Sunday, April 24, 2016

Risks of Probiotics - Who Cares?

Earlier this year I read about a medical study that concluded that a diet high in saturated fat won’t kill you after all.  Moreover, piling on polyunsaturated fat won’t save you.

Hee hee.  I love this stuff.  Established medical dogma back flips every 10 years.  Butter in, butter out.  Hormone replacement treatment for perimenopausal women is mandatory, until it isn’t.

Who knows what to believe when even doctors are confused or just don’t know.

We have a medical industrial complex that is a beast that needs to be fed.  It fuels itself on our fidelity to medical practices that are labeled as truths.  ‘Wellness’ rules.  How many decades did the public and the medical community preach that the P.S.A. blood test saved men’s lives?  While I believe that urologists were sincere in their mistaken beliefs and practices, there was a whole industry behind the scenes that was fueling the fire.  It was good business for hospital operating rooms, medical device companies and radiation therapy suites. 

Of course, you could make this same point with respect to my own specialty of gastroenterology, as I often do on this blog, as readers know.

Just because something sounds true, or we want it to be true, doesn’t make it true.

Is obesity really a killer on the loose?  When a reputable study is published that pulls back from this draconian conclusion, what happens?  The study is attacked by those who either truly believe that the study is flawed or by those who are threatened by it.  Mammography is a superb example of this phenomenon.  It is increasingly recognized that mammography is deeply flawed, problematic and harmful, but try discussing this with a mammography zealot.  If you dare to do so, don the Kevlar first.

Kevlar - Use for Zealot Protection

Probiotics are the rage for maladies spanning digestive disorders to depression to chronic fatigue.   Do they work?  Does it matter?   The science girding most of their claims is porous, deceptive or absent.  We should demand that their products be rigorously and independently tested, but this will not happen.  Why should these companies tamper with perfection?  We’re already buying their potions faster than you can say ‘gluten-free’.  Why risk the pesky scientific method that might cast a penumbra of doubt on their healing claims?

Think about the probiotic process.  Folks are swallowing billions (that’s billions with a ‘b’) of bacteria every day.   Of course, these are ‘good bacteria’, little microscopic elves that will gobble up diseases that are beyond the reach of conventional medicines.  First, let’s call them what they are – germs.   Is there any brave voice out there who is willing to vocalize concern about changing the human flora which took a gazillion years to develop through evolution?  Are bifidobacteria really smarter than millions of years of natural selection?

Years from now, when probiotics are off the shelves, folks will nod their heads wondering how millions of us swallowed billions of germs just because we wanted to believe. 

Skeptics of the world unite!

Sunday, April 17, 2016

Weight Loss Breakthrough Melts Pounds Off!

What’s all this chatter I hear about how hard it is to lose weight?  Relax.  Obesity has finally been conquered.  Those stubborn extra pounds that you’ve been stuck with will soon melt faster than a popsicle on a steamy summer day.  Although I am a practicing gastroenterologist who deals with nutritional issues routinely, I did not learn of this breakthrough in my medical journals or from experts in the field.  I learned it just by listening to the radio.

I’m in the car several times a day, so I get my share of radio time.  Not a day passes that I don’t hear an ad for some kind of fat-busting pill or potion.  The products are different but the pitch is always the same.

Obesity on the Run!
  • Rapid weight loss
  • No excercise
  • No work or effort.  Pound magically disappear

This seductive pitch is followed by testimonials from smiling ‘customers’ posing on the beach who corroborate the amazing result.  Their script usually includes:

'I've tried everything and nothing works.  When I heard about (insert product name), I was skeptical, but I've dropped twenty pounds and I'm eating more than ever!'

Then, viewers will see the before and after photos.  The 'before' shot is a grainy black and white photo with bad hair and a scowling expression.  You know what the 'after' shot looks like.

Then the announcer returns and cautions viewers that this product should only be taken for serious weight loss because it is 'extremely potent'.   Then, we will hear the incredibly clever tag line,' the only thing you have to lose is weight!'

As the ad concludes, a disclaimer is read at a speed faster than the human ear can process.  I can barely pick out the phrase, ‘results may vary’.  I think we all know what that means. 

Losing weight is tough work, as folks who have been battling against their bathroom scales can attest.  The weight loss journey should be regarded as a slow marathon jog, not a high speed sprint.  If losing weight were easy, then we’d all be thin.

But, it can be done.  We all know people who cracked the code against obesity and trimmed down.  How did they do it?  What are their secrets?

