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8 April 2009

Believing in Treatments That Don’t Work

As Washington debates health care reform, emergency room physician Dr. David H. Newman explores how medical ideology often gets in the way of evidence-based medicine.

By David H. Newman, M.D.

In the early throes of a heart attack, caused by an abruptly clotted artery, the stunned heart often beats quickly and forcefully. For decades doctors have administered “beta-blockers” as a remedy, to reduce consumption of limited oxygen supplies by calming and slowing the straining heart. Giving these drugs in the early stages of a heart attack represents elegant medical ideology.

But it doesn’t work.

Studies show that the early administration of beta-blockers to heart attack victims does not save lives, and occasionally causes dangerous heart failure. While two studies support the use of beta-blockers after heart attack, there are 26 studies that found no survival benefit to administering beta-blockers early on. Moreover, in 2005, the largest, best study of the drugs showed that beta-blockers in the vulnerable, early hours of heart attacks did not save lives, but did cause a definite increase in heart failure.

Remarkably, the medical community has continued to strongly recommend immediate beta-blocker treatment. Why? Because according to the theory of the straining heart, the treatment makes sense. It should work, even though it doesn’t. Ideology trumps evidence.

The practice of medicine contains countless examples of elegant medical theories that belie the best available evidence.

* Recent press reports detailing the dangers of cough syrup for children have noted that cough syrup doesn’t work. True: No cough remedies have ever been proven better than a placebo, either for adults or children. Yet their use is common.
* Patients with ear infections are more likely to be harmed by antibiotics than helped. While the pills may cause a small decrease in symptoms (for which ear drops work better), the infections typically recede within days regardless of treatment. The same is true for bronchitis, sinusitis, and sore throats. Unnecessary antibiotics are still given to more than one in seven Americans each year for these conditions alone, at a cost of more than $2 billion and tens of thousands of serious adverse medication effects requiring treatment.

* Back surgeries to relieve pain are, in the majority of cases, no better than nonsurgical treatment. Yet doctors perform 600,000 of these surgeries each year, at a cost of over $20 billion.
* More than a half million Americans per year undergo arthroscopic surgery to correct osteoarthritis of the knee, at a cost of $3 billion. Despite this, studies show the surgery to be no better than sham knee surgery, in which surgeons “pretend” to do surgery while the patient is under light anesthesia. It is also no better than much cheaper, and much less invasive, physical therapy.

Treatment based on ideology is alluring. Surgeries to repair the knee should work. A syrup to reduce cough should help. Calming the straining heart should save lives. But the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.

The critical question that looms for health care reform is whether patients, doctors and experts are prepared to set aside ideology in the face of data. Can we abide by the evidence when it tells us that antibiotics don’t clear ear infections or help strep throats? Can we stop asking for, and writing, these prescriptions? Can we stop performing, and asking for, knee and back surgeries? Can we handle what the evidence reveals? Are we ready for the truth?

The administration’s plan for reform includes identifying health care measures that work, and those that don’t. To place evidence above ideology, researchers and analysts must be trained in critical analysis, have no conflicts of interest and be a diverse group.

Perhaps most importantly, we as doctors and patients must be open to evidence. Pills and surgery are potent symbols of healing power, but our faith in these symbols has often blinded us to truths. Somewhere along the line, theory trumped reality. Administering a medicine or performing a surgery became more important than its effect.

During the first week of 2009, in what may be a hopeful sign, hospital administrators around the country received a short, unceremonious e-mail from the Centers for Medicare and Medicaid Services. The e-mail explained that, due to recent evidence, immediate beta-blocker treatment will be retired as a government indicator of quality care, beginning April 1, 2009. After years of advocacy that cemented immediate beta-blockers in the treatment protocols of virtually every hospital in the country, the agency has demonstrated that minds can be changed.

The much more important question for health care reform is, can ours?

Dr. Newman is author of “Hippocrates Shadow: Secrets From the House of Medicine.”

6 April 2009

Irradiated Food Causes Brain Damage

Scientists studying a mysterious neurological affliction in pregnant cats that have been fed irradiated food have discovered a surprising ability of the central nervous system to repair itself and restore function when placed back on a normal diet.

