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Better Health Interviews - Fact or Fiction: Attention Deficit Disorder

Last Thursday (9/16/10) I had the pleasure of attending a conference on Attention Deficit Disorder.  The following are my two interviews.  They are both very interesting, and both apply greatly to my practice as a primary care physician. The first is Dr. Ari Tuckman, author of the book More Attention, Less Deficit, as well as the podcast with the same name:

The second interview is with Katherine Schantz, head of the Lab school, an innovative school for kids with ADHD and other learning problems.

I hope you enjoy watching these as much as I enjoyed doing the interviews.

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Tylenol can Kill

angel_of_grief_roma2

My worst night as a doctor was during my residency.  I was working the pediatric ICU and admitted a young teenager who had tried to kill herself.  Well, she didn't really try to kill herself; she took a handful of Tylenol (acetaminophen) because some other girls had teased her.

On that night I watched as she went from a frightened girl who carried on a conversation, through agitation and into coma, and finally to death by morning.  We did everything we could to keep her alive, but without a liver there is no chance of survival.

Over ten years later, I was called to the emergency room for a girl who was nauseated and a little confused, with elevated liver tests.  I told the ER doctor to check an acetaminophen level and, sadly, it was elevated.  She too had taken a handful of acetaminophen at an earlier time.  She too was lucid and scared at the start of the evening.  The last I saw of her was on the next day before she was sent to a specialty hospital for a liver transplant.  I got the call later that next day with the bad news: she died.

The saddest thing about both of these kids is that they both thought they were safe.  The handful of pills was a gesture, not meant to harm themselves.  They were like most people; they didn't know that this medication that is ubiquitous and reportedly safe can be so deadly.  But when they finally learned this, it was too late.  They are both dead.  Suicides?  Technically, but not in reality.

For these children the problem was that symptoms of toxicity may not show up until it is too late.  People often get nausea and vomiting with acute overdose, but if the treatment isn't initiated within 8-10 hours, the risk of going to liver failure is high.  Once enough time passes, it is rare that the person can be cured without liver transplant.

Acetaminophen overdose is the #1 cause of liver failure in the US.  According to a Reuters article, there are 1600 cases of liver failure per year (2007), 450 from acetaminophen overdose.  This is a large number.  In comparison consider that the cholesterol drug Cerivastatin (Baycol) was withdrawn from the market when there were 31 deaths from rhabdomyalysis (severe muscle break-down, which is far more common than liver failure in these drugs).  These happened mainly when the drug was used in combination with another cholesterol drug.

Should the drug be pulled from the market?  No, it is safe when used properly.  The toxic dose is generally 10 times the therapeutic dose.  My complaint is not that they have dangerous drugs available; ALL drugs should be considered dangerous.  Aspirin, decongestants, anti-inflammatories, and even antacids can be toxic if taken in high dose.  The problems with acetaminophen stem from several factors:

  1. Most people don't realize the danger.
  2. There has been very little public education and no significant warning labels on the packages.
  3. The drug is often hidden in combination with other drugs, including prescription narcotics and over-the-counter cold medications.  This means that a person can take excess medication without knowing it.

I would advocate putting warning labels on medications containing this drug.  I am sure this doesn't thrill the drug manufacturers, but the goal is not to make them happy.  I have thought this since that terrible night during residency.  If there was such a warning, perhaps she wouldn't have died.

It seems a bit silly that this action by the FDA is coming after their pulling of children's cough/cold medications.  Those drugs have very small numbers of true harmful overdoses.  The reason they were pulled was probably more that they didn't do anything over the fact that they were dangerous.  Acetaminophen, on the other hand, can be deadly.

Just ask the parents of my two patients.

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The Real Vitamin C

Linus Pauling won the Nobel Prize twice, once for his work in the field of chemistry and once for his activism against above-ground nuclear testing.  What I remember him for, however, was his strong advocacy of mega-doses of vitamin C.  This is a shame, because this advocacy of what was termed orthomolecular medicine somewhat sullied his otherwise wonderful reputation.