Here are some of the lessons I have learned from them after a quarter century of medical practice.
  • Losing weight is a mental and psychological process.  Don’t try to lose an ounce until you have made a strong mental commitment to the effort.
  • Understand why you eat excessively.  It’s usually not from hunger.  Understanding ‘why’ will help you plan an effective strategy.  For example, if you reach for food when you are stressed, then exploring stress reduction options will be a key component of your plan.
  • Avoid gimmicks.  They don’t work.  There’s no quick fix here.
  • Set modest weight loss goals and try to achieve them.  If you intend to lose 2 lbs per month, keep to this level.  Don’t overshoot – stay at a steady pace.
  • Make dietary changes that you can live with forever.  This is why gimmicks fail and nearly these folks regain the weight after experiencing initial rapid weight loss.
  • Have a friend or family member to serve as your coach and cheerleader.
  • You’re not perfect.  Don’t hold yourself up to an infallible standard.  Backsliding is not failure, it’s human.
P     Physicians can help here, but we can't do the work for you.  We can share with you the secrets of successful patients and we will do our best to make you one of them.  Talk to your doctor.  You have nothing to lose except....


Sunday, April 10, 2016

Calling the Doctor After Hours

Of course, patients are entitled to medical care around the clock.  You would not expect to show up at 2:00 a.m. at an emergency room to find a ‘Closed’ sign.  If you are having chest pain on a weekend, and you call your doctor’s office, you should expect a prompt response from a living and breathing medical doctor.  Patients are aware that when they call the doctor at night, that they are unlikely to reach their own doctor.  Similarly, when a patient is admitted to the hospital, they will likely be attended to by a hospitalist, not the primary care physician.  Such is the reality of medical practice today.

No Patient Zone at Hospital

Here are 3 types of after hour calls that merit mentioning.

(1)One of my partner’s patients calls me because the diarrhea is still not better and it’s been more than 3 months.  While I completely understand the frustrated patient’s rationale for calling, there’s not much I can do in these circumstances.  It is generally not helpful to call a doctor at night to discuss chronic medical complaints, as you will likely not reach your own physician.  For example, if you have been having nausea for months, and have had several diagnostic tests and tried different medications, it is doubtful that a covering physician on the phone at night who does not know you will crack the case. 

(2)The radiology department calls me at night to give a reading.  Here’s how this works when one of my partner's patients undergoes an evening radiologic test. 

“Dr. Kirsch.  a patient you have never heard of who left the hospital a half hour ago had a CAT scan of the abdomen.  The radiologist suspects mild diverticulitis.  Good luck, doctor and have a nice evening!”

What this means, of course, is that the radiology department has ‘checked off a box’ that I have been notified and is now in the clear.  It is now my responsibility at 11:00 pm to sort through this.  When I call the patient and can't reach him, how well do you think I sIeep that night?  I don’t have a solution here, but clearly, this is not ideal medical care.   

(3)A hospital nurse calls me at night to approve a patient’s discharge.  This is always a killer.  It’s generally one of my partner’s patients whom I have never seen.  He may have had a complicated hospital course that involved multiple consultants.  There is an extensive medication list.  The patient still has stomach pain, which the medical team can’t explain.  If I give the nurse the green light on sending the patient home, then I am accepting full responsibility for this decision even though I have never laid a hand on him.  How you would suggest I respond to the nurse in this situation?

Yes, our practice is available to our patients at every hour.  But, some hours are more equal than others.  It’s challenging enough to take care of patients we know well.  How can we take care of patients we have never seen? 

Sunday, April 3, 2016

Does Appendicitis Need Surgery?

Some issues do not need to be studied.   For example, would we expect the National Institutes of Health to fund a study to determine if drivers wearing blindfolds have better outcomes?   In the past few weeks, the National Football League (NFL) has conceded that head trauma is linked to chronic traumatic encephalopathy (CTE), a fancy term that means brain damage.  Of course, there have been multiple studies that have examined this question.  And, in a nod to the tobacco companies, the NFL for too long failed to admit what any school child could have deduced.  Smashing your head several hundreds of times against the ground or another helmeted gladiator does not promote good brain health. 

Sometimes industries will cite their own ‘studies’ that astonishingly contradict what our intuition and common sense tell us should be true.  Would we accept the results, for example, of a movie industry  ‘study’ that extolled the health benefits of popcorn?