In a study published today (March 30, 2009) in the Proceedings of the National Academy of Sciences, a team of researchers from the University of Wisconsin-Madison reports that the restoration in cats of myelin - a fatty insulator of nerve fibers that degrades in a host of human central nervous system disorders, the most common of which is multiple sclerosis - can lead to functional recovery.

“The fundamental point of the study is that it proves unequivocally that extensive remyelination can lead to recovery from a severe neurological disorder,” says Ian Duncan, the UW-Madison neuroscientist who led the research. “It indicates the profound ability of the central nervous system to repair itself.”

The finding is important because it underscores the validity of strategies to reestablish myelin as a therapy for treating a range of severe neurological diseases associated with the loss or damage of myelin, but where the nerves themselves remain intact.

Myelin is a fatty substance that forms a sheath for nerve fibers, known as axons, and facilitates the conduction of nerve signals. Its loss through disease causes impairment of sensation, movement, cognition and other functions, depending on which nerves are affected.

The new study arose from a mysterious affliction of pregnant cats. A company testing the effects on growth and development in cats using diets that had been irradiated reported that some cats developed severe neurological dysfunction, including movement disorders, vision loss and paralysis. Taken off the diet, the cats recovered slowly, but eventually all lost functions were restored.

“After being on the diet for three to four months, the pregnant cats started to develop progressive neurological disease,” says Duncan, a professor of medical sciences at the UW-Madison School of Veterinary Medicine and an authority on demyelinating diseases. “Cats put back on a normal diet recovered. It’s a very puzzling demyelinating disease.”

The afflicted cats were shown to have severe and widely distributed demyelination of the central nervous system, according to Duncan. And while the neurological symptoms exhibited by the cats are similar to those experienced by humans with demyelination disorders, the malady does not seem to be like any of the known myelin-related diseases of humans.

In cats removed from the diet, recovery was slow, but all of the previously demyelinated axons became remyelinated. The restored myelin sheaths, however, were not as thick as healthy myelin, Duncan notes.

“It’s not normal, but from a physiological standpoint, the thin myelin membrane restores function,” he says. “It’s doing what it is supposed to do.”

Knowing that the central nervous system retains the ability to forge new myelin sheaths anywhere the nerves themselves are preserved provides strong support for the idea that if myelin can be restored in diseases such as multiple sclerosis, it may be possible for patients to regain lost or impaired functions: “The key thing is that it absolutely confirms the notion that remyelinating strategies are clinically important,” Duncan says.

The exact cause of the neurological affliction in the cats on the experimental diet is unknown, says Duncan, who was not involved in the original study of diet.

“We think it is extremely unlikely that [irradiated food] could become a human health problem,” Duncan explains. “We think it is species specific. It’s important to note these cats were fed a diet of irradiated food for a period of time” (Courtesy of Eurekalert).

Hot Climates Produce Baby Girls

People who live in the tropics have more baby girls compared with those living in other parts of the world, work reveals.

It may be down to the hotter weather or the longer days, says US researcher Dr Kristen Navara in the Royal Society journal Biology Letters.

She says this climate may change miscarriage rates and sperm quality.

Or there may be some evolutionary advantage to having more girls than boys if you live by the equator.

Experts already know that the birth rates of boys and girls vary across the globe.

While some of this can be explained by society - in countries like China baby boys are favoured and many unborn girls are electively aborted - there are natural processes at work.

Research suggests the female foetus is less fragile than the male foetus, which is more prone to the effects of the environment on pregnant women.

At times of extreme environmental stress, including war, the birth rate of girls outstrips that of boys.

Wide variations

Experts have suspected that latitude could have an effect. Past work has shown that the chances of giving birth to a boy increase as you head south - at least in Europe.

But it is difficult to draw conclusions looking at regions in isolation because of wide variations in things like culture, society and economy, to name but a few.

Dr Navara, of the University of Georgia, set out to gain a global perspective by looking a the sex ratios at birth of 202 countries over a 10-year period and taking into account socio-economic differences between nations and continents.

The accepted global average is slightly male biased, at 106 males per 100 females, or 51.5 %.

