Surgery Trumps Intensive Medical Therapy for Obese Diabetics

Patricia Salber

Posted 3/26/12 on The Doctor Weighs In

Two back-to-back articles in the March 26, 2012 issue of the New England Journal of Medicine show bariatric surgery to be more effective than intensive medical therapy when it comes to glycemic control.  Pardon the pun, but this is BIG.

The studies, one American and one Italian were both randomized, but not blinded (it is hard to blind a surgical versus a non-surgical intervention).  Both were relatively small (150 patients in the American study and 60 in the Italian study).  And, both were relatively short term (12 months in the American study and 24 months in the Italian study).  Nevertheless, the results are dramatic.

Continue reading “Surgery Trumps Intensive Medical Therapy for Obese Diabetics”

The Amazing Journey of the Lowly Aspirin

Dov Michaeli

There are few stories in the annals of medicine that can rival the rise of aspirin from an obscure chemical to the status of something akin to a folk hero (well, at least among medical history buffs). And now it has attained new heights of media fame; every newspaper, news broadcast or blog worth its name has commented on the latest finding of its cancer-protective effect.

Who discovered aspirin?

Like everything else, all paths lead to the ancient Greeks.  Hippocrates, who lived in the 4th century B.C.E described a powder made from the bark and leaves of the willow tree to help heal headaches, pains and fevers. And there it lay for 23 centuries, unexplored and forgotten.

Continue reading “The Amazing Journey of the Lowly Aspirin”

Human Understanding, Randomness, Free Will, and Delusion – Part V

Kent Bottles

Posted 3/17/12 on Kent Bottles Private Views

I am just as tired of this five-part blog post as you are. That is assuming anyone has bothered to read all five parts (one of my twitter followers nicely tweeted that he liked my posts, but enough already with this particular post that seems to be going on forever). I am happy to announce that this is the final installment. I am unhappy to announce that the seventeen really smart people whose writings I have read for Parts I through IV really have not been able to answer my simple question, “What is going on in the world of Kent Bottles.” The seventeen experts who have accompanied me on this journey so far are: Tom and Ray Magliozzi, Nikoli Tesla, Misha Angrist, Ricki Lewis, Jackie Fenn, Mike Gazzaniga, Kurt Godel, Edmund Gettier, John Barrow, Karl Popper, Francis Crick, Raymond Tallis, Terrence Dean, Benjamin Libet, Tim Crane, and Robert Laughlin.

In Part V of our exploration, we have to deal with one more really smart person and one really dumb person.

The really smart person, whose views I do not always agree with, is Donald Rumsfeld, the youngest and oldest person in the history of the United States to hold the position of Secretary of Defense. Rumsfeld is famous for many things, but I want to focus on his classification of knowledge: known knowns (things we know to be true), known unknowns (things we know we don’t know), and unknown unknowns (things we are unaware that we don’t know).(http://www.youtube.com/watch?v=GiPe1OiKQuk)

Continue reading “Human Understanding, Randomness, Free Will, and Delusion – Part V”

The Reality Behind the “Death Panel” Rhetoric

Kenneth Lin

Posted 3/14/12 on Common Sense Family Doctor

In a moving piece recently published in the Annals of Internal Medicine, surgeon Mark Vierra describes his emergency room encounter with a man dying from colorectal cancer. Called to discuss possible surgery for a perforated bowel, Dr. Vierra sadly observes that despite the patient’s grim prognosis, he and his wife “had not discussed limits on his care, how far to carry things, what to do when the treatment stopped working, or when the end was in sight.” They had not had any of these discussions with their primary care physician or either of his oncologists. After Dr. Vierra reviews the options and the patient’s wife chooses hospice care, he reflects on the wide gulf between the reality of end-of-life decision-making and the damaging political rhetoric of “death panels”:

I should not have been called to see this patient. Decisions like the one we had to make that day should have been made among friends and family or in the company of his family physician or oncologist, at a time when he was awake and at his best, when he was not in pain, and he could remember who he was and he could explain to those he would leave behind how he wanted to be remembered. To have to make such decisions the way we did that day—counseled by a stranger in the sterile alcove of a busy emergency room—is not what any of us would want. That it turned out the way it did, I believe, was fortunate. It would have been so easy for the powerful momentum of modern medicine to have carried his broken body into the operating room and from there to the ICU, where he would be nurtured by the finest medical technology and the clinical compassion of strangers.

Continue reading “The Reality Behind the “Death Panel” Rhetoric”

Our Aim Is At 100%. Other Than That, We Are At Zero

Paul Levy

Posted 3/21/12 on Not Running a Hospital

The power of transparency, as I have noted, is that it provides creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

MIT’s Peter Senge explains this more fully in his book The Fifth Discipline:

[T]he gap between vision and current reality is . . . a source of energy. If there was no gap, there would be no need for any action to move toward the vision. Indeed, the gap is the source of creative energy. We call this gap creative tension.

