Category Archives: Health Care

Random Thoughts and Staircase spirits

Time, said Auden, will say nothing but I told you so. Time also gives one the opportunity to brood – darkly – on so many of the idiocies out there in the ever-expanding world of health information.  So here, in no particular order, what’s been making me especially cranky:

Monster under the bed roams city streets  

Diabetes, the latest health scourge to hit the news, is now a City of Vancouver problem, at least according to a headline in a throw-away newspaper I threw away,

“Vancouver to track and attack diabetes”.  With what, one idly wonders. Bicycle spokes dropped on those bicycle lanes? Pointed sticks? Stern warnings? Nothing so mundane it turns out. This, apparently is part of some international initiative (a word that sets my teeth on edge) and creme de la creme cities like Houston, Mexico City, Copenhagen, Shanghai and Tianjin (where?) are on board, tracking “people at risk of diabetes” as part of a campaign to promote “healthier cities”. Curiouser and curiouser. Who knew cities were sentient and could get sick.

So the plan is – what? Skulk behind anyone leaving Starbucks with a large, frothy coffee? Tap anyone who seems a bit plump on the shoulder and read them the health riot act? (Honestly officer, it’s this outfit. Makes me look fat.)

Why Social Media Marketing Is Like Herding Cats [Cat Photos Included ...

Lurking in the shadows ….. (so, what’s your AiC?)

Someone with the unlikely title of managing director of social policy at, one assumes, the City of Vancouver  will start “consultations” with Vancouver Coastal Health and – wait for it – Novo Nordisk, the sponsor of this demented plan.

Of course. Silly us, not to have realized a drug company had to be involved.

Novo Nordisk, a nominally Danish but probably multinational drug company almost exclusively manufactures diabetes drugs (oral hypoglycemics) as well some types of insulin. (The old insulin by the way, the non-patent-able kind that came from animal pancreases and was easily tolerated isn’t around any more at least on this continent. Banting, bless him, donated his discovery to the people of the world; he didn’t believe anyone should benefit financially from diabetes. Unfortunately he had no way of knowing that by the late 20th century pretty much anything could be “property”: manufactured and sold, up to and including a person’s genome.)

This diabetes sneak attack has already started up in Houston where they “mapped” various areas (for what one wonders) and went door to door to “educate” people about diabetes. Then, if their numbers don’t match some ideal level no doubt they need some of Novo Nordisk’s boffo drugs. (This class of drugs, by the bye, doesn’t tend to have a long shelf life as they usually are fairly toxic to the liver and quite a few of them have come and gone.) These hapless people will be told to get their fasting glucose and A1C* checked and down the rabbit hole they will go. We will all go.

These days after all it has nothing to do with the actual human being who may be in there somewhere but about the numbers. (There’s an American drug ad that doesn’t even pretend it’s about anything but “bringing your numbers down”.)  I suppose racial profiling could play a part as well, given that, statistically, people of South Asian, Hispanic, Asian and First Nations background may be at greater “risk” – whatever that means.

What few people realize is that this ostensible epidemic of type 2 diabetes sweeping the world has much to do with the continual lowering of inclusion criteria. A few decades ago “normal” glucose levels were around ten. Now they’re about half that. For people over 50 the latter number is especially problematic as close to half of us, as we age, tend to have somewhat higher levels of glucose and if you think about it, it simply makes no sense that a physiologic change that affects close to half the population in a particular demographic is a pathology. It’s what’s called, um, normal.

As for me, if anybody tries to corner me and talk to me about my diabetes risk, I plan to run shrieking into oncoming traffic. At least that’s a risk that makes sense.

Fight them on the Beaches

In that previous story what initially struck me was the term “attack”. As though a glucose level that could potentially be problematic was some kind of enemy – not some fluctuating number based on a myriad factors ranging from weight to diet to sleep. A number that moves up and down depending on the time of day and a host of other factors.

Physiology is dynamic, not that you’d ever know it these days given how mesmerized we are with the numbers.

Oliver Sacks, RIP

Someone who understood the complexities of physiology – and stood up for clinical knowledge and patient narratives – was Oliver Sacks., who died last August.

Physician, author, eccentric and host of oddball characteristics, Sacks wrote some amazing books (Migraine, The Man who Mistook his Wife for a Hat, An Anthropologist from Mars, A Leg too Few are some of the ones I enjoyed reading. Apologies if I got the titles slightly wrong as I’m quoting from memory). Most important, his writing reminded us of the diversity and variation(s) there are between us; not simply the similarities that clinical trials, statistical averages and guidelines exploit. Sick or well we’re all different and, to paraphrase Hippocrates and Osler and other famous sorts, medically the person with the disease matters as much as the disease. Or ought to. Alas, the trajectory of modern medicine whether it’s so-called preventive care, apps or genetics has a tendency to iron out those differences and push us towards some mythical average or “normal” that few of us come close to.

Colourful, thoughtful clinicians like Sacks have become vanishingly rare. Perhaps it was Sacks own differences – Jewish, gay, former biker and user of psychoactive drugs, gefilte fish aficionado – that made him realize just how much one’s personal history and narrative played into one’s physiology. Or just how vital it is for clinicians to listen as well as talk.

Dem bones, dem bones

L’esprit de l’escalier is a French phrase referring to all the pithy remarks one ought to have made but which only come to mind some hours later. Usually as one’s interlocutor is long gone.

So, to the pleasant woman who came up to me after my CAIS (Canadian Association of Independent Scholars) talk last year to ask about vitamin supplements, more specifically calcium, what I omitted to mention was that calcium is not a vitamin, it’s a mineral. An element, if one wants to be pedantic, Ca+ (20 on the Periodic Table). Hence, the “elemental calcium’ you can buy in the drug store.

The notion that we all need to take calcium supplements for our bones is based on somewhat simplistic notion, namely that simply ingesting this mineral will somehow magically increase bone density which we are told we are losing at an alarming rate, especially if we are women over 50. Clever advertising ably preys on our fears of “weak” bones, metaphors being what they are.