"The only country in the world which produces more females than males is the Central African Republic," she told the BBC's Network Africa.

In her study, Dr Navara found countries closer to the equator produced significantly fewer boys annually than those at temperate and subarctic latitudes - 51.1% and 51.3%, respectively.

This pattern held strong despite "enormous continental variation in lifestyle and socio-economic status", said Dr Navara.

"The results could indicate an adaptive strategy employed by humans, or there may be another non-adaptive strategy.

"Perhaps male ejaculate quality or miscarriage rates vary on a latitudinal scale," she said.

Survival advantage

Dr Bill James of University College London, who has spent his career studying sex ratio patterns, said although the differences found were statistically significant, it was not as meaningful as other factors that have been linked to sex ratios at birth.

"In general, when people face hard times they tend to have more girls than boys, although there are exceptions.

"For example, women who carry hepatitis B virus are more likely to have boys. So are women who have pre-eclampsia in pregnancy."

He said there were evolutionary explanations for sex ratio changes.

"The idea is that, in mammals, males have a greater variance in their reproductive success.

"Some have lots of offspring and others have none, whereas most females will have at least one offspring.

"So it pays a women who is reproductively fit in good times to have a boy because he may well give her more grandchildren.

"But when times are hard and if she is less reproductively fit, she is better off having a girl because in this way she should gain at least one grandchild."

Advice for Athletes -- Eat Real Food

Some nutritionists believe sports drinks, power bars and timetables are crucial to a successful workout, others say listen to your body and eat real food.

How to Achieve Peak Performance

Among nutritionists, a 4-to-1 ratio of carbohydrates and proteins, consumed during and directly following endurance events, is considered the best way to heighten performance and speed recovery.

However, two doctors at McMaster University in Canada take a more lax approach to sports nutrition.

Dr. Mark Tarnopolsky and Dr. Stuart Phillips are both in their 40s and very active endurance athletes, but “neither one feels a need to ingest a special combination of protein and carbohydrates within a short window of time, a few hours after exercising,” reports The New York Times.

Furthermore, neither doctor regularly consumes energy drinks or energy bars, preferring to drink water and eat regular foods, such as fruit, instead.

Others, including San Antonio dietitian Laurel Tierney, emphasize eating the right foods at the right times, especially after exercising. Tierney believes 50 percent of performance is related to diet. She explains, recovery eating “sets you up for your next training session."

An article in Play Magazine, a New York Times publication, echoes Tierney's post-work-out concerns adding, “Repeated hard workouts can tax the body in insidious ways … Without remediation, those muscles won’t respond as well during your next workout. They’ll be more prone to injury.”

Experts have found that muscle regeneration begins with a post-workout meal, and it does not have to be laden with carbohydrates. According to John Ivy, chairman of the department of kinesiology and health education at the University of Texas in Austin, protein is key to stimulating insulin response; insulin increases muscular intake of glucose, which refuels the body.

As ABC News explains, adenosine triphosphate (ATP) is the key to energy during exercise. However, before the body can use it, ATP must be processed, which occurs slowly. Thus, experts recommend eating hours before working out, rather than shoving down food just beforehand.

With the range of advice available to athletes, perhaps the wisest advice is to pay attention to what feels best to you, which foods aid your workouts, and at what times, says ABC News.

Related Topics: Should you eat just before your workout?; Chocolate milk's sweet rewards

As ABC News explains, adenosine triphosphate (ATP) is the key to energy during exercise. However, before the body can use it, ATP must be processed, which occurs slowly. Thus, experts recommend eating hours before working out, rather than shoving down food just beforehand.

