September 23, 2011 | 11:57 am

Arsenic in Your Apple Juice is Safer than Dr. Oz in Your Education

Posted by Albert Fuchs, M.D.

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There’s arsenic in apple juice, and I just poured my daughter a big glass. Go ahead, call Child Protective Services.

On his show last week Dr. Oz tried to scare us about arsenic in apple juice. It was a feat of ratings-driven fear-mongering that was shameful even by daytime TV standards. His show tested various brands of apple juice for arsenic, announced that the levels were too high, and concluded that we should all