Sometimes, in medicine, we need a study to derail a standard treatment that is based on habit, rather than on medical evidence.  For decades, appendicitis has been treated with appendectomy, surgical removal of this finger-like structure at the uppermost portion of the large bowel.  Diverticulitis, a presumed infection of the colon, has been treated with antibiotics long before I became a doctor 30 years ago.  In the past few months, I have read expert opinions that challenge the embedded dogma of the treatment of these two diseases.

There is evidence and belief that appendicitis can be successfully treated with antibiotics, rather than surgery.  And, some authorities have suggested that diverticulitis may resolve on its own without antibiotic treatment. 

Appendix at bottom right

These were fascinating and refreshing new observations on old diseases.  So much of what we do in medicine is based on scant data and evidence.  Despite these lapses, these practices become the standard of care, leading patients and physicians to believe that there is firm underlying scientific support for them.  When my kids were small, most case of otitis, an ear infection, were treated with antibiotics.  Why?  Because that was how it was done.  Over time, this practice has changed.

Medical practice is an ocean liner whose direction cannot be easily or quickly changed.  Of course, we would not want a truly effective treatment to be abandoned on the basis of one study whose results may not be sound.  Conversely, it is difficult to cull the profession of established treatments that should have never become established in the first place.

Finally, just because there is no persuasive evidence that a treatment works, doesn’t make it quackery.  There’s plenty of stuff in medicine and in life that works well despite the absence of supportive data.  Sure, medicine is a science.  But it’s also an art.

If a sport requires that an athelete wears body armor and a helmet, then do we need a study to conclude that this head-smashing and bone-breaking activity isn't the best strategy to stay well?  

Sunday, March 27, 2016

Plan to Steal the Nomination from Trump - Chicanery in Cleveland

Trump is roaring toward securing the GOP nomination in Cleveland this summer.  While I am excited that the convention will occur in my city, I expect chaos and gridlock downtown.  I won’t be visiting the Rock and Roll Hall of Fame, or any of our city’s other outstanding attractions, during that week.

I think that Trump may garner the necessary 1237 delegates prior to the convention.  For self-serving reasons, the trailing 2 candidates are stating that no candidate will meet the required threshold and that the convention will select the nominee according to rules, yet to be decided.  My candidate Kasich – who has won only Ohio – crows that it’s now a 3 man race!  Sorry, John.  Wining 1 out of 32 states, while Cruz and Trump have won 9 and 19 states respectively, does not make this a 3-way tug of war.

The New White House?

The media is preoccupied to determine if the candidates and the GOP establishment will award Trump the nomination if he falls a few delegates shy and the 2nd place finisher, likely Cruz, is several hundred delegates behind.  Cruz and Kasich maintain that rules are rules and unless Trump reaches 1237, then the nomination becomes an open contest.

Is this fair?  If a candidate has won more states than his competitors, and has nearly reached the 1237 delegate level, then shouldn’t the system bend in his favor?  If not, wouldn’t his millions of voters feel disenfranchised?   Should a candidate be nominated based on his electability in a general election rather than on voter preference?  If we opt for the former, then why have primaries at all?  We could simply select the most electable candidate through an elaborate polling process. 

I’m not offering a firm opinion here on how this process should be handled.  We all know that if Trump is very close and the nomination is snatched away – even if done by the books – that this will generate anger in a large segment of the population who are already disgusted with establishment politics.  Additionally, I wonder if Cruz and Kasich would have the same view on an open convention if their situations were reversed with Trump’s.  I’ll offer my opinion here.  No. 

Life beyond politics often has seemingly unfair processes and results.  Consider these scenarios.
  • A baseball team at bat loads the bases. The next 3 batters strike out and the inning ends.  Why shouldn’t the team get some credit for putting 3 men on base? 
  • A man misses winning the lottery by a single digit.  Should he get nothing when he was so close?  Shouldn’t he be rewarded more than a ticket that was a complete miss?
  • A hospital requires that a surgeon who is applying for privileges for a specific operation must have performed 50 of these surgeries.  If he has only done 48 with perfect outcomes, should he be denied privileges as if he has done none at all?
Cleveland will be on public display this summer.  But, what may really matter is what will be happening under cover. 

Sunday, March 20, 2016

Is Uterus Transplantation Ethical?

I am not a woman.  I cannot contemplate the physical and emotional experience of carrying a pregnancy and birthing a child.  I imagine that it is a singular experience that is as deep and awesome today as it has always been.  We have all seen the explosion in reproductive technology with in vitro fertilization, surrogate mothers, fertility agents and other emerging techniques.  This process, beyond the high costs, can create anguish for those who are on this journey.

