Archive for the 'A Country Doctor Reads' Category

A Country Doctor Reads: February 16, 2019

Find Nutrients Depleted by Medication – Nutrient Depletion Calculator –

I came across a cute website that lists common deficiencies associated with medications, for example B12, iron and many others from Nexium, esomeprazole:

— Read on

How Long Do Hip Replacements Last? -The Lancet

There is concern about hip replacements performed in middle aged adults. Will they wear out? The Lancet has an open access impressive review, which outlines the odds of failure over the remaining lifetime of 50-something patients:

“Moreover, these results are particularly important because of the growing number of younger, more active patients receiving hip replacements, as well as increasing population ageing and life expectancy.7,  8 In fact, lifetime risk of revision of total hip replacements for patients aged 50–54 years is estimated to be 29%, but only 5% in patients aged 70 years.9 Much of the increased risk of revision is due to component wear. The findings from Evans and colleagues’ study can therefore be used to more appropriately counsel patients”

A Country Doctor Reads: February 9, 2019

Feed a Cold, Don’t Starve It – Cell via The Atlantic

“Feed a fever, starve a cold”, the saying goes. But, unlike many old adages, this one is turning out to be dead wrong, literally.

A 2016 article in The Atlantic, number 3 under “Popular” on their website, quotes an article from the same year in Cell with a longer and less catchy title: “Opposing Effects of Fasting Metabolism on Tissue Tolerance in Bacterial and Viral Inflammation”.

The Atlantic staff writer James Hamblin, MD, explains, “Sometimes sugar causes inflammation. Sometimes it does the opposite.”

Researcher Ruslan Medzhitov conducted a series of distasteful experiments on mice with various infections, and found that mice with listeria, a bacterial infection, survived when they were refusing to eat and perished if they were force fed, but only if their diet was essentiallly sugar; they survived if they were fed fat and protein.

Mice with influenza fared better if they were force fed glucose than if they were allowed to refuse food.

The Cell article concludes: [In influenza infection,] “inhibition of glucose utilization is lethal.” Whereas glucose was “required for survival in models of viral inflammation, it was lethal in models of bacterial inflammation… Glucose Utilization Promotes Tissue Damage in Endotoxemia”.

And the article implies that ketosis has a protective effect in bacteremia.

The conclusion: Drink juice and tea with sugar or honey when you have the flu. But don’t eat if you don’t feel like it when you have pneumonia.


Association of Thyrotropin Suppression With Survival Outcomes in Patients With Intermediate- and High-Risk Differentiated Thyroid Cancer – JAMA

A dear friend and an anxious woman with a history of thyroid cancer is simply not tolerating suppressive doses of thyroid hormone, so with the blessing of my go to endo, she is on suboptimal suppressive doses. This article helps me sleep better at night:


Eczema and Our Skin Biome – The Wall Street Journal and the AAAAI

The prevalence of eczema in children has doubled in the past 17 years. Now we are starting to think of our bacterial skin flora as another area where promoting good bacteria can improve health. The Wall Street Journal reports on two small studies that demonstrated that applying healthy bacteria to eczematous skin brought clinical improvement.

“15 pa­tients, in­clud­ing five chil­dren, sprayed their rashes with bac­te­ria that re­searchers sus­pected could im­prove eczema. Two-thirds re­ported less itch­ing, less need for top­i­cal steroids and bet­ter sleep af­ter us­ing the spray twice a week for four months. On av­er­age, these mea­sures im­proved by 84% in adults and 78% in chil­dren.”

This led me to look for more information, and it’s out there:

A Country Doctor Reads: February 2, 2019

McDonaldization of Chronic Pain Therapy (and All of Primary Care?) in the USA – BMJ

A recent Open-Access piece in the British Medical Journal about what they called the “McDonaldization of Chronic Pain Therapy” made me think that this phenomenon, which I hadn’t heard called that before, was certainly present in Primary Care, too. I have sometimes found myself saying, or at least thinking, that 15 minute medicine is more like McDonald’s than fancy restaurants.

The article lists four dimensions of what they have termed McDonaldization:

Number four stopped me cold – this is Healthcare today. The BMJ article states:

“The fourth dimension of McDonaldization is control—control of employees, of the system and of consumers. McDonald’s uses a controlled system, comprising a combination of humans, computers and cooking technologies to serve ‘precut and preprepared food’ to hungry customers, eager for their salty fix. This system minimises the need for human creativity and effort on the part of both employee and consumer. In the context of chronic pain management, OxyContin worked very similarly and thus produced a strange control over both doctor and patient. Physicians no longer had to parse out what exactly the cause(s) of a patient’s pain was and what therapies they might benefit from, but rather, now had the option of giving one drug to keep it all at bay.

