Category Archives: Medicine and Health

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.



Lyme Lies – Ticks me Off

Each season has its own medical threats or so they tell us, so by rights I should be warning you about the flu – but I’ve already done that. Or I could warn you about carnivorous Christmas trees (sorry, old joke c/o the late Chuck Davis who mocked a pamphlet referring to “deciduous and carnivorous* trees”) but I promised you Lyme Disease and Lyme Disease it shall be. As it happens,  to my way of thinking, Lyme and flu may well share an immunologic link: as with the flu, where the virus is spoken of as though it’s a rampaging army, similarly, with Lyme Disease it is that original tick bite that has gained iconic status. Differences (biological, physiological, genetic) between people ironed out in the search for easy answers and someone to blame.


Lyme Disease, for anyone raised by wolves who’s missed the thousands of news items over the last 40 years, is a tick-borne disease that tends to cluster in areas such as New England where there are deer, believed to be the vector. Named after the county in Connecticut where it is said to have originated, Lyme has garnered increasing attention as some patients seem to develop vague but debilitating symptoms usually years after the original infection; symptoms that experts tend to dismiss as psychosomatic and unrelated to Lyme (even as conspiracy theorists maintain these medical denials are a plot and There Be Skullduggery afoot). Maybe aliens are involved, who knows.


(I use the term “disease” here , by the bye, with some disquiet; there seems to be much overlap in descriptions and discussions of Lyme between disease and illness – illness usually being defined as the patient’s experience versus the more objective signs and symptoms which are classified as a disease.)


It all begins with a bull’s eye – usually, maybe, sometimes


Ticks, said, Aristotle, clearly not a fan, are “disgusting and parasitic”. Ugly too. These tiny thumbtack creatures survive by boring into a host organism such as mouse, deer or human and – a la Twilight – sucking its blood. They’re vampires in other words. Once the tick has sunk its, er, fangs some patients develop a rash resembling a target or bull’s eye and a bacterial infection that may or may not have symptoms. This, it is said, results from the tick passing on a rare type of bacterium called a spirochete.  Known as Borrelia burgdorferi (after Willy Burgdorfer, who painstakingly identified spirochete in a tick the early 1980’s) a spirochete looks a bit like a coiled telephone cord, hence its name. I will not bore you with the intricacies of the different types of tick, the link to another disease, babesiosis, a malaria like illness also found in New England, though I could. Believe it or not parasitology is actually quite fascinating.


The problem, at least from a purely scientific perspective, is that the spirochete hypothesis came after the realization that, in most cases, Lyme Disease responded quickly and well to antibiotics. This led researchers to work backwards to find the culprit bacterium. In other words, as physician Robert Aronowitz in Making Sense of Illness (Cambridge University Press, 1998) writes, “To say that the discovery of the Lyme spirochete led to rational treatment is to put the cart before the horse [and] owes more the idealization of the relationship between basic science and therapeutics than to the actual chronology of investigation.” It is, Aronowitz suggests, more like a Texas bull’s-eye: you shoot the gun then draw the bull’s eye around the bullet hole.


This is especially problematic since early antibiotic treatment means that any trace of bacteria are usually wiped out and their existence is more in the abstract than anything else.


If you’re a disease, at least be new, modern and famous


Nevertheless, the narrative that’s evolved around Lyme Disease is as follows, this quote from that recent New Yorker article that sparked my curmudgeonly instincts: “Lyme Disease was all but unknown until 1977 when Allern Steere, a Yale rheumatologist produced the first definitive account of the infection.”  Just one problem. It ain’t necessarily so.


If we want to nitpick (and you know I do), a disease called ECM  (erythema chronicum migrans) which is uncannily similar to Lyme Disease appears in European medical texts as far back as the late 19th century. Also characterized by a bull’s-eye rash (called erythema migrans wouldn’t you know) – ECM, in some people, also appeared to result in flu-like symptoms. It was never definitely demonstrated whether it was a tick (which are also common in northern Europe) or a virus, and since the majority of cases were mild and self limiting, nobody paid that much attention.