Bone is an amazing substance. It is dynamic – the collagen demineralizes and then degrades even as other cells (in sync) remineralize the collagen that has just .. diminished for want of a better word. It ebbs and flows (how else could a broken bone heal?) to achieve a balance; a balance that alters with age. When we are young/growing bone builds to its apex, in our twenties. It then plateaus for a time then, as we pass age 35 or thereabouts we gradually lose bone density. This is what we used to realize was normal development. And the bone in your body differs in form, hardness and elasticity depending on where it is and what it does – the vertebrae in your spine and the long bones in your body are of a different consistency and respond to changes in pressure differently than the ribs or the wrist.

The calcium/Vit D directive has become so engrained however that most people believe what they are doing is somehow maintaining or feeding their bones with supplementation.

But our endocrine system monitors the blood level of calcium and maintains it at our personal set point. One that is different for each person. This means that taking in more calcium is generally pointless as it simply cannot be absorbed. To quote Nortin Hadler, an MD, in his book, The Last Well Person, “If the blood calcium level trends down, vitamin D is converted to an active metabolite, which makes the intestinal absorption of calcium more efficient and vice versa”. More is not better; it’s useless. And potentially harmful as calcium can deposit in joints and other bits. As for vitamin D, it too has a set point that differs in each person; too large doses can build up and become toxic. So, those generic amounts you’re advised to take may or may not apply to you. Probably don’t in fact.

We tend to think that the supplements we take as a kind of top-up to diet, like adding oil to a car or salt to soup. Our bones rely on calcium so we basically assume that bone density is improved by taking supplemental calcium. And since our bones contain calcium, and as we get older our bones become less dense, we should “supplement”. It’s a mechanistic form of thinking about the body, one that took off after the Industrial Revolution when an “engineering mentality” took hold about physiology (in anthropologist Margaret Locke’s term). It certainly doesn’t hurt that the nice people at Bayer (who are taking over the world and now sell everything from vitamins to glucose meters) continually tell us we should. Alas, physiology is rarely so cut and dried and our understanding of how bone (or anything else) works remains primitive.

The real advantage of dietary calcium is when we are young and our bones are developing (in our teens). Unfortunately, short of building a time machine and going back in time there’s not much we can do to reverse the bone mass we accrued before our twenties.

So for now the basics of health remain the same as they were in decades past. Relax, eat well, exercise and stop stressing out about supplements. Most important: stop listening to all that bogus advice out there. If all we do is obsess about our health, our diets, our bodies – well, we won’t actually live any longer but it sure will seem that way.

 

*A1C is a measure of a red blood cell that is said to provide a “snapshot” of your glucose levels over the previous three months. It’s rather elegant but is still a correlation. A good one to be sure but correlation is not, as we all know, causation.

 

 

 

 

Civil Scientific Discourse RIP

It’s no secret that I am not fond of hot weather in general and summer in particular. Making me especially cranky at the moment is the hyperbole surrounding the science/non-science discourse, e.g., around childhood diseases like chicken pox or measles, mumps and rubella (the three dire conditions the MMR vaccine is supposed to prevent). The crux  appears to be that either you’re either one of those unscientific, Jenny McCarthy-quoting, loons who believes vaccines causes autism – or you’re a normal, nice, sane person who believes in science. Paradoxically, science appears to have gained the status of a deity in this discourse.

No need to get hysterical about skepticism.

No need to get hysterical about skepticism, Hume might way.

Case in point, a headline last year: “Shun anti-vaccine talk, SFU urged”. Some anti vaccine conference was going to take place at some SFU campus and an angry group of critics were whopping mad lest this event “lend credibility” to this “dangerous quackery”.  This, er, quackery was some symposium where the discussion was on how “families are facing increasingly intense pressure from the vaccine lobby and big government to comply with vaccine mandates” and was  organized by something calling itself the “Vaccine Resistance Movement”. Hardly saving the free world from tyranny but hey, the resistance carries on, large as life and flakier than thou.

The 18th century philosopher David Hume, the granddaddy of skepticism would no doubt be turning in his grave at this hysterical, humourless assault.

BC’s Chief Medical Officer replied in his usual vein: “Vaccines, like any medicine, can have side effects, but the benefits … outweigh the risks,” By and large this would seem to be true. But, surely, it can’t be verboten to wonder whether suppressing all childhood diseases may perhaps also have consequences? Especially the trend towards vaccinations against diseases “such as chicken pox which cause only inconvenience rather than danger” in the words of British sociologist and science and technology writer Trevor Pinch. (In Dr. Golem: How to Think About Medicine by Harry Collins and Trevor Pinch, University of Chicago Press, 2005). Especially given the sheer number of jabs (approx. 20 I think) that infants now get.

SFU president Andrew Petter apparently refused to cancel anything, merely saying universities stand for freedom of expression and, as far as I know, the conference went ahead. I have no idea what was discussed but I suspect it was a lot of nonsense. That’s not the point. What’s perturbing is the vitriol of the protesting group and the smug suggestion that if one dares to question the many vaccines tiny babies are subjected to (or suggest these might, just might, have adverse immune or other effects) one has no right to speak. Either you toe the party line or you’re a crazy person. One who should be run out of town on a rail to coin a phrase. (I’ve never been sure why being run out on a rail – which to me implies a train – would be such a bad thing. Personally I am mega fond of trains.)

The photo of the conference protestor indicates that the group (“The Centre for Inquiry”) is just as obscure as the one they’re protesting. Maybe the whole thing was a publicity stunt or performance art, who knows.

Any child not vaccinated against the measles should not be allowed in school, someone firmly said to me last month. Measles can cause deafness and blindness, not to mention encephalitis, someone else said. I mildly agreed, merely pointing out that the numbers on these dire effects in the developed world were actually vanishing small, at least based on the (admittedly limited) research I had done. Buried in the contradictory numbers one small group of children was clearly at risk from measles, namely children undergoing cancer treatment.

Years ago, when I wrote a book on the immune system, I did a bit of desultory research on measles; there was some evidence that a natural bout of measles appears to reduce the incidence of allergies and asthma in later life. (Operative word appears – the data was correlational and based on medical records; there is no way to know for sure if this was cause and effect. Bearing in mind that most health recommendations, from lowering cholesterol to vitamins, are based on correlation.)