Purdue Pharma’s aggressive and patently false advertising of the safety of the drug positioned OxyContin as the most rational and efficient choice a physician could make in treating a patient in pain. This only served to benefit the controlled McDonaldized system Purdue Pharma was helping construct, because people—physicians included—are ‘the great source of uncertainty, unpredictability and inefficiency in any rationalizing system’.

The responsibility of treating patients with chronic pain often falls to primary care physicians, and as such, they were Purdue Pharma’s prime target in expanding the ‘OxyContin prescribing base’. With the increasing demands of medical McDonaldization, one of the highest burnout rates of all physician specialties, and the shortage of primary care physicians ever growing, they were understandably susceptible to believing the promises of the drug. Furthermore, these physicians were already fighting multiple American epidemics, like pre-diabetes and hypertension (for which McDonald’s itself happens to be a significant contributor). So, if there was a quick, effective treatment for another complex finding—pain—available, then there was little desire or opportunity to take the time to question the legitimacy of Purdue’s claims. Thus, they prescribed the drugs liberally, as they were instructed to at their Purdue-funded educational conferences.”

Yours truly wrote a little while ago about the downside of even using the word “treatment” for chronic conditions, instead thinking “guidance” better describes what we ought to be providing.

“Treatment”, the second part of the traditional duad, is too simplistic a notion, only useful for lancing boils and prescribing penicillin for strep throat. Most diseases are multifaceted and most patients have several health and disease considerations. Most diseases are also chronic, even ones we thought of as rapidly terminal earlier in our own lifetime, like HIV and an increasing number of cancers.

The physician’s role is not a knee jerk intervention, it is informing and educating the patient and helping each patient choose a plan of action that is right for them.

Primary Care does what Google can’t, it applies knowledge of the patient and of the relative importance of medical facts and factoids and offers guidance in the sense of ranking options.

Does Anybody REALLY Want to Fix Physician Burnout?

In my inbox the other day was an AMA update that was mostly about burnout:

This is getting out of hand. We have two crises converging to soon cripple and bankrupt our health care system and quite possibly our entire economy:

1) An aging population and people of all ages that are increasingly affected by chronic diseases that were rare a generation ago.

2) A burned-out, disillusioned and hamstrung medical profession, unable to do anything in their allotted 15 minute visits about the lifestyle-dependent epidemics beyond prescribing $400-$1,000 a month drugs that allow the disease snowball to keep rolling and growing, albeit at a somewhat slower rate.

I recently wrote about burnout:

“Put simply: If anybody wants to define and manage our work for us instead of letting us do it, they become responsible for the outcomes if we aren’t given the time or the tools we, as the ones who went to school, know we need.

The cure for physician burnout is simple: Listen to us when we say what we need in order to do our best. We didn’t spend all this time and energy so we could collect our salaries and goof off.

Most of us still have a professional mindset. We want to do a good job and we know how to do it. Let us.”

BUT, as one commenter wrote:

“Well said, and so true. But the solution is NOT ‘simple”, because THEY will never listen to us. The difficult, but only realistic solution is to be independent…”

So, we need some honest answers and some new paradigms here:

What is disease?

What is public health?

What do we need doctors to do if there are so few of them?

Does every “stakeholder” benefit if people get healthier? Or do some profit from continuing worsening of our nation’s health?

That last point is obviously rhetorical. What kind of health care system can reconcile when insurance companies and pharmaceutical companies actually profit from people being sicker?

A Country Doctor Reads: January 26, 2019

Average is No Longer Normal – The New York Times & The British Medical Journal

I didn’t have a real handle on what the average weight or BMI in this country is. But recently NYT announced:

“Meet the average American man. He weighs 198 pounds and stands 5 feet 9 inches tall. He has a 40-inch waist, and his body mass index is 29, at the high end of the “overweight” category.

The picture for the average woman? She is roughly 5 feet 4 inches tall, and weighs 171 pounds, with a 39-inch waist. Her B.M.I. is close to 30.”

So, cause for pause: In a few years, the average American will be obese. Will someone then advocate for redefining obesity?

I also didn’t have the exact correlation between BMI and all cause mortality, so I googled for an answer and came up with a 2016 paper in the British Medical Journal with a systematic review of 230 cohort studies with 3.74 million deaths among 30.3 million participants. This paper puts ideal BMI between 22 and 24, and the relative risk at the average American BMI of 29 is in the 1.2 range compared to people with ideal BMI.

It is sobering to look at the exponential increase in death risk when BMI exceeds ideal: 20% excess risk for even average Americans, 50% greater risk at a BMI of 35 and double the risk at a BMI of 40.

Better Words for Better Deaths – The New England Journal of Medicine

I appreciate the philosophical pieces in many of the major medical journals. Medicine isn’t only about technology.

Ours is a vocation of emotion and communication; we work with words and need to use them wisely.