Plus, ECM was described by a lowly branch of medicine, dermatology (think, Lars, Phyllis’s husband on the Mary Tyler Moore Show if you can remember that far back). Lyme Disease though, was identified through the exalted ranks of a specialty with more nous, rheumatology and then championed by a group of angry, well-off mothers in New England who were furious that their children seemed to be coming down with some kind of disease nobody knew much about; a disease, moreover, that seemed to mimic rheumatoid arthritis.  Since the focus was children, the media immediately jumped on board (and the ringleader-mother, Polly Murray, appears to have been adept at channeling their interest). There may have been joint pain in the European ECM patients but the patients were all adults, in whom joint pain may well have been considered more or less normal.


But in New England, well, there you had a veritable PR maelstrom: children being bitten by these vampiric insects; distraught mothers and heroic scientists swooping in to figure out what this strange, dire new disease could be.


Why does this matter? It matters because new things, new diseases are always more terrifying than old, known ones. Just as we all relax when we find out the potentially lethal symptoms keeping us up at night are actually shared by three quarters of the people in our office and is just what’s “going around”. But a new disease? Affecting children? With bizarre symptoms? That’s scary. And whenever there are descriptions of disease, incidence of that disease increase.


In the case of Lyme Disease, that interest hasn’t waned, with the end point always the same: a plea for more good science (not that bad kind of science people usually like to do).


Guidelines uber alles


The American Infectious Diseases Society guidelines maintain that Lyme Disease is usually easy to treat and cure. A few weeks of antibiotics does the trick in most cases and relapses are rare. Patients, advocates, as well as some rather strange conspiracy sorts, disagree and here’s where we run into one of my pet peeves, that objective/subjective, disease/illness demarcation that shouldn’t be a problem but all too often is.


Patients and their families and friends, at least in the fairly small number of Lyme sufferers who develop lingering and mysterious symptoms (ranging unpleasant but benign ones like headache and insomnia to weird and wonderful: “joints on fire”, “brain wrapped in a dense fog”), feel that the medical community has deserted them and is ignoring their very real pain, the very real fact that their lives have been horribly affected. As with chronic pain and other conditions that simply defy our reductionist explanations, the rhetoric descends into and either/or proposition. Either the disease exists as explained by the guidelines, or it does not. Either the tick bite leads to dreadful long-term symptoms in everyone – or it does not. Nothing in between.


Which is clearly nonsense.


Terms like “idiopathic” (of unknown origin) or “post” (post-viral, post traumatic) have been coined to describe these symptoms, these patients, mostly because we simply don’t know what to do with them. And by “we” I mean everyone.  Society. The culture at large. (I wrote about our issues around chronic pain in an earlier post.)



The biomedical model simply cannot explain the complexities of human experience, human disease, illness. Not only are there vast differences between individuals in their physical and physiological selves, there are social and cultural and dietary and a myriad others. It is simply not feasible to “fix” every underlying “cause” to get rid of a “disease”. Even infectious disease that we know is caused by a virus or bacterium does not affect everyone. Necessary but not sufficient is the phrase. The TB (or any other) bacterium is necessary for TB but not sufficient. Other factors must be present.


So why is it so difficult to believe that in some people that tick bite, with or without the bull’s eye rash, might lead to long term problems; problems amplified by the individual who also believes there is a problem that needs fixing and whose stress levels rise as a result. After all, if they feel so lousy it must be something terrible – cancer, maybe.