Immunologically measles appears to have a modulating effect; in a way allowing the immune system to become less inappropriately reactive and reducing the incidence of asthma and allergies. Perhaps this struck a cord with me because in my own case a natural bout of German measles (rubella) massively and obviously cleared the really bad eczema (also an auto immune over reaction) I had suffered since I was two or three. Large, itchy welts covering my legs, arms and face, especially knees and elbows. Then poof, I get sick, high temp, general malaise and my eczema essentially clears. I still occasionally get eczema, usually in reaction to an allergen (like aloe). But, by and large, I’m fine. The research I did years later gave me a context for that (better than my grandmother’s “well, the high fever burned it off” which made the eczema sound like a forest fire – though, come to think of it, that’s not the worst description).

But when I wondered out loud some weeks ago if maybe, maybe, over zealous vaccination programs could have anything to do with the increase in peanut allergies out loud some months ago you’d have thought I had suggested a plot for Criminal Minds. It was speculation, people. I’m not the vaccine police.

I’m not sure quite how this binary, myopic perspective evolved and became so engrained, but it seems now that any questioning of standard medical dogma (“vaccines are good”, “sugar is bad”) ends up as some version of t’is/t’isn’t, t’is/t’is NOT: all the subtle dynamics of a nursery school. Either you’re a feeble minded dweeb who fell for the fraudulent, discredited Wakefield Lancet article linking vaccines with autism (actually GI problems not autism but that’s lost in the mist of rhetoric) – or a sensible, right thinking person who believes in science, good government and iPhones. (As it happens I now have a Blackberry Z10 which I think is far, far superior. Were we to pause for a commercial break.)

Science is a method. Neither static nor dogmatic. But I guess if you’re going to turn science into a religion then it will end up that way. Pity, since scientific inquiry was, to a large extent, what dragged us out of the Dark Ages.

 

 

Why cats make the worst patients (and the dog ate my homework)

Charlie stopping to smell the flowers in healthier times

Charlie stopping to smell the flowers in healthier times

Charlie, one of the cats, was seriously ill and Lyme Disease (which was the designated subject for this post) went clear out of my head. It shall return. Meanwhile, I’ve been nursing Charlie, aka Houdini cat (who will literally disappear into the towel you think you’ve wrapped around him securely), reminding myself that nursing is a noble, noble profession. (That’s what you call professions that are bloody hard and nobody appreciates.) I’ll say one thing, taking a cat to the animal hospital does give one a quick lesson in the perils of for-profit medicine (my Visa may never recover) – especially in our risk-obsessed age where tests and scans trump individual history, personality and symptoms (human or animal). It also reminded me that one must be vigilant when faced with the ponderousness of Expertise.

In Charlie’s case it began with a neurological condition called Horner’s, an irritation of a nerve running down one side of the face, eye and down the neck and into the chest – not a disease but a symptom. Naturally Expertise immediately rushed to the worst possible diagnosis: lymphoma, or, in a pinch, brain tumour. (Do not pass ‘go’, just head for the hills.) I mildly posited inflammation or infection, probably ear related, particularly since Charlie’s had those before. But noooo.

Critical Care, human or animal, is rife with Expertise: grave, gravel toned and confident. Why? Because they have tech toys, that’s why. Cool devices and imaging technologies that purport to explain the mysteries of life. Even (ha ha) a cat scan. All of which push the patient into ever higher levels of care – because they can. Problem is, the patient often can’t.

I tried to hold my ground but it’s a slippery slope that one; the surer they are the more one caves, especially when they start to say, well, with cats elevated white blood cell count could mean X. I mean, what do I know from cat physiology?

So the cash register tinged and Charlie looked steadily worse. Of course nobody looks good in ICU between the ugly fluorescent light and the tubes but there’s something especially pathetic about a small furry creature sitting in a cage. And Charlie, well that cat could have taught Stanislavsky a thing or two about looking sad.

I kept getting calls to tell me things I already knew (he has a heart murmur). The last time I snapped, “I know. I have one too. Big deal.” That didn’t, naturally stop them from getting a cardiology consult. Bearing in mind that cats don’t hold still for much of these so need to be anaesthetized.

Finally, after every possible dire diagnosis had been ruled out, we came round to my original hypothesis: ear infection.

Don’t get me wrong. I have enormous respect for veterinary physicians. They study long and hard (far longer than human doctors) and by and large they are great. They deal with a diverse patient population who’s uncooperative and uncommunicative. And when I say diverse I’m talking species. And they need to make a living, I get that.

What they, and most of us, do not get however is that they are part of the culture at large and the culture at large is obsessed with the “science “ of medicine, leaving the art further and further behind. Watching Charlie work his way through the system reminded me of just how much medical focus has shifted away from the patient and towards disease, technology; towards what tend to be called “objective” results (versus the messy subjective ones patients bring).

I see this on a human level very time I go to the retinologist with my mother (that, by the bye, is a sub-specialty of ophthalmology). First, they get her to read the letters on the chart and are all impressed at how well she sees. Then they take their pictures and look grave: how could she possibly see that well with those terrible ridges in her retina? (To me they just look like the Alps.) Then they look puzzled. Scan says you can’t but you actually did see. What a gonzo dilemma. So, they go with the scan and give her the medication. Objective trumps subjective.

Question is, should it? Does it make sense for the patient to get lost in this morass of ostensibly objective ‘data’?

Not to my way of thinking. “Normal” – blood pressure, lipid level, whatever – is a best-guess average based on population statistics and what some committee has deemed appropriate. If you’re truly sick it shows up. C-reactive protein in the clouds – well, objective and subjective tend to match. Your joints hurt, you have some kind of inflammatory condition and the test backs you up. It’s that grey zone that’s problematic. Levels fluctuate in every individual, tests can be wrong (some more than others).  Error rates in some tests are as high as 75%. But we forget that.

So, cat or human we are lumped in with the many-too-many – and our individual narrative gets lost. In Charlie’s case nobody believed this pretty little cat who had only been ailing for a week could possibly “just” have a madly inflamed  ear affecting his balance and appetite. An infection is no picnic. But it’s not a brain tumour. And of course Charlie’s Oscar winning ability to look mournful didn’t help. This cat can look sad when he feels ignored; imagine how dreadful he looked when he was dizzy and queasy. It’s a gift. But it’s not diagnostic.