Linguist-turned-doctor Anna DeForest writes about the words we use for when patients die and also of the words doctors use when we acknowledge that death is inevitable.

DeForest writes about how she stopped using the D-word:

“I was an intern with a half-year of training, and we saw five deaths in the first week before I stopped counting. “He’s gone,” we’d say. “She passed, we lost her.” Or when we felt dark, we’d say among ourselves, “He was transferred to the morgue.” At first I tried to just say “died.” Physicians, at least, should call death what it is. It didn’t take me long, though, to begin using the euphemisms. The families weren’t the only ones who needed consolation.”

She also writes about the expression “Withdraw Care”, pointing out that withdrawing efforts to cure should in no way mean we stop delivering all care.

“I have a reflex like the snap of a ruler when I hear someone say that. When the end of life is inevitable and patients or their families consent, we may withdraw aggressive therapies or medications, or stop interventions, but we should never withdraw care.”

She describes a situation when, as an intern in the ICU, she ordered a patient to be extubated by respiratory therapy and was not there herself to help manage the patient’s process of dying:

“I do regret that we did not make the time to find the right combination of morphine and glycopyrronium or atropine to prepare her for extubation, to spare her sons the trauma of seeing her die that way. Our inattention to her symptom burden at the end of her life represents a real withdrawal of care.”

A Country Doctor Reads: January 19, 2019

Are Crohn’s and Ulcerative Colitis Infectious Diseases?

This week, an article in JAMA by Costello and colleagues describes a successful, brief protocol for fecal transplants in ulcerative colitis:

“In this preliminary study of adults with mild to moderate UC, 1-week treatment with anaerobically prepared donor FMT compared with autologous FMT resulted in a higher likelihood of remission at 8 weeks. Further research is needed to assess longer-term maintenance of remission and safety.”

Last year I had a patient with refractory clostridium difficile colitis go to Portland for a single fecal transplant and return home cured, with a normal bowel movement the next day.

So, we understand clostridium difficile as an infection, but are Crohn’s Disease and ulcerative colitis also infections? We have thought of them as autoimmune. Now many thinkers are proposing that diet influences bacterial homeostasis and intestinal permeability, which in turn causes our immune system to become exposed to antigens it normally doesn’t encounter. This in turn triggers an inflammatory response that manifests itself as autoimmune disease in any of many organs.

In recent years there have been several articles published about the use of fecal transplants in Crohn’s disease, including a 2017 paper by Bak and colleagues, which expands a bit on the concept of DYSBIOSIS, altered gut flora. The idea is apparently quite old:

“The concept of FMT for treatment of human intestinal diseases was described in China during 4th century, and human fecal suspension by mouth was used to treat patients who had food poisoning or severe diarrhea.”

The paper continues:

“Increasing evidence suggests that specific changes in the composition of gut microbiota, termed as dysbiosis, are a common feature in patients with inflammatory bowel disease (IBD). Dysbiosis can lead to activation of the mucosal immune system, resulting in chronic inflammation and the development of mucosal lesions. Recently, fecal microbiota transplantation, aimed at modifying the composition of gut microbiota to overcome dysbiosis, has become a potential alternative therapeutic option for IBD. Herein, we present a patient with Crohn’s colitis in whom biologic therapy failed previously, but clinical remission and endoscopic improvement was achieved after a single fecal microbiota transplantation infusion.”

What Causes “Leaky Gut?”

“Leaky Gut” has been triggered by any degree of gluten intolerance and many other things.

Chris Kresser, a prominent Functional Medicine practitioner wrote last summer:

“Obesity, diabetes, and metabolic syndrome have long been associated with gut barrier dysfunction and an altered gut microbiota composition”.

He goes on to quote work on how ingested sugar causes leaky gut, but also points out that leaky gut has been noted to cause insulin resistance, an apparent vicious cycle:

To many, dysbiosis and leaky gut are at the root of many of today’s chronic diseases, while others downplay the importance of these mechanisms even though they acknowledge that they exist. The conservative British National Health Service states:

“Alcohol, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are well-known irritants of the bowel lining. They can damage the seals between cells, allowing some substances to pass through the gaps and into the bloodstream.”

Other causes of increased gut permeability listed by the NHS are chemotherapy drugs, radiation, immunosuppressants, HIV/AIDS and Cystic Fibrosis. They also list Inflammatory Bowel Disease as a cause of leaky gut, but it now seems it’s the other way around.

Once considered “fringe” theories, leaky got and dysbiosis are rapidly becoming mainstream.