Linus Paulings Book on Vitamin C

The real shame, however, is that he was on the right track with the wrong molecule.  He even got the letter "c" right.  No, the wonder molecule for health and long life is not ascorbic acid, it is that wondrous molecule known as caffeine.

This is my Theory that is Mine

I have a theory that is supported by a huge amount of circumstantial evidence and tainted with enormous personal bias.  I still think it's true, though.  Here it is (ahem):

  • Observation: Children are boisterous and energetic; some are more so than others.
  • Observation: As I have gotten older, my energy level has dropped significantly.  Nobody could use the word "boisterous" in a description of me except when preceded with "he sure isn't."
  • Observation: When I have a cup of coffee from Starbucks (Venti), I regain my youthful energy.
  • Conclusion: Children have high levels of endogenous caffeine that gives them energy.
  • Conclusion: As I got older, my caffeine levels dropped.
  • Application: Supplementation of coffee (not decaffeinated) is a natural thing that restores things to the way God meant them to be.

I'll have the Double-Paranoid Latte

While my logic is obviously without flaw, it is clear there is a perception that caffeine (especially in it's coffee state) is harmful.  The PR agency that this molecule hired was really pitiful.  Here are some examples of these negative perceptions:

From the Natural News:

Most a.m. coffee drinkers don't realize it, but their morning cups of coffee set their bodies up for a rollercoaster day of highs and lows, only to bottom out at the point of exhaustion. Just a few hours after consumption, when the artificial high dies down, many people may reach for more coffee or something sugary to get another lift, leading to daily fluctuations in energy and alertness, and possibly to eventual chronic adrenal exhaustion.

Chronic adrenal exhaustion?  My adrenal gland feels energized by my double-shot espresso.

The Healthy Diet and Optimal Living blog states:

Caffeine contains one of these protoplasmic poisons called theobromine which is found in cocoa beans of coffee and chocolate. Caffeine is the most commonly used stimulant with over eighty percent of the population consuming it. It comes in the form of coffee, chocolate, tea and these all contain substances called methyxanthines.

Caffeine gives us myriad of physical ailments. Caffeine is known to cause birth defects in babies and should be avoided in pregnancy. It also causes enlargement of breast tissues which leads to benign lumps and can even be connected to breast cancer. Avoiding caffeine will help prevent bone disorders as it is shown to cause a loss of calcium in the bones. There are many obvious signs that caffeine is an addictive drug such as headaches, fatigue, tension and depression lasting for many days after with drawing from it. Finally, this drug also promotes the following examples: elevated heart rate, irregular heartbeat, increased blood pressure, frequent urination, increased gastric acid secretion (which contributes to indigestion, gastritis, and ulcers), nervousness, irritability, insomnia, loss of appetite, nausea, and diarrhea.

Ew!  Protoplasmic poisons?  Are they poisons made up of protoplasm or are they things that poison our protoplasm?  The truth is that caffeine is a molecule that is in the class of molecule called methylxanthenes.  Theobromine is another methylxanthene that happens to abide in the other nutritional c-containing substance known as chocolate.

The Bunks are Removed

Regarding the birth defects,  here is a common-sense summary from the American Pregnancy Association (which I suppose you can only belong to for 9 months at a time):

Statement: Caffeine causes birth defects in humans.

Facts: Numerous studies on animals have shown that caffeine can cause birth defects, preterm delivery, reduced fertility, and increase the risk of low-birth weight offspring and other reproductive problems. There have not been any conclusive studies done on humans though. It is still better to play it safe when it comes to inconclusive studies.

0715squirrel-with-coffee-cup

Editor's Note:  Beware of Mutant Squirrels

Statement: Caffeine causes infertility.

Facts: Some studies have shown a link between high levels of caffeine consumption and delayed conception.