You need a proper history; the back story. The person with the disease is as important as the disease, said Hippocrates. Let’s say you end up in hospital with severe abdominal pain. It matters whether you’ve had this pain before, but less intense or of shorter duration. Sudden abdominal pain could be many dire things; a worsening of an existing problem is probably nothing that will kill you (otherwise you wouldn’t be in the ER in the first place). The clinical picture changes with the history. Someone has to factor it in.

Charlie’s doing better now. As for the rest of us – who knows. We may never survive the tech age.

Is there an epidemiologist in the house? *

There’s an appalling advert for one of the adjunct health unions/associations/whatever where someone collapses in a restaurant and the doctor starts to call for various “technologists” (x-ray, CT scan, etc.). I don’t doubt their word that health care today is complex; still, call me crazy but if I collapsed somewhere I’d really rather have an actual health professional, a clinician, by which I mean a nurse or physician, at my side than someone who knows how to operate an ultrasound machine thank you very much. Remember, machines don’t “know” whether something is a concern or not – it’s people, actual humans, who make that determination.

A determination that all too often relies on over-optimistic beliefs regarding the accuracy of “tests”.

(But as neurologist and author Oliver Sachs once sadly remarked: They don’t give Nobel prizes to clinicians, only medical researchers.)

Worse, everything from the images and data we get from those machines not to mention the health information that’s flung at us from all sides is based on statistics. More accurately, a statistical approximation of “normal”. The normal person, whatever or whomever that may be. Another term, whether one is being statistically accurate or not, is “average”.

Now I don’t know about you but I’ve never met an “average” person. Everyone I know is distinctive, sometimes eccentric, often times interesting, funny and, well, different. People are a jumble of ethnicities, backgrounds, socio-economic and otherwise; their education and passions and hobbies and interests differ as does everything from their diets to their bad habits. Er, risky behaviours to the epidemiologists in the house.

So here we all are, contorting ourselves into bizarre shapes trying to fit into the statistical moulds they’d have us fit, from the not-so-benign lipid levels and blood pressure (for which drugs are available should one not conform to aforesaid norm) to clothing sizes and availability in everything from lipstick colours to food. Oh, yeah, tell me you haven’t noticed that your favorite kind of frozen chips appeals to you and six other people so it’s been discontinued.

From supplements to ideal weight, glucose and you-name-it, normal follows us around like some malevolent mosquito, buzzing in our ear and biting us in the you-know-what when we try to ignore it. Whether it’s Dr. Google or the news items on everything from your phone to your TV.

But when we’re feeling off, or sick or have had something bad happen what we want and need is a clinician: someone who knows how to set that broken bone, do that tracheotomy, or CPR and know just how much morphine to prescribe so we’ll keep breathing. Unfortunately, the spate of bad health news out there makes us all so nervous that all to often when we do end up at the clinic or the ER we’ve got nothing more terrifying than bronchitis or a particularly bad bout of cystitis. Not for us former generations stoicism; we race over ‘just in case’ for everything from a sore knee to a cough.

An American chap once disparagingly told me Canadian health care was simply dreadful. How did he know? Well, when he lived in Montreal he had a bad cold. One assumes in winter when people get those in cold climates. Then, late Saturday night he decides to head over to the Emerg because his cough was worrying him. Could he breathe? Yes. Was he running a temp? No. But he went anyway. And couldn’t figure out why the ER staff didn’t rush him to have tests and x-rays. Ah, d’you think you could have picked a less busy time? Of course not.

Where’s an epidemiologist when you need one?

* Not my line, though I wish it were. I read it in Gordon Clark’s column in The Vancouver Province on July 8. Laughed out loud as a matter of fact.

They got stones, I’ll give you that

I was going to call this post “nobody knows the trouble I seen” except that it seems ludicrously self indulgent to whine that one has been living through construction hell when the rest of the world has revolutions, civil wars, hurricanes and so on to contend with. (But, to paraphrase Will Rogers, everything is manageable provided it’s happening to someone else.) This isn’t to say my curmudgeonly instincts have been dormant . One particular item a while back had me seething.

“Sugary drinks are not so sweet”  was the headline in the Health section of the Globe and Mail (24 May 2013).  Apparently, drinking a sugar-sweetened drink a day not only rots your teeth and adds up to empty calories (with the added bonus that it makes New York’s Mayor Bloomburg crazy) but “may increase the risk of kidney stones”.  Gasp. I had to pause to take a sip of my ginger ale* while that sank in.

I puzzed and I puzzed, to reference one of my favorite curmudgeons, the Grinch. Didn’t make sense. How on earth could fructose cause blobs of crystallized minerals to form in the kidney? (To reinforce the point that sugary drinks are Evil the accompanying photo was of a surgeon with a scalpel. Someone had fun with that.)

The research cited was from 2007, published in a journal called Kidney International (2008, 73; 207-212).  The worthiest journal nobody’s ever heard of.  My curiosity got the better of me and I downloaded the article and read through the cringe-inducing prospective study; yet another data-mining expedition hoping to find a “link” between X and Y. (For more on my distaste for the term, see post.) The data? From – wait for it – the appalling Nurses’ Health Study, formerly used to “prove” that taking estrogen was just a boffo idea.  Here, the research cites some 19,000+ women along with some 46,000 men from the Health Professionals Follow-up Study. Impressive numbers. Pity the hypothesis is so feeble.

Not of course to our heroes, researchers Taylor and Curhan, unspecified experts at a renal division/lab at Brigham Young and Harvard who engage in enough statistical jiggery-pokery to make the world go round.  (Pity nobody blinks when data gets tortured.)

Just a few problems here. As I explained, in often far too exhaustive detail in The Estrogen Errors, extrapolating to the general population from the Nurse’s Study is massively problematic. For starters, there’s its basic design, bi-annual self reports, which are notoriously unreliable. We’re all prone to error as any gibbon with half a brain knows: we forget, lie and generally get things wrong. Good grief, most of us stutter when they ask us how much we weigh when we get a new driver’s license. Plus, there’s the healthy user bias – people who respond to any questionnaire tend to be richer, smarter, better off, i.e., healthier than the average bear. Er, person. Often they’re white and frequently younger. All of which means they are not like the real at-risk population who, by and large, tends to be poorer, less educated, older, more diverse, less health and diet conscious, more stressed and sicker. Face it, d’you think you’d have time to sit around reading some blog if you had to work at two or more minimum wage jobs just to put food on the table and pay your rent? Could you even afford an iPad or even high speed internet?