A Country Doctor Reads: January 13, 2019

The Making of the Picky Eater – The Wall Street Journal

Picky eaters are said to be a newish phenomenon among children. An article in The Wall Street Journal gives some interesting history, from children being fed scraps to medically suggested bland diets to letting children eat whatever they wanted:

Doc­tors scram­bled to find so­lu­tions. One of the most widely noted re­sponses came from the Cana­dian pe­di­a­tri­cian Clara Davis, who con­ducted a se­ries of ex­per­i-ments in the 1920s and ’30s to see what would hap­pen if small chil­dren, in­clud­ing ba­bies, were al­lowed to pick their own foods. For her study, Davis was able to round up 15 in­fants from in­di­gent teenage moms or wid­ows and su­per­vise all of their eat­ing for pe­ri­ods rang­ing from six months to 4½ years, ac­cord­ing to ar­ti­cles she pub­lished in 1928 and 1939 in the Cana­dian Med­ical As­so­ci­a­tion Jour­nal and a 2006 re-ex­am­i­na­tion of her work in the same pub­li­ca­tion.

The chil­dren were al­lowed to choose among 34 items, in­clud­ing milk, fruit, veg­eta­bles, whole grains and beef, both raw and cooked. They made some rather ec­cen­tric choices, in­clud­ing fist­fuls of salt, and most were ap­par­ently fond of brains and bone mar­row. Some-times they ate lit­tle, and some­times more than an adult (no­tably, six hard-boiled eggs on top of a full meal, or five ba­nanas in a sin­gle sit­ting). The tiny sub­jects var­ied widely in their self-cho­sen menus, but the idio­syn­crasies evened out over time, and each child, Davis re­ported, ended up eat­ing a bal­anced and com­plete diet.

Sickly and scrawny at the start of the study, they be­came healthy and well-nour­ished, she wrote, sup­port­ing a con­cept that was be­com­ing known at the time as body wis­dom. “For every diet dif­fered from every other diet, fif­teen dif­fer­ent pat­terns of taste be­ing pre­sented, and not one diet was the pre­dom­i­nantly ce­real and milk diet with smaller sup­ple­ments of fruit, eggs and meat that is com­monly thought proper for this age,” she wrote. “They achieved the goal, but by widely var­i­ous means, as Heaven may pre­sum­ably be reached by dif­fer­ent roads.”

The Grace of Denial – The New England Journal of Medicine

This week’s “Perspective” essay is by a physician who has sympathy for patients and families who fail to accept a terrible disease diagnosis until well after it should have been obvious. Dr. Heather Sher insisted and believed her father had Lyme Disease instead of Amyotrophic Lateral Sclerosis.

So yes, I am familiar with denial. When I see patients who cannot face the prospect of a terrible diagnosis, I understand their delay, their reluctance, their trepidation on a deep level — a level that perhaps only someone who has witnessed a loved one’s slow demise from a terminal illness can appreciate. In the face of a diagnosis for which there is no effective treatment and no cure, our denial allowed my family 6 months of relative peace before things became unbearable. We had a few extra months with my father without the constant awareness that his death was imminent. My medical inexperience, clouded clinical judgment, and desperate desire for more time with my dad extended our denial of medical reality for longer than is typical.

Today, when I hear detached descriptions of patients who’ve waited too long to address a devastating illness, I understand. “Denial helps us to pace our feelings of grief,” Elisabeth Kübler-Ross explained. “There is a grace in denial. It is nature’s way of letting in only as much as we can handle.”

There Are Few Shortcuts to Health

People aged 70-90 who follow a Mediterranean diet, are physically active, have moderate alcohol use, and are nonsmokers have less than half the heart attack, cancer and overall death rate of people who eat an average Western diet and have more average habits. This was the remarkable conclusion of the 2004 HALE study, involving people from eleven countries.

And the 2014 PREDIMED study demonstrated a 35-50% reduction in cardiovascular events by simply consuming extra virgin olive oil.

But there’s little money to be made for the pharmaceutical and health care establishment by promoting healthy eating habits.

In this week’s New England Journal of Medicine, there are two articles with opposite results from the use of different omega-3 fatty acids.

The first one, sponsored by the pharmaceutical industry, showed a 25% risk reduction from a supplement with Eicosapentaenoic acid (EPA), naturally found in fatty fish like salmon.

“Among patients with elevated triglyceride levels despite the use of statins, the risk of ischemic events, including cardiovascular death, was significantly [25%] lower among those who received 2 g of icosapent ethyl twice daily than among those who received placebo. (Funded by Amarin Pharma; REDUCE-IT number, NCT01492361.)”

I remember reading about this substance way back in Barry Sears book, The Zone.

The second article showed no benefit from generic omega-3 fatty acids:

Supplementation with n−3 fatty acids did not result in a lower incidence of major cardiovascular events or cancer than placebo. (Funded by the National Institutes of Health and others; VITAL number, NCT01169259.)

Conclusion: Good food and good clean living reduces risk by 50+%, branded supplements by 25% and generic supplements possibly not at all.

Is anybody surprised?

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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