Statement: Caffeine causes miscarriages.

Facts: A few studies have shown that there may be an increase in miscarriages among women who consume more than 300 mg (three 5 oz. cups of coffee) a day. Other outcomes include preterm labor and low-birth weight babies. Again, it is safer to avoid caffeine as much as possible.

Statement: A pregnant woman should not consume ANY caffeine.

Facts: Experts have stated that moderate levels of caffeine have not been found to have a negative effect on pregnancy. The definition of moderate varies anywhere from 150 mg - 300 mg a day.

I would add that this clearly shows that you should not let any of your pets drink coffee if they are pregnant.  You don't want mutants running around the house.

But Does it make Julienne Fries?

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It turns out, these guys are way off base.  Not only is your protoplasm safe around Juan Valdez, it is actually quite better off.  Here's something from WebMD:

Want a drug that could lower your risk of diabetes, Parkinson's disease, and colon cancer? That could lift your mood and treat headaches? That could lower your risk of cavities?

If it sounds too good to be true, think again.

Coffee, the much maligned but undoubtedly beloved beverage, just made headlines for possibly cutting the risk of the latest disease epidemic, type 2 diabetes. And the real news seems to be that the more you drink, the better.

Hah!  Not only is my protoplasm safe, it seems the ectoplasm, and even endoplasmic reticulum is safe!  The diabetes study actually showed that drinking six or more cups a day decreased a man's risk of diabetes by 54%.  I suspect these guys are burning off all of their abdominal fat by being shaky all the time (although the Parkinson's risk bit makes me think twice).  Dang, six cups would be as good as having a total gym.

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But wait!  There's more!  No, I am not selling Ginsu Knives, there is an even more impressive study for the ladies (who may be feeling left out right now).  US News and World Report gives us the following:

Coffee drinking was not linked to either the lowering or the raising of stroke risk among women who developed high blood pressure, diabetes or high cholesterol.

But after considering factors such as cigarette and alcohol consumption, van Dam and his colleagues found that healthy women who consumed two to three cups of caffeinated coffee a day had, on average, a 19 percent lower risk for any kind of stroke than did women who drank less than one cup a month. Drinking four or more cups a day lowered risk by 20 percent.

Women who drank five to seven cups of coffee a week were 12 percent less likely to have a stroke than were those who downed just one cup a month, the study found.

The team then zeroed in on the impact tobacco might have on the coffee-stroke link, noting that coffee drinkers are often also smokers.

What they found was striking: Among women who never smoked or had smoked but quit, drinking four or more cups of coffee a day conferred a 43 percent reduced risk for all types of stroke. However, among women with similar coffee habits who also smoked, stroke risk fell by just 3 percent.

That's right ladies, the ground goodness can reduce your stroke risk if you want it to.  You just have to be committed to the cause, drinking at least four cups per day.

I do need to point out that their definition of a "cup of coffee" is not what some of us would use:

coffeecup

So, my java-loving friends, let us raise our mugs for a toast to this beloved bean.  It is truly nectar of the gods.

And believe me, these gods don't have strokes or diabetes!

[poll id="21"]

PS:  10 points to those who figure out the reason I named the first section as I did.

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EMF

Fomite
Pronunciation: primarystressfomacr-secondarystressmimacrt
Function: noun
Inflected Form(s): plural fo·mites /-secondarystressmimacrts; primarystressfäm-schwa-secondarystresstemacronz, primarystressfomacrm-/
: an inanimate object (as a dish, toy, book, doorknob, or clothing) that may be contaminated with infectious organisms and serve in their transmission <the much maligned toilet seat is a remarkably ineffective fomite -- M. F. Rein> <what are the most common fomites for rotavirus in day-care settings -- Pediatric Report's Child Health Newsletter> (from Merriam Webster)

There was a study done recently regarding the cleanliness of computer keyboards (from Science Daily):

ScienceDaily (2005-04-18) -- Some potentially harmful bacteria can survive for prolonged periods of time on the keyboards and keyboard covers of computers, a study conducted at Northwestern Memorial Hospital has found. Gary A. Noskin, MD, who is medical director of healthcare epidemiology and quality at Northwestern Memorial and who led the study, advises periodic cleaning of computer equipment and hand washing after every computer use.