This is on top of the fact that professionals in general can’t stand in for “everyone” and basing one’s conclusions of what these people do (or say) is what’s popularly known as being spectacularly wrong.

What really interested me, though, was what these researchers thought might be going on physiologically. In other words, how did we get from basic sugar metabolism to blobs of crystallized minerals in the kidney? Gremlins? Evil spirits? The authors do obligingly admit that the underlying mechanisms are “unknown” (ah, ya think?!) but postulate various processes, none of which make sense. Hence their masterful use of language:

“Fructose may also increase urinary excretion of oxalate, an important risk factor for calcium oxalate nephrolithiasis. Carbohydrates, along with amino acids, provide the majority of the carbon for glyoxylate and oxalate synthesis, and fructose may be an important dietary sugar influencing the production of oxalate.” (emphasis mine)

 The authors concede backing for their hypotheses are “sparse”; personally I would have said nonexistent. Rats make up the bulk of their research subjects in this section and the one study they cite using humans consists of eleven – yes, 11 – men whose pee was analyzed for calcium loss (versus calcium intake).  Fructose intake made no difference in the calcium these men excreted but the researchers still concluded that the reason fructose laden drinks caused kidney stones “may be related to the effect of fructose intake on urine composition”.  How they concluded this I have no idea. Maybe they were on a sugar high.

The only marginally plausible explanation had to do with uric acid metabolism and for a moment I thought, OK, this might make sense. Then I checked the reference and realized it only applied to people with gout, whose uric acid metabolism is already dysfunctional (that being the definition of gout). 

Kidney stones, by the bye, are hardly that common and rarely if ever life threatening. Even Wikipedia’s overblown, hyperventilating piece on the topic, that sounds as though it was written by a nephrologist who had just passed one, admits that the incidence or number of new cases a year is “0.5%”.  (Of course it doesn’t specify 0.5% of what which is rather an important point, but let’s not nitpick at this late point in the post.)

How did this 5-year-old study even make it into the health news section? Having spent some years as a medical writer and journalist, I can tell you exactly how. A group of people in an editorial meeting, drinking coffee – or pop – were bouncing around story ideas and someone suggested a piece vilifying soft drinks, currently Public Enemy No. 1 (see NYC, Bloomburg).  So, they wrote the headline then they contacted the hapless writer who cast about for some new and nifty problem that could be blamed on aforesaid sugary drinks.  Everyone  knowing full well that the majority of people only read the headline and the first paragraph; it’s only mutants such as myself who check the original research and parse the methods section.

If sugary drinks do give you kidney stones, these people didn’t prove it.

There are a lot of good reasons to consider soft drinks a treat, not a staple. They’re empty calories; they rot your teeth and many of them contain fairly high amounts of caffeine which can make you nervy and insomniac. But kidney stones? Really?! We think not. And it takes stones to say they do.

 

 

 

* oh get over it. It’s summer. There’s construction outside. Yes, I have the occasional ginger ale or Coke. Sometimes, when I’m especially cranky, two days in a row. Sue me.  

So they continue being a pain ..

Painkillers increase risk of car crashes proclaims the headline in today’s Globe and Mail. Apparently, researchers at the “Toronto based Institute for Clinical Evaluative Sciences have found a correlation between even low-dose regular opioid use (two Tylenol 3’s three times a day) and an increased risk of car accidents.

Not a huge risk, the head researcher David Juurlink, hastens to add; certainly nowhere near as high as alcohol, but a risk nonetheless.

Wonderful. Two of my favorite things – correlational studies and experts rambling on about opioids in the same piece with blinkered experts continuing on their merry way, all pleased and sending out press releases (don’t kid yourself, that’s the only way a paper from something called the Institute for Clinical Evaluative Sciences that nobody has ever heard of would get a piece in the Health section of the Globe and Mail).

Um, did it ever occur to these geniuses that the reason people take those drugs, namely pain, might have something to do with those slightly increased numbers of car crashes? I use the term slightly advisedly: the risk increases between 21 and 42% according to the “scientists”. (Scientists in quotes because surely any scientist worth his salt knows that unless you know what you’re comparing something to a percentage – relative risk – is absolutely meaningless.)

Surely pain – which means someone gets more easily fatigued and could become less alert – could have a thing or three to do with it?

Oh no, it’s the opioids.

Of course by the same token, ice creams causes an increased number of drownings. Think about it. In the summer people eat more ice cream – and more people drown. QED.

Last March I wrote a post on Oxycontin and made some disparaging noises (OK, loud, angry noises) about the ado being made about addiction and pain killers. Notably, a Fifth Estate that had me virtually apoplectic with rage. Using largely American stories the CBC newsmagazine insisted that addiction to oxycontin was a  massive problem that we should all get worked up about, especially when it came to First Nations communities in the north.

By contrast, a few weeks ago I happened to come across a BBC mini-documentary about the same topic and the contrast could not have been more marked. I missed the start of the piece but what I did watch was superb. It was a program called “Our World” and the journalist’s name was Linda Sills. (I hope that’s how one spells it.) She had travelled to several communities in northern Ontario, spoken to various tribal elders, artists and addicted individuals and – wonder of wonders – had actually done some research and thought about the subject.

Sills, like the people she spoke to, all agreed that the problem was not opioids (in the ‘80’s it was alcohol and in the ‘90’s glue sniffing) but the situation. The environment. The socio economic conditions. When people are unhappy and hopeless they take solace in drugs, whatever is around, whatever they can get. Solutions are complex, multi-factorial and must emerge from the grassroots of the community itself. An artist who looked to be in his forties, addicted to oxycontin himself, talked of how his art was helping him reduce his drug intake (even though he genuinely looked as though he was still in pain, physical and psychic).

Opioids have been around for thousands of years. Officially they were discovered around the time of the Trojan War (war has always been excellent for medicine) but no doubt people knew of the pain relieving properties of the poppy long before that. They are the single most effective agent in treating pain and although we’ve tried to come up with synthetic variants (Demerol, Fentanyl) and alternatives (non-steroidal anti inflammatories) there simply has never been a drug that works as well, as consistently.