According to the Sacramento Bee, sports nutritionists and dietitians have different opinions regarding “what specifically to eat and how much protein to mix with carbs.” Seattle sports nutritionist Susan Kleiner, for example, prefers chocolate milk to energy bars after a workout. “The whey and casein proteins have an ideal array of amino acids,” Kleiner said.
Reference: Dietary specifics; Nutrition for runners
The Mayo Clinic outlines what to eat and when to eat it to reach maximum performance. Learn the specifics of why carbohydrates, proteins, fats and water fuel workouts, and get advice for timing your meals.
Source: CNN

The findingDulcinea Web Guide to Sports Nutrition links to sites to help you improve your performance, track your diet, find a nutritionist or discover healthy recipes to complement an active lifestyle.
Source: findingDulcinea

For endurance runners, deciphering what to drink, how often to drink and when to drink can be particularly daunting, the experts at Runners World Magazine say. The publication provides an analysis of the options, including water and enhanced water, recovery drinks, sports drinks, juice and soft drinks. “Whatever you choose, drink it cold and in frequent small amounts,” said the article.
Source: Runner's World

What Makes Laughter the Best Medicine?

In honor of April Fools’ Day and National Humor Month, we look at the science behind laughter and uncover some sites that encourage this stress-relieving phenomenon.

Celebrate National Humor Month
Today is April Fools’ Day, an annual celebration of jokes, pranks and light-hearted trickery. But did you know April is also National Humor Month? According to the Librarians’ Internet Index, National Humor Month was founded by Larry Wilde, Director of The Carmel Institute of Humor. Competing with National Poetry Month for attention, National Humor Month “is designed to heighten public awareness on how the joy and therapeutic value of laughter can improve health, boost morale, increase communication skills and enrich the quality of one’s life.”

National Humor Month’s Web site provides some background on April Fools’ Day, but explains that no one can precisely say when the tradition started. Mentions of it can be traced back to Europe in the 1500s, but “Shakespeare, writing in the late sixteenth and early seventeenth centuries, made no mention of April Fool’s Day, despite being, as Charles Dickens Jr. put it, a writer who 'delights in fools in general.'" So we’re left with some mystery and plenty of documented examples of the holiday in practice.

The National Humor Month site points out that even when April Fools’ Day pranks are bad, they’re still funny. To that end, the site lists “The Top 100 April Fool’s Day Hoaxes of All Time," from the Museum of Hoaxes, along with “The Top 10 Worst April Fool’s Day Hoaxes Ever."

The science of Laughter

Why do we laugh? Is there a scientific explanation of what happens when we do, and why it’s considered the “best medicine”? Dr. Know of Discovery Health explains that in a recent study at the University of Maryland, subjects were observed as they watched serious movies and comedies. During the comedies, subjects’ arteries dilated and their blood pressure dropped, leading Dr. Know to conclude that while laughter isn’t definitively “the best medicine,” it is “certainly strong stuff.”

Want to know more? Read the press release on that University of Maryland Medical School study. The study, conducted in 2005, recruited 20 heart-healthy, non-smoking participants with an average age of 33. The results showed “for the first time that laughter is linked to healthy function of blood vessels. Laughter appears to cause the tissue that forms the inner lining of blood vessels, the endothelium, to dilate or expand in order to increase blood flow.”

The study also showed that the opposite effect occurred on the blood vessels when the subjects watched suspenseful films, which “suggested there was a link between mental stress and the narrowing of blood vessels.” So, like exercise, laughter is stress-reducing (and exercises the lungs, as Discovery’s Dr. Know points out).

But so much of laughter is social, begging the question whether there aren’t more community-linked benefits to the phenomenon and clues to our evolution as humans in laughter. In a 2000 study, Robert Provine, a psychology professor at the University of Maryland, observed 1,200 people “laughing spontaneously in their natural environments, from the student union to city sidewalks.” Provine and his team made some intriguing observations: The speakers “laughed almost 50% more than their audiences.” Even banal questions and statements like “Where have you been?” and “It was nice meeting you, too” provoked laughter, which “suggests that the critical stimulus for laughter is another person, not a joke.”

Provine detailed his observations about laughter in an article in Psychology Today. He also noticed that laughter “was 30 times more frequent in social than solitary situations. The students were much more likely to talk to themselves or even smile when alone than to laugh. However happy we may feel, laughter is a signal we send to others and it virtually disappears when we lack an audience.”

The study also revealed that females laugh more than males; “positive emotional tone,” groups and playfulness trigger laughter; and laughter is a form of “self-effacement” that Provine suspects does not display itself as much at the top of the corporate ladder.

But don’t listen to him! No matter what job you have, keep on celebrating National Humor Month with the links below.