has only been intensified by my over 20 years of reviewing articles). This blog will discuss the possible aspirin-colon cancer reduction link, and the next will discuss robotic surgery.
Let us look at the aspirin-colon cancer article first. As some background, let me inform my non-medical readers that it appears that it takes 5 years from the time a polyp first develops in the colon until it becomes cancerous (and I am here excluding any familial cases). Since as the polyps enlarge they tend to put drops of blood into the stool, the first screening for colon cancer that was shown to reduce the death rate from colon cancer was the annual test for blood in the stool. When I started practice in the early 1980"s, it was known that five year examinations of the distal 25 centimeters of the colon by a rigid proctoscope detected enough cancers to reduce the death rate from colon cancer, and this became a standard practice for me. One curious fact that was noted and unexplained was that even though only a minute part of the distal colon was examined, fatal cancers originating in the proximal colon were also reduced (although not by as much). The proctoscope, or rigid signoidoscopy was soon replaced by the flexible sigmoidoscope, which reached further into the distal colon. This examination, if given every 5 to 10 years, also reduced colon cancer deaths in the proximal as well as the distal colon, but, again the incidence of cancers in the distal colon were much more strongly affected, than that of cancers in the proximal colon .
A few years ago, a 5 year retrospective study of 5,000 female American nurses was published. The study showed that the frequent use of NSAID's (usually Advil or Alleve) reduced the incidence of and death from colon cancer. (I might here mention that a parallel 5 year study of females placed on a low fat diet showed no reduction in the incidence of either colon or breast cancer, but people still seem to think, without any hard evidence, that animal fat is carcinogenic for humans.) This study led to the Vioxx study, where Merck hoped that they could show that Vioxx, another NSAID, also reduced the incidence of colon cancer, so they could get FDA approval to market it as such. Unfortunately, the initial data showed an increase in cardiovascular events, so the study was terminated, as was Vioxx. I leave it to the audience to search the published reports to see which NSAID is the safest and which is the most apt to produce cardiac events. The last time I reviewed the subject (and this may not be true now) prescription Celebrex was the safest anti-inflammatory , and OTC Alleve/Naprosyn had the highest incidence of cardiac events.
So now we come to the latest study, published in Lancet (Vol. 376, Nov. 20, 2010, pp1741-1750). The study found that a dose of 75 mg. of daily aspirin (a baby aspirin has 81 mg) reduced the incidence and mortality of colon cancer, and the benefit was highest for proximal cancers. A few caveats. This article was the result of pooling 5 different studies, and in none of the studies was colon cancer the endpoint. Furthermore, the pooling showed a much greater effect in men than in women.We also think we know that aspirin reduces the incidence of colon polyps by suppressing COX-2, and tumors in the distal colon seem to have greater interaction with COX-2 receptors than do proximal tumors. It also did not compare the use of daily aspirin with q. 5 year colonoscopes with regard to reduction in the incidence of colon cancer.
Now when my patients ask me about how to apply the results of this study to their own medical lives, I will reply as follows: There is now some evidence that taking a daily 81 mg. (children's) aspirin will reduce your chance of getting colon cancer, but no one has compared the % reduction achieved with aspirin with that achieved by either an annual stool-for-blood test or q. 5-10 years colonoscopy, and daily aspirin use increases your risk of GI bleeding. We also have absolutely no idea if adding daily ASA to the suggested routine of colonoscopy plus stool-for-blood will have a positive synergistic effect. On the other hand, it is evident that if aspirin does have a preventive effect, it is greater for proximal colon tumors than distal tumors, and proximal tumors are the ones least likely to be detected by either colonoscopy or stool-for-blood. I would also suggest that if they absolutely refuse to ever have a colonoscopy then a daily children's aspirin is probably a good idea.
Let us look at the aspirin-colon cancer article first. As some background, let me inform my non-medical readers that it appears that it takes 5 years from the time a polyp first develops in the colon until it becomes cancerous (and I am here excluding any familial cases). Since as the polyps enlarge they tend to put drops of blood into the stool, the first screening for colon cancer that was shown to reduce the death rate from colon cancer was the annual test for blood in the stool. When I started practice in the early 1980"s, it was known that five year examinations of the distal 25 centimeters of the colon by a rigid proctoscope detected enough cancers to reduce the death rate from colon cancer, and this became a standard practice for me. One curious fact that was noted and unexplained was that even though only a minute part of the distal colon was examined, fatal cancers originating in the proximal colon were also reduced (although not by as much). The proctoscope, or rigid signoidoscopy was soon replaced by the flexible sigmoidoscope, which reached further into the distal colon. This examination, if given every 5 to 10 years, also reduced colon cancer deaths in the proximal as well as the distal colon, but, again the incidence of cancers in the distal colon were much more strongly affected, than that of cancers in the proximal colon .
A few years ago, a 5 year retrospective study of 5,000 female American nurses was published. The study showed that the frequent use of NSAID's (usually Advil or Alleve) reduced the incidence of and death from colon cancer. (I might here mention that a parallel 5 year study of females placed on a low fat diet showed no reduction in the incidence of either colon or breast cancer, but people still seem to think, without any hard evidence, that animal fat is carcinogenic for humans.) This study led to the Vioxx study, where Merck hoped that they could show that Vioxx, another NSAID, also reduced the incidence of colon cancer, so they could get FDA approval to market it as such. Unfortunately, the initial data showed an increase in cardiovascular events, so the study was terminated, as was Vioxx. I leave it to the audience to search the published reports to see which NSAID is the safest and which is the most apt to produce cardiac events. The last time I reviewed the subject (and this may not be true now) prescription Celebrex was the safest anti-inflammatory , and OTC Alleve/Naprosyn had the highest incidence of cardiac events.
So now we come to the latest study, published in Lancet (Vol. 376, Nov. 20, 2010, pp1741-1750). The study found that a dose of 75 mg. of daily aspirin (a baby aspirin has 81 mg) reduced the incidence and mortality of colon cancer, and the benefit was highest for proximal cancers. A few caveats. This article was the result of pooling 5 different studies, and in none of the studies was colon cancer the endpoint. Furthermore, the pooling showed a much greater effect in men than in women.We also think we know that aspirin reduces the incidence of colon polyps by suppressing COX-2, and tumors in the distal colon seem to have greater interaction with COX-2 receptors than do proximal tumors. It also did not compare the use of daily aspirin with q. 5 year colonoscopes with regard to reduction in the incidence of colon cancer.
Now when my patients ask me about how to apply the results of this study to their own medical lives, I will reply as follows: There is now some evidence that taking a daily 81 mg. (children's) aspirin will reduce your chance of getting colon cancer, but no one has compared the % reduction achieved with aspirin with that achieved by either an annual stool-for-blood test or q. 5-10 years colonoscopy, and daily aspirin use increases your risk of GI bleeding. We also have absolutely no idea if adding daily ASA to the suggested routine of colonoscopy plus stool-for-blood will have a positive synergistic effect. On the other hand, it is evident that if aspirin does have a preventive effect, it is greater for proximal colon tumors than distal tumors, and proximal tumors are the ones least likely to be detected by either colonoscopy or stool-for-blood. I would also suggest that if they absolutely refuse to ever have a colonoscopy then a daily children's aspirin is probably a good idea.
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