Treating pain with opioids allows people who suffer from chronic pain to function. To have lives. To work, interact with families and friends and feel like the are part of the world.  But in recent years, perhaps with the rise of right wing moralizing in the U.S. and what some people call the rise of the nanny state we have taken a sharp turn away from treating pain to calling individuals who need medication “addicts”.

Our reverence for numeric reasoning and bad statistics naturally hasn’t helped any; after all, what could be more qualitative and unmeasureable than pain, which, by definition, is whatever the person says it is?

 

Boundless enthusiasm for Overtreatment

Last week in Slate, sent along by my friend Maryse whose blog, Frogheart  covering nanotechnology, art, technology and so on is immensely popular (one tries very hard not to be too envious of her close-to-a-million visitors daily), based on an update in the respected Cochrane Review: how treatment of mild hypertension essentially useless.

What neither piece points out is that what we call “mild hypertension” today (systolic 140-159) was considered essentially normal a scant fifteen years ago. Well, 140 anyway. Or that thoughtful (often older) clinicians would not consider this hypertensive in older patients today.

Ah, it’s just a number people. A number, determined by a group of individuals, often cardiologists but also other “experts” (many of whom have ties to the drug companies who make antihypertensive drugs) as to what should be considered “normal”.

I’ve spent much of my research career debunking this notion of “normal”.  Particularly as it pertains to physiology, biology and humans, who, as we all know, tend to come in a variety of shapes and sizes and whose health status is determined by many variables, not the least of which is how much money they have and how happy they are in their lives.

Women, of course, have long been outside this matrix – normal consisting essentially of the male body without its circadian rhythms and cyclic hormonal elements, never mind pregnancy or menopause.  The vast majority of clinical trials, the gold standard of evidence as it has been called, excluded woman altogether and even when they tried to bring them in often women themselves wouldn’t play ball.

The reasons seemed complex, social, domestic, personal, economic and psychological.  Women generally have been socialized to be risk averse, which means if they are told they have condition X then they want the damn treatment. They don’t have time to worry about whether or not they’re taking the placebo. Plus, large multi-centre trials require the time not to mention transportation to get to those bi-weekly weigh-ins or tests or what-have-you and women, particularly women over 40 tend to be overwhelmed with children and grandchildren and ageing parents and work and housework and life. “Who’s got the time to enter a trial?” most will ask. “I’ve barely got time to sit down never mind volunteer my time at a clinical trial.”

No doubt there are other reasons but at this point I haven’t researched it. I just know that women are vastly underrepresented in what we optimistically consider evidence-based medicine.

I see something inherently male and American in this perspective, this enthusiasm for aggressive treatment (as the cultural critic Lynn Payer in her wonderful book Medicine and Culture once remarked, there has to be something culturally satisfying in the notion of ‘aggressive’ given how often the term is used in American medicine; even the recommendations for gentler treatment of newborns was advised to be pursued aggressively).  Or overtreatment.

Cross cultural studies have repeatedly shown that countries like Canada, which can’t afford as many cardiac surgeries and procedures as the U.S., as well as countries like Finland, which simply doesn’t believe in them, have the same outcomes as the U.S. In other words, Americans spend huge amounts of time and money doing things – cardiac bypass, cardiac catheterization, stents, etc. – but cardiac patients are no healthier than in countries where they do half the number per capita. All that activity doesn’t result in better health or lower morbidity or mortality.

Less is often more in medicine. And bodies are fragile. Drugs, surgeries, procedures, tests: these are not benign. They exact a toll on the body. And all for what?

All because somebody somewhere decided they know what was best and what magic number was “normal” blood pressure.  Or what an artery “should” look like in a person with no symptoms.

The worst part is that as patients we are complicit in this, increasingly believing that more is better – and reject the notion of watchful waiting, considering a physician who says, “just take it easy for a while, it’ll get better on its own” a quack. So, fewer and fewer physicians say such things. As a doctor once said at a conference I was at: It’s easier to just write the prescription that to take twenty minutes to explain to a patient (who’s not going to believe you anyway) why she or he doesn’t really need it.

But hey, we wouldn’t want to miss out on something that could be really terrific now, would we?!

 

Beware the Bandersnatch my son (aka the “link”)

If I read the word “link” one more time in some ostensibly serious health article I will – well, let’s just say that like Dorothy Parker’s Tonstant Weader I will thwow up.

Looks like a Bandersnatch to me …

Last week “scientists” apparently linked one’s gait as one aged to one’s likelihood of developing Alzheimer’s. Yet another observational study, casting about for some connection to something; naturally they eventually found some tenuous connection somewhere – at least one that they could write a press release about.

(As a researcher once described estrogen – “a drug in search of a disease”.)

No mention of whether this gait thing might have had something to do with other, perhaps undiagnosed, problems such as osteoarthritis or inner ear issues or what-have-you. No, one more thing for us to worry about as we get older – our damn gait.

Earlier headlines with that vile word “link” (plus variations like “linked”, “linking” and so on) always seem to be in the headline, which, of course, is what most people read. So we read that higher levels of Vitamin D3 are linked to all manner of marvelous things, from not getting cancer and heart disease to staying young and sharp and simply mah-velous. Never mind that when you simply test people who are well and compare them to people who are not, measure their “level” of D3 (as though all of us have the same ideal level) and then say, ‘oh, look, high D means better health so why don’t we all take a supplement” you have no way of knowing which came first, the good health or the D3. For all we know, various diseases deplete the body of D3 and the lack of the vitamin is not the cause of the problem but its consequence.

A number of more cautious researchers have been saying exactly this, to no avail. Various and sundry institutions from the Cancer Agency to the WHO have all decided to chime in with their recommendations that people take supplements.

This same kind of nonsense proliferated in the talk around estrogen for pretty much most of the 20th century.  Researchers gushed that women who took estrogen “replacement” therapy (later “hormone replacement therapy” or HRT after it was found that estrogen alone could cause endometrial cancer) kept women young and healthy and prevented heart disease and dementia and probably hives and hangnails.