"The problem is especially important in hospitals and other healthcare environments where patients are at risk of contracting bacterial infections from healthcare providers who use computers," Dr. Noskin says. He presented his findings at the 15th Annual Scientific Session of the Society for Healthcare Epidemiology of America (SHEA) in Los Angeles this week, and the study generated coverage from various news outlets including CNN, the Chicago Sun-Times and Reuters.

Noskin and his colleagues studied bacteria commonly found in the hospital environment. To determine the ability of bacteria to survive on computer keyboards, the researchers inoculated the equipment with three types of bacteria: vancomycin-resistant Enterococcus faecium (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PSAE). VRE and MRSA are examples of bacterial strains that have developed resistance to the antibiotics (including vancomyin and methicillin) commonly used on them. Although VRE and PSAE seldom cause problems except in hospitalized patients whose immune systems are compromised by other disease or illness, recent outbreaks of MRSA skin infections in otherwise healthy persons (community-acquired MRSA) have raised concern among infectious disease experts.

 

churchseats I believe in Electronic Medical Records.  I believe they can save lives if used properly through better care.  We have been using EMR for the past 12+ years with terminals in every exam room.

While it is common to worry about patient contact with the computer and access to data (or little kids turning it off), I have honestly never considered the cesspool we may harbor in each room.  There are moments when I am tempted to swat people with the keyboard, but the risk this may expose patients to needs to be considered by anyone with an EMR.

Afraid of toilet seats?  Be more afraid of keyboards.

I see an opportunity for an entrepreneur here:  make a washable keyboard and market it to hospitals and doctors.  We really don't need Electronic Medical Fomites.

Perhaps we need a sign that says:  Employees must wash their hands after touching the keyboard.

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Testing 1-2-3

Kevin recently posted an article about unnecessary tests, stating "We need to say no to unnecessary tests." I agree with him. As an internist, I am not a procedure guy. My job is to listen to people, make a list of the possibilities, and then make a plan to narrow the list. The two most important things I do when I see a patient are:

  1. Rule out bad things - this is the most important thing. People come because they want to "make sure it is not X." People with enlarged lymph nodes want to know it is not cancer. People with stiff necks often want to know it is not meningitis. People with sore throats want to know if it is strep. You rule things out that would require immediate intervention.
  2. Make a person feel better - Once I have ruled in/out the serious possibilities, I figure out what intervention will make the person better. Sometimes that "intervention" is doing nothing and letting the body do its own thing.

Notice that making the diagnosis is not always the goal. As long as you rule out bad stuff and make the person feel better, finding the diagnosis is gravy.

So the goal of testing is to make a decision: is there a serious problem? What needs to be done to make the person feel better? The goal of testing is not generally to make a diagnosis. If someone has sciatic nerve pain, I order an MRI scan only if there is an intervention needed: so I ask myself, is this person a surgical candidate (the main intervention)?

A few cases I saw recently show that this is not always straightforward.

The first was a man without high risk of colon cancer who asked for a colonoscopy. He had a friend who had it diagnosed at a young age, and was worried about this. Cost was not an issue. So I asked myself:

  • Would a negative test adequately reassure the person that he did not have colon cancer?
  • What is the chance of a false positive test, causing unnecessary worry, and more testing?
  • What is the risk of the test?

A colonoscopy is a good test - it has a very low chance of false negatives (so a negative test is reliable), and the likelihood of a false positive is near zero. In the hands of an experienced gastroenterologist, the risk of the test is fairly low. I ordered the test with a warning about the small risk.