I have felt in many instances that the ethical ramifications of some of these techniques are minimized or dismissed.  Sadly, we often do stuff because we can, not because we should.  Do we really think we can stop human cloning?

Recently, a woman in Cleveland had a cadaver uterus placed during an extremely demanding 9 hour operation on 2/24/16.  This was the first time this was performed in the United States.  Only a handful of these operations have been performed worldwide.  This woman, who has adopted children, was born without a uterus and yearned to carry a pregnancy.  As this operation was part of a clinical trial, I assume that it was paid for out of grant funds.  Shortly after surgery, a complication developed and the uterus was urgently removed. 

Transplanting a Uterus and our Ethics?

A uterine transplant is not a one day affair.  To prepare, the recipient’s eggs are harvested and then embryos are created and frozen.  Then, the complex process of finding a donor is triggered.  The donor organ is harvested and must be transported to the recipient.  Then, the all-day transplant surgery occurs.  The patient is then kept on anti-rejection drugs.   A year later, the embryos are implanted.  Deliveries are performed by Caesarean sections.  After the desired number of pregnancies, the uterus is removed so that the anti-rejection drugs can be withdrawn.

The cost of all this is unfathomable, assuming that no complications occur that would require additional care.  It is certainly possible that a woman could go through the entire process and not carry a baby to term.  Indeed, very few successful pregnancies have occurred worldwide.

I request that readers contemplate the following concerns regarding uterine transplant.
  • Can society justify this massive cost for a procedure that is not necessary to save a life or cure a disease?
  • Is it ethical to risk a healthy patient’s life with highly complex surgery even if she consents to it?
  • Is it ethical to maintain anti-rejection drugs, which has risks of severe complications, for years to preserve the transplanted uterus?
  • Is there a right to pregnancy that the medical profession is obligated to satisfy regardless of the financial, emotional and ethical costs? 
If this technique gets perfected, then it might become possible to implant a uterus in a man.  Then, perhaps, I will have the opportunity to experience the profound wonder that has eluded my gender since the beginning of time. 

Sunday, March 13, 2016

Do Nexium and Heartburn Medicines Cause Dementia?

Proton pump inhibitors, or PPIs, are among the most common drugs prescribed in the United States.  They are extremely safe and highly effective for gastroesophageal reflux disease (GERD).  Are there potential side-effects?  Of course.  Look up the side effects of any of your medicines and you will soon need an anxiety medicine to relieve you of side-effect stress.  The side-effect lists of even our safest medicines are daunting. 

PPIs are associated with a growing list of potential serious side-effects, at least according to the lay press.  A few clicks on your computer, and you will find that these medicines can cause pneumonia, C difficile colitis, malabsorption of nutrients, bone fractures and anemia.   The latest report to emerge links these drugs with dementia.  In the past two weeks, I’ve been questioned about this repeatedly by my patients.  One stopped her medication from fear that her heartburn medicine might be incinerating her neurons.

Enemy of Heartburn Medicines?

While no drug, including PPIs, is entirely safe, I have never seen a serious PPI side-effect having prescribed them to thousands of patients.  I’ll bet that your gastroenterologist and internist can boast a similar track record.  Doesn’t that experience mean something? 

The lay press, in my view, often covers medical science carelessly and without context.  The science underlying the above listed PPI side-effects is extremely thin.  Yet, the headlines describing them can sound authoritative and persuasive.  Remember the adage of local TV news, if it bleeds it leads?  Same concept.

Which of these two headlines or sound bites would be more likely to appear?

Nexium, superb heartburn fighter, may have questionable effect on bones, although results preliminary.

Nexium leads to hip fractures!

The scientific studies that link PPIs to bone disease or dementia are not high quality research studies.  These studies are done on large populations of individuals and do not demonstrate any actual causative effects of the medicines.  When you read the word associated, as in Nexium is associated with cognitive decline, you can accurately interpret that statement to mean there is no proof that Nexium causes dementia.  Association is a weak link which has results from a weak study.

For the same reason, favorable results from similar studies should be viewed with great skepticism.  Next year we may read that Nexium is associated with a reversal of male pattern baldness and enhanced libido.  (If this hypothetical were to truly occur, then I hope that I can time my stock purchase just prior to the announcement.)

So, if heartburn patients have forgotten their keys somewhere, there is no need to flush your heartburn medicines down the toilet.  You are not losing your mind, just your keys.  Remember, much of what we read and hear in the lay press is associated with ignorance.

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