Replacement is in quotes earlier, incidentally, because it makes no sense to consider the hormone level of a woman of 23 normal for a woman at all other stages of life, particularly midlife, when all women’s hormones naturally decline.

Observational study upon observational study found a correlation (“link”)  between women who took hormones and improved cardiac function, fewer heart attacks and strokes, better health, you-name-it.  Well, except for the smidgeon of extra risk relating to breast cancer which epidemiologists dismissed as irrelevant. Of course this was not irrelevant to women, who didn’t rush to take hormones in droves, much to the researchers’ dismay.

Then the other show dropped. The largest clinical trial in history, the Women’s Health Initiative definitely showed that not only did estrogen not protect women from various and sundry age-related conditions, it actually could cause them.  Cardiac disease was higher in women who took hormones and there was nothing “healthy” about HRT at all.

But hey, they had studies that “linked” estrogen use with health and who were we to argue?

A lot of people ask me about supplements, Calcium and D3, this and that, largely, I think, because of those headlines linking this and that arcane nutrient with health. Which is where my problem with all of this lies.

You can print whatever nonsense you want, provided you don’t make it sound as though you know what you’re talking about. Especially in the headline. People actually change their behavior based on these things. People start taking things, adding things, subtracting things. Forgetting that health is multifactorial, complex and begins in the womb.

You won’t have strong bones as an adult if you were malnourished as a child. Wealth tends to lead to health. People are different. And the nutrients we ingest in food are in a balance and ratio that the body can absorb. Versus our best-guess estimate of what an ideal amount of D3 or B3 or T3* might be.

So beware the dreaded link as though it were the bandersnatch. On average, I think the latter is more benign.

 

*Tylenol 3

On Clutter, Hoarding and Medical Mistakes

Nobody likes a crisp, neat look more than I do – Ikea wouldn’t be the multi-gazillion corporation it is without my patronage throughout the years. I own pretty much every KASSETT and GLOK organizer doo-dad they make. (I like that they sound Klingon.) Given the sheer number of articles, blogs, television shows and companies on clutter (and its crazy cousin in the attic, hoarding) I am clearly not the only person with this particular fascination.

I sometimes think that if I could just create a prefect, clutter-free world then, as Buckminster Fuller suggested, everything I wrote and worked on would be effortlessly beautiful. Of course I sometimes also think of  Roswell and of the aliens that live among us. So it’s not like I’m totally sane all the time.

Trouble is, compared to a lot of people I’m bloody Einstein, given that this mania for de-cluttering the detritus of life appears to have permeated and penetrated into large areas of life; areas that simply do not lend themselves to neat solutions.

Some things are inherently messy and there’s not a damn thing we can do about it.

Take disease/illness and the complexity of patient care, all of which I have gone on about ad nauseum.  Much as we would like to make it all iPad-neat and high-tech cool the reality of surgery and hospitals and elder care and whatnot just isn’t going to be minimalist-zen. And trust me, if you’re a patient you don’t want it to be because if your clinical team decides you’re just a carbon copy of everybody else you’re going to get shoddy care.

Right on cue enter a medical director at the  Birmingham University Hospital in Britain who, enchanted with the local BMW plant’s “flawless”, failure-free operation, wondered how the hospital could duplicate the plant’s figurative tracking down of every “loose screw”.  (Yes, I am biting my tongue.) One assumes the director hoped patients would leave the hospital all shiny with that new car smell …

So, mixing everything from metaphors to minds, a “bespoke computer system” was ordered – no doubt to bring German engineering to an off-the-rack hospital. The cost? Some 4 million pounds sterling or approximately $5.4 million U.S..This computer’s claim to fame was that its operation actually mimicked the dashboard of a car, presumably that of the aforementioned BMW. The dashboard thingies became standard issue at the hospital; their point to “catch” problems before or as they evolved, problems ranging frompost-surgical infection levels and falls to bed sores. Which sounds sensible you might think. Except you’d be wrong.

A computer that posh couldn’t possibly stop at patient problems; where’s the fun in that? So those bedside dashboards also have dials to let managers and ward sisters know when efficiency (“benchmarked against comparable wards and recent performance”) falls, even as response time is recorded to let higher-ups know who and what might be doing poorly. Ouch. So not only is Big Brother watching but his name is HAL.

The mind boggles. German engineered hospital care run with military precision – oops, that has nasty militaristic WWII overtones. Rephrase, rephrase …

(For more see The Economist, 16 June 2012.  http://www.economist.com/node/21556924)

Admittedly it is tempting and attractive, to believe that better health, better post surgical and treatment outcomes, fewer medical errors as simply being a matter of organization and method. Problem is, Sherlock, people go into hospital for a reason – and that reason is that they’re sick, injured or otherwise poorly. These days, given cost containment issues, hospitalized patients tend to be really sick. Often they are also old, which means they are frail and have a lot of other things wrong with them: from cardiac issues to arthritis and various and sundry ailments.

True, we do much better with acute care than we did even 40 years ago – brain tumours that would have killed your grandfather can sometimes be removed, e.g., – but the reality of patient care is that some people do get worse and some people die. Even the ones who do all right and go home are rarely if ever  good as new. Surgeries cause scar tissue and pain and a host of other problems. As they used to say, the only really safe surgery is the one they do on the other guy.  No nifty BMW dashboard can change that.

A few more staff nurses might but that’s another story.

So, boys and girls, can anyone tell me what some issues with this perspective might be? Anyone? Anyone except Tiffany? Sigh. OK. Tiffany. That’s right.Human bodies, physiology, biology: these are complex, messy, hard to classify and all too often problems that arise are  idiosyncratic and incomprehensible. Funny that, but bodies don’t tend to have read the textbooks. Many people do well but some do not and each case is different.

True, the medical system does screw up (as America’s Institute of Medicine never stops reminding us) and sometimes errors and problems do lie in systemic, functional issues that ought to be fixed – like that ICU checklist everyone’s so keen on or better labeling on medications and so on. But an over-focus on process and a lack of understanding of the underlying messy complexities of medicine not only aren’t the answer but are increasingly becoming part of the problem.

Talk to any person who’s recently experienced hospital care and what you hear is just how vigilant you have to be and just how essential it is to have someone there with the patient to ensure the clinician walking into the room actually knows who the patient is and what his or her problem might be, what drugs s/he might be on, etc.