The other case was a woman who was fairly low risk for heart disease who presented with chest pain. My partner saw her earlier in the week and ordered a stress test. The cardiologist actually performed a myoview stress test, which looks at images of blood flow to the heart at rest and with exercise, looking for changes with exercise. The test came back negative.

She came to the office yesterday still having chest pain. She had a few more episodes; one time the pain was worse when she ate a big meal and exerted herself. It went away after resting for five minutes. In this case, I asked myself:

  • With a negative stress test, what is the chance that she still has heart disease?
  • What other diagnoses are possible?

In her case, there was very few other possibilities. I did a lung-function test to rule out asthmatic type symptoms. It was negative. The symptoms were so classic for coronary symptoms, I had to entertain the possibility that the stress test was wrong. There are a few cases when this can happen, either if the blood vessel narrowing is at the back of the heart, or it is very early in the coronary vessels, and so the whole heart was symmetrically decreased in bloodflow. These are causes of false-negative stress tests.

Since this was a significant thing to rule out (potentially a "widow-maker" or left-main coronary), I called the cardiologist and he agreed that the patient needed a catheterization. He called me today and informed me that she had a 95% lesion on the right coronary vessel. He placed a stent.

This demonstrates that stress tests do have a false-negative rate which is not insignificant.  It also showst that the clinical picture should always trump the test in this setting. In this case, the stress test should have been positive, with the lesion. If the catheterization was negative, then the chance of her still having significant heart problems is much smaller, and other possibilities should be pursued.

So for any test, there needs to be a good understanding of:

  • The chance of a false positive
  • The chance of a false negative
  • The pre-test probability of the person having the disease (based on risk factors and the story the patient gives)
  • The risk of the procedure (and the cost).
  • The risk of not making the diagnosis.

Each time I order tests, I think about these things (as should any doctor).

This is why I get frustrated when gnomes from the insurance company say they won't pay for a test. Do they know all of these things on this patient? They just sit in front of a computer and plug the data into a program. They have no idea.

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Placebos, Supplements, and Toxic Pets

Picture 061The NY Times health blog (by Tara Parker Pope) ran an article about toxin levels in cats and dogs. The bottom line: our pets are full of toxins. Which, given what my dog and cat eats is not actually that surprising. My cat probably has very high serum bug levels, and my dog is especially fond of dirt. It didn't, by the way, say anything about lobsters. The question raised in the article was whether or not these levels were actually significant.

The analysis, released by the Washington-based Environmental Working Group, used blood and urine samples from 35 dogs and 37 cats collected at Hanover Animal Hospital in Mechanicsville, Va. The study found high levels of numerous chemicals in dogs and cats, including chemicals used in the making of furniture, fabrics and electronics. Mercury was also detected at high levels, likely from fish used in pet food.Picture 148While the data sound scary, it’s not clear what they really mean. Pets chew on plastic toys and spend a lot of time on the ground, where chemicals and pesticides accumulate, so it makes sense they would have higher levels of various toxins in their blood compared to humans.But the report raises more questions than it answers. Is this added chemical exposure having a meaningful effect on pet health? More important is the question of how these chemicals affect people, through exposure to food animals as well as fruits and vegetables, but the report doesn’t go that far.

While people may get all upset about the fact that our animals, and perhaps we ourselves are being exposed to toxins, it came at the same time as the FDA issued this warning:

FDA Finds Hazardous Levels of Selenium in Samples of "Total Body Formula" and"Total Body Mega Formula"