We believe in the magic of medicine so when it fails us we are hurt, angry, disappointed. This explains why Lyme (or chronic fatigue etc.) activists so often sound like such loony tunes. Even as they decry the evils of the medical establishment they search for legitimacy from it, absolution, that what they are feeling is “real”. (Which will also translate into other institutions recognizing said condition which then has other consequences like disability.)  True, there is the odd hypochondriac, Munchhausen’s, factitious patient. But there are also people who suffer from pains and disabilities that medicine cannot explain – and abandons, using the term “psychosomatic” like a cudgel. So what if it’s psychosomatic? All psychosomatic means is that the illness or symptoms originate from the mind, not the body (at least insofar as we can tell – our imaging and tests and so on not being exactly infallible). Who cares where the problem originates when people need help?  Isn’t medicine about exactly that, doing no harm, helping people feel better, function better? It seems logical that some people have the type of immune system that reacts, over time, to some kind of toxic insult, tick related or otherwise. These are the folks who develop rheumatic and other symptoms over time, the ones that medicine refuses to countenance.


What I do not understand is why.  Why does not having a diagnosis, a label, mean you have to deny people even have a problem?  (Some Hon. Members: Shame, Shame.)






* they meant coniferous

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.

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.  

‘ear ‘ear (better yet, turn it down)

The Oscars were last night and no I didn’t watch. To paraphrase Ogden Nash, my interest in the subject would have to grow to be even cursory. (And you thought the curmudgeon in the title was just for alliteration.)

Frankly, I’d sooner mindlessly stare into space. At least it wouldn’t be deafening.

Well, not the Oscars so much; they are, after all, on television and one can turn the volume down. One cannot say the same thing about what the Oscar celebrate: movies.

When was it decided – and who did this deciding and why weren’t we consulted? – that we shouldn’t just hear the sound but feel it vibrate down from our toes to the top of our tinny tin heads? How did going to a movie turn into a full frontal assault on our senses, from movement and colour and flashing lights to that ubiquitous noise they are careful to remind us is the patented Dolby surround sound?

Once upon a time one could go to a movie, yes even action ones without going deaf. I was first in line when those early Star Trek movies came out and I saw the first Die Hard in the movie theatre. It was loud, but I don’t recall coming out feeling like I’d just been put through the wash cycle.

In those days I wasn’t flinching and stuffing my ears with Kleenex or covering my eyes to protect them from the flashing lights that would end up giving me a migraine. The last “action” movie I saw, one of the Johnny Depp pirate movies, well, I left that so dazed and battered that I barely remembered what I’d seen.

How did deafeningly loud become normal? Or is everyone just deaf? 

So much of the noise around us we barely notice. The hum of computers and air cleaners and refrigerators; the constant hum of traffic, the honking, the music blaring out of car stereos … And of course everyone is in their own little world of sound, with those earbuds.

I’m not a total Luddite, I got an MP3 player years ago. I filled it with music. I listened. Then I realized than as I was walking I kept turning the sound up to compensate for the noise all around me – and if I had been listening for a few hours at night there was a constant ringing in my ears. It would go away but what I know about the sensitivity of the ear told me that if I kept doing this it eventually would not and the result would be tinnitus. A ringing that simply never goes away.

I doubt most of the people on the subway or the bus or walking down the street really pay that much attention. Which suggests to me that in a decade or two anything relating to enhanced hearing will make a fortune since most people will be partially deaf. (We should all buy stock now.)

A number of big names – William Shatner, Jerome Groopman (author of the best selling How Doctors Think book) – have gone public with their tinnitus. Experts tell us that it’s probably the result of prolonged exposure to loud noise.

Then there’s the Who’s Pete Townshend, who is essentially deaf. The Who, as you might recall, is credited with having performed the loudest concert in history, at least at the time, circa 1976: decibel level 120. That’s about as loud as a jackhammer. Almost as loud as a jet engine. That’s loud.

Respect the ear – or it’ll give up on you

The human ear is an amazing thing. Inner, middle, outer ear: each have their function, each play a role in funneling sound through tiny cilia (little tiny hairs) and through the ear drum, into the brain where it’s interpreted and experienced. A human ear can pick up the dripping of a faucet in the middle of the night on another floor, hear a symphony or a the swish of even a piece of paper falling to the floor.