Comparing medicine to aviation or to BMW’s is ridiculously reductionist and ultimately counterproductive since one of the basic aspects of physiology is that it is not simply what is done to the patient but what the patient does back so to speak. With drugs, it is not merely the effects that the drug has on the body (pharmacodynamics) but what the body does to the medication (pharmacokinetics). The arrows, should one care to diagram it, go back and forth and every which way.

Treating people like units of production was exactly how this mess all started. And Ikea simply doesn’t have an organizer for that.

Voodoo Medical Science

Where to begin, where to begin.  I get busy with end-of-semester things and head out of town for a few weeks and poof! Bloody chaos.

Women’s reproductive rights suddenly back on the table in the U.S. and the legality of abortion tabled in the House of Commons here as a private bill.  Good grief. Was that plane I took the one in that Twilight Zone episode; the one that goes through the clouds and goes back in time?  More idiocy in the Commons, with this ludicrous Omnibus bill as they’re calling it.  Long guns taken out of the registry which means that automatic weapons can more readily be sold in Canada.  And of course zombie killers. (OK, that last one was ghoulishly interesting, I have to confess.)

And in health care news, as always some bright lights insisting they know what’s best – most recently a report from researchers at McGill (the term researchers usually being code for statisticians) expressing shock, shock I tell you, that drugs are used off-label when this lacks “scientific support”.

Um, OK. So what scientific support would that be? Drug company funded clinical trials – given that all other funding has been cut to the bone? Or do they actually mean data which, I would remind you, does not equal knowledge and can be massaged, manipulated and moulded to fit the theory-du-jour.

One class of drugs these experts took exception to was the use of anti-psychotics in situations where no clinical trials had been done. Years ago a physician friend of mine discovered that one of the anti-psychotics, quitiepine I think, seemed to help a patient with Huntington’s with some of her more onerous symptoms. But of course Pharmacare wouldn’t pay for it because – yup, you guessed it – there was no “evidence” that it worked for Huntington’s.  And naturally we all know that everyone, especially drug companies, are lining up to do an expensive drug trial with a teensy subgroup of patients with a rare, fatal, genetic disease ….

Needless to say, there’s never going to be “scientific support” for this. A point these McGill researchers who’ve clearly never had to deal with an actual patient don’t appear to have twigged to.

Research, clinical trials are expensive, time consuming and difficult to do. Who in their right mind is going to fund one for an old drug that’s no longer on patent that’s been around forever – but that still helps a lot of people? Not going to happen.

The pendulum has so swung so far, moreover, in favour of the stats and the algorithms and the “evidence” that everybody from Obama to your pharmacist to that nice young doctor in the clinic down the road honestly believe that medicine is a science and if we could just figure out the right questions to ask and do the right research (which  angels – taking time out from their dancing-on-a-pin thing – would fund) then All Would Be Revealed and we would all live happily and healthily ever after. As if.

What few people realize, alas, is that the bedrock of “scientific” medicine, the clinical trial, is very recent –though to hear people ramble on about  it you’d swear the dratted thing was on one of those tablets Moses brought down with him.

1948. That’s when the first official clinical trial was conducted: by the first medical statistician on record, Bradford Hill, who gave one group of patients with TB streptomycin (then a very new drug) and another group nothing. The idea took off and before his death in the 1990’s Hill’s book on medical stats (Principles of Medical Statistics) was in its 12th printing.

Hill was no dummy though and realized he’d created a monster. He backtracked. Where once he’d exhorted statisticians to “rise from their humble place” to help medicine become more scientific through the clever application of numbers he suggested we should “relax and reflect”; that such single-mindedness could easily lead to poor patient care: “cookbook medicine”.  It would be better, Hill wrote, if clinical trials were designed to “promote rather than hinder the traditional method in medicine of acute observation … by the clinician at the bedside”.  (All quotes from Richard Horton, the editor of The Lancet writing in 2000 in the journal Statistics in Medicine, “Common Sense and Figures: the rhetoric of validity in medicine” Vol. 19, pp 3149-64)

Probably what Hill had not appreciated in the early fifties as he began his little crusade was the extent to which post-war enthusiasms, technological advances and various social, political and institutional changes – ranging from the ascendancy of the United States to the shifts in finance, corporate influence and law – would transform his notions into a paint-by-numbers fiasco.  Biomarkers and surrogate end points (blood sugar, cholesterol, blood pressure, bone density) would reign supreme and you could feel perfectly fine but be told you had minutes to live.

Then it was EBM guru, David Sackett who picked up where Hill left off. Ably assisted by the new profession of health economics whose sole purpose it was to assist payers (like HMO’s in the U.S. and governments of countries with public health care) cut costs (and realized this statistical scientific rhetoric could aid their cause), the newly minted evidence-based medicine or EBM took off like wildfire, leading to the proliferation of guidelines and Hill’s cookbook medicine.

Sackett also backtracked, emphasizing that “the practice of evidence based medicine means integrating individual clinical expertise with the best available clinical evidence” everybody pretty much ignored him. After all, who cared if patients were different and physiology, difficult; as long as you had your bullet form guidelines and decision trees.

Meanwhile, everybody forgets that evidence has serious limitations, not the least of which is human error, external validity (in other words the people in the trial are not representative of the people in the community who actually take the drug or use the treatment) and conflicts of interest. At best even the best designed of trials tend to encapsulate a narrow slice of life which is not the reality of medical care which tends to be centred around the elderly and those with chronic conditions. (duh)

The old and the sick, precisely the people who use medicine, are excluded from clinical trials; in fact as Bradford Hill pointed out, the clinical trial “at best shows what can be accomplished with a medicine under careful observation and certain restricted conditions”.  I won’t even mention the exclusion of women from trials until the NIH stepped in in the ‘90’s to enforce its own regulations because the top of my head would blow off and that would create such a mess.

Ironically, where scientific medicine and epidemiology do excel is at giving us clues as to what doesn’t work, e.g., in common preventive measures such as mammography and PSA testing. But we don’t like those recommendations so we ignore them.

Turns out the “science” of medicine is like the Sasquatch. Often sighted and excitedly talked about but not actually real.