Continue reading “Our Aim Is At 100%. Other Than That, We Are At Zero”

PSA Screening: Does It Or Doesn’t It?

Marya Zilberberg

Posted 3/15/12 on Healthcare, etc.

study in the NEJM reports that after 11 years of follow up in a very large cohort of men randomized either to PSA screening every 4 years (~73,000 subjects) or to no screening (~89,000 subjects) there was both a reduction in death and no mortality advantage. How confusing can things get? Here is a screenshot of the headlines about it from Google News:

How can the same test cut prostate cancer deaths and at the same time not save lives? This is counter-intuitive. Yet I hope that a regular reader of this blog is not surprised at all. For the rest of you, here is a clue to the answer: competing risks.

Continue reading “PSA Screening: Does It Or Doesn’t It?”

Human Understanding, Randomness, Free Will, and Delusion Part IV

Kent Bottles

Posted 3/16/12 on Kent Bottles Private Views

In many ways this long and meandering four-part blog post is entirely Michael S. Gazzaniga’s and Benjamin Libet’s fault. We have already met Gazzaniga and his left-brain interpreter theory that resulted from studying split-brain patients who underwent surgery to treat epilepsy. Gazzaniga has explored what these studies mean in several books, all of which are written in a way that the layperson can understand. David Wolman has recently published in Nature a nice overview article that would be a good place to start for someone just starting to grapple with their brain’s inherent need to explain things, even when the brain does not have a clue as to what is really going on (http://www.nature.com/news/the-split-brain-a-tale-of-two-halves-1.10213)

As shocking as my brain’s need to confabulate to make sense of a world that increasingly makes no sense is the work of Benjamin Libet of UCSF who stimulated the brain of an awake patient undergoing surgery; he discovered a time lapse between stimulating the cortex that represents the hand and when the patient signaled they were conscious of sensation in the hand. In more recent studies, John-Dylan Haynes showed that the outcomes of an inclination can be encoded in brain activity up to 10 seconds before the patient is conscious of it. Chung Siong Soon also expanded Libet’s work when he showed that regions in the cortex associated with voluntary movement lit up on fMRI scans five seconds before the subject was aware of making a choice. Song concluded that a network of control areas in the brain “begins to prepare an upcoming decision long before it enters awareness.” This phenomenon has been labeled Bereitschaftspotential, which I cannot pronounce, or readiness potential, which is easier for me to say. Gazzaniga summarizes the staggering implications of these experiments:

Continue reading “Human Understanding, Randomness, Free Will, and Delusion Part IV”

Medical Ethics Crisis

Tom Emerick

Posted 3/17/12 on Cracking Health Costs

A huge medical ethics divide exists today among doctors.

In one camp, the ethic is that if a treatment may help someone, let’s do it.  This is the prevailing medical ethic in the US.  This sounds reasonable, doesn’t it?

However, there is a higher medical ethic practiced by only about 5% of doctors in the US today.  The higher ethic calls for doctors to work with the patient to determine the desired outcome, then use the safest and least invasive treatment to achieve that desired outcome.  If doctors would follow this higher ethic, we could eliminate a huge amount to back and heart surgery and billion and billions of wasted dollars.  Further, fewer patients would be harmed by unneeded surgery.

Which ethic do you want?  The one that uses surgery when non-invasive treatment will get the same result?  What informed patient would make that choice?

Do you want (1) evidence-based medical care?  Or (2) one doctors opinion?  I’ll take option 1 every time.

In Reason.com Dr. Jeffery Singer has written an opinion contrary to mine.  If you care to read it click here.  He writes, “For centuries, my predecessors and I have been inculcated with what has come to be called the ‘Hippocratic Ethic.’ This tradition holds that I am ethically required to use the best of my knowledge to recommend to my patient what I consider to be in my patient’s best interests—without regard to the interests of the third-party payer, or the government, or anyone else.”  [Italics mine.]

The problem is for many doctors today their “best knowledge” falls woefully short of science-based medicine.

Human Understanding, Randomness, Free Will, and Delusion: Part III

Kent Bottles

Posted 3/12/12 on Kent Bottles Private View

In this exercise I am trying to understand what is going on in my world. Car Talk with the Magliozzi brothers is popular with 4 million listeners because they attempt to fix real world problems that callers have with their cars.Genomics, proteomics, and gene therapy have captured the attention of the public and science journalists because they attempt, so far with limited success, to move us from diagnose and treat to predict and prevent which should help us lead longer and more satisfying lives. In Part I and Part II, we saw that even experts like Ray and Tom Magliozzi sometimes are stumped and that science does not always deliver what I desperately need and want: a clear and truthful understanding of what is going on in my world.

Neuroscience and evolutionary psychology are fascinating subjects to read and claim to provide a framework to give me what I want. The natural sciences claim to give an explanation for everything in my world, including me as a human being. However, the explanation the scientists offer clashes with my understanding that I am a conscious person who has a coherent and unified self that is capable of exercising free will. I am a little worried that my left-brain interpreter is making up this story, but that is how I feel.

Continue reading “Human Understanding, Randomness, Free Will, and Delusion: Part III”

Is It True What They Say About Fructose?

Dov Michaeli

High-fructose corn syrup (HFCS) has been the whipping boy of nutritionists and advocates for several years now. Many ills that afflict us and the globe (global warming?) were attributed to this gooey liquid. So let’s examine the evidence dispassionately, and maybe we can add some light to the heated controversy.

What is fructose?

Fructose is a sugar, a monosaccharide, just like the more familiar glucose. In fact, in most cases they are found together, either as a mixture or as the disaccharide sucrose (table suger), which is made up of equal proportions of glucose and fructose.

Continue reading “Is It True What They Say About Fructose?”

Human Understanding, Randomness, Free Will, and Delusion Part II

Kent Bottles

Posted 3/10/12 on Kent Bottles Private Views

In Part I we explored how human beings jump to conclusions when they think they understand reality. This usually occurs when the explanation makes sense, and all of us tend to generate reasons why things are the way they are. It makes sense that understanding our genome would allow us to predict what diseases we are predisposed to developing and to try to do something to avoid getting the disease. Predict and prevent make sense. It makes sense that gene therapy should work because it is so logical and understandable. If you replace the defective gene with the correct gene you should cure the disease.

Why do we humans assume we have the capacity to understand reality?

“This what our brain does all day long. It takes input from other areas of our brain and from the environment and synthesizes it into a story.”

Continue reading “Human Understanding, Randomness, Free Will, and Delusion Part II”

Human Understanding, Randomness, Free Will, and Delusion Part I

Kent Bottles

Posted 3/10/12 on Kent Bottles Private Views

Just because something makes sense does not mean it explains reality. And yet we are always trying to make sense of a world that scientists increasingly believe is totally random. And if the world is totally random, why do I think I have free will?

I usually do not listen to Car Talk, but I did happen to be driving in Gladwynne when Sally of North Salem, New York proclaimed, “I stumped the Car Talk guys.” Their immediate response is important. One brother said, “No, we do not have any experience with it. We haven’t given you an answer, but we will.” The other brother chimed in, “It doesn’t mean we don’t have an answer.”

Continue reading “Human Understanding, Randomness, Free Will, and Delusion Part I”

Exercise and Sleep Quality

Dov Michaeli

Posted 3/11/12 on The Doctor Weighs In

According to a report issued by the National Commission on Sleep Disorders Research, 30% to 40% of people in the United States have insomnia within any given year, defined by the National Institutes of Health as ‘‘an experience of inadequate or poor quality sleep’’.

Continue reading “Exercise and Sleep Quality”

Weekend Athelete: Should You Have Sex Friday Night?

Dov Michaeli

Posted 3/06/12

Incredulous Dov

The Rabbis of the Talmud decreed that having sex on Friday is a Mitzvah (a must do)! But I have a sneaking suspicion they didn’t have athletic performance in mind. On the other hand, for many years, football coaches, Olympic athletes, and even Muhammad Ali, have advocated sexual abstinence the night before an athletic event. Marty Liquori, one the world’s number one-ranked 5,000-meter runner believes that Sex makes you happy, and happy people don’t run a 3:47 mile. Marv Levy, head coach of the Buffalo Bills, insisted that the team be separated from their wives before their appearance in four Super Bowls; a policy that apparently was not successful (four losses out of four Super Bowls).

On the other hand, there are also plenty of anecdotal stories of athletes who claim to have benefited from sex the night before an event. Both U.S. track star David Wottle and Canadian downhill skier Karin Lee Gardner attribute their Olympic gold medals in part to their pre-race preparation.

Continue reading “Weekend Athelete: Should You Have Sex Friday Night?”

The Myth of Noblesse Oblige

Dov Michaeli

Posted 3/4/12 on the Doctor Weighs In

In this season of hateful rhetoric and screams of “class warfare”, one cannot be blamed for perceiving people on the lower socioeconomic rungs as unprincipled, predatory, entitlements-moochers, and welfare cheats. President Reagan rode into office on the back of the “welfare queen” who, it turned out later, was invented out of whole cloth. But perceptions persist, and in politics perception trumps fact. Some social theorists even invoke Darwinism to describe the social environment of the lower classes as a Hobbsian, dog-eat-dog world. Except that in Darwin’s world dogs don’t eat dogs -they actually cooperate, which makes them extraordinarily successful hunters.

Recently, a raft of studies took a close look at the question of lower vs. upper socioeconomic behavioral patterns. And the results are truly amazing, albeit not surprising.

Continue reading “The Myth of Noblesse Oblige”