Dietary supplement products linked to adverse reactionsbodybuilderThe U.S. Food and Drug Administration announced today that it has found hazardous levels of selenium in samples of certain flavors of the dietary supplement products "Total Body Formula" and "Total Body Mega Formula." The FDA has received 43 reports of persons from nine states who experienced serious adverse reactions using these products.On March 27, the FDA warned consumers not to purchase or use "Total Body Formula" in flavors Tropical Orange and Peach Nectar and "Total Body Mega Formula" in the Orange/Tangerine flavor of these products after receiving reports of adverse reactions in users in Florida and Tennessee (www.fda.gov/bbs/topics/NEWS/2008/NEW01812.html). The adverse reactions generally occurred after five to 10 days of daily ingestion of the product, and included significant hair loss, muscle cramps, diarrhea, joint pain, deformed fingernails, and fatigue.Selenium, a naturally occurring mineral, is needed only in very small amounts for good health. Selenium can boost the immune system. Generally, normal consumption of food and water provides adequate selenium to support good health. Excessive intake of selenium is known to cause symptoms to include significant hair loss, muscle cramps, diarrhea, joint pain, fatigue, loss of finger nails and blistering skin.Presently, FDA has 43 reports of adverse reactions including cases from Alabama, Florida, Georgia, Kentucky, Michigan, New Jersey, North Carolina, Tennessee, and Texas. Analyses of samples of the products by FDA laboratories have now found most of the samples contain extremely high levels of selenium--up to 40,800 micrograms per recommended serving, or more than 200 times the amount of selenium per serving (i.e., 200 micrograms) indicated on the labels of the products.The FDA continues to investigate the matter to determine how excessive amounts of selenium were added to the products.

So what is "Total Body Formula?" The web site for the product states:

Now you can BALANCE YOUR BODY THE WAY NATURE INTENDED.

TOTAL BODY® FORMULA - BALANCED NUTRITION is a powerful combination of Vitamins, Colloidal Minerals, Amino Acids, Essential Fatty Acids and Antioxidants scientifically designed in a great tasting liquid formula to meet today's nutritional requirements for maintaining energy and sustaining health.

It goes on to state that the formula of "colloidal minerals" it contains are one of the keys, calling them "Amazing Nutrients."

The minerals in TOTAL BODY® FORMULA are nature's most amazing nutrients - COLLOIDAL MINERALS. Unlike metallic minerals mined from geological deposits which can be toxic, our colloidal minerals are taken from plants which have absorbed the elemental minerals from the earth. These plant-derived colloidal minerals are from natural organic mineral rich prehistoric plant-matter deposits from a mine in Utah.

It is interesting that on one hand we are trying to avoid toxins in ourselves and our pets, on the other we are ingesting things that are potentially harmful (and definitely unproven). The claims made in the website about colloidal minerals is not accepted in the mainstream of medicine and I am not certain it has any real scientific basis.Yet people keep taking this kind of thing. Why?

Because they work.image

You heard me right, they do work - in a certain percent of people. The placebo effect is very potent and for vague endpoints like "feeling better" or "more energy," a significant percent of patients taking this kind of supplement will succeed. They will attribute it to the supplement, but they are really just part of the placebo effect.

I am not saying that they think they feel better, the placebo effect is a real effect. It may make joints hurt less, blood pressure drop, and make people live in harmony. (OK, not the last one.)

Which is fine with me as long as it does not harm them like this supplement could do. I have patients coming to me all the time asking what I think of their taking Mona Vie, Glucosamine, or drinking an ounce of vinegar every day (really). As long as it does not harm them, I say it is fine. Although I do warn them of a possible side effect of wallet shrinkage.

So the real question is whether the pets are consuming Total Doggy Formula, stocked full of colloidal dirt. I know my dog would go for it.

She has been fatigued lately.

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To Tan or not to Tan...

george400

Calling all dermatologists!  What's the deal with tanning?  Should I put SPF 2000 on my kids whenever they go out, or should I let them look like George Hamilton?  He does look marvelous, doesn't he?

Seriously, I am very much caught between the hype of the sun-screen addicts and the known risks of Melanoma.  Is the evidence iron-clad, or is it more hype than it deserves? 

I ask these, and more questions on MedPage.

toast

I actually look more like this guy than like George.

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