It’s amazingly balanced between the inside, conduit to the brain, and the outside world. Precisely balanced in between are three small bones (the smallest bones in the body) that are shaped somewhat like a stick figure or one of those triangles your music teacher would have you play if you weren’t musical enough to actually play something normal (like me). OK, I played piano but she was the one doing that.

These tiny bones can easily work their way out of alignment after a blow to the head or trauma – I believe that today they can be repaired with microsurgery but it’s complicated.  In between are the smallest bones in the body that reverberate in response to the ear drum (timpanic membrane) vibrating in response to sound waves in your environment. Like the tiniest of precision percussion instruments, eventually turning into an electrical pulse that is interpreted through the neurotransmitters in your brain.

Culture often determines what we think of as noise versus music. That dripping tap of which I spoke earlier (which has been known to drive me insane and keep me awake) is, apparently, music to the Shinto-based Japanese mind. I don’t think that anyone truly enjoys a jackhammer however.

Currently I am surrounded by construction noise and have been for the least four months. It is exhausting, tiresome, intrusive and dreadful. And my ears hurt. Even with noise reduction headphones, the noise is unrelenting. The last thing I need is to go out for an evening’s “entertainment” to find myself surrounded by noise, be it the latest James Bond, war film or science fiction flick.

I hope you enjoyed the Oscars. And the nominated films. Just remember that once your hearing is gone, it’s gone. There’s no going back.

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?


I stress, Eustress

It’s become such an ubiquitous concept that it’s difficult to imagine how recent a term “stress” really is. When Hans Selye first proposed that all tension, all sources of anxiety created the same kind of reaction within the body it seemed ridiculous. And this was in the fifties to the best of my recollection.  Of course now we all know that too much stress is bad for us and that stress is a factor in disease.

[So so many things that we take for granted – cardiac risk factors, prevention, stress – are such recent concepts. But we think they’ve been around since the year dot.]

Stress is hard on the immune system, affects us hormonally and causes muscle tension and fatigue. It gets in the way of sleep, which causes its own set of problems ranging from poor concentration to anxiety, and depresses normal pain signals. Which is why soldiers and athletes often don’t feel the pain of a major injury and it is only later that they realize they’ve damaged something.

Then there’s the good side of stress, or eustress. Without some stress we would have zero motivation, zero reason to excel or create. That’s why there’s that old graph showing how some stress is good before a major task, say an exam; with some stress performance gets better. But, if it gets too high then performance suffers.

Which we all know from our own experience.

Wandering around Paris what strikes me as well is the extent to which our actual, physical environment can create or reduce stress. When what is around us is beautiful, when we hear laughter, when the sun is shining – well, it’s hard to feel to unhappy or stressed. No accident that depressed areas inevitably are ugly.

It’s hard to be too stressed when one is a tourist in Paris, well, unless one tries too hard to make the French conform to one’s North American ideas of time, speed and interaction.  Personally, something that I think is rather wonderful here is the very formal aspect of saying ‘bonjour’ whenever one walks into a place, any place. It is a way, I think, of humanizing the service person, the waiter, the person in the store. When one stops to say ‘bonjour madame’ or ‘bonjour monsieur’, one has to pause and look at the person and realize this person is not simply part of the scenery, they are an actual human being. It adds a touch of humanity to what is often a rather soulless encounter.

The French are currently pilloried for their dislike of capitalism, their failing economy, their rising youth unemployment.  Several august bodies are miffed that in spite of all of this money markets still love France, which can borrow money at brilliantly low rates, which suggests they’re not worried about France’s future. There’s a palpable sense of outrage about this on the part of business writers, The Economist, various commentators – usually Anglo Saxon. Why? Why does everyone need to conform to the same ideas?

The French fought a revolution which had at its basis the value of the human being.  Extreme wealth, especially ostentatious wealth, is frowned on in France. I can think of worse things.

In any event, given the stress we all experience when all we focus on is money and making more of it, it seems to me that the French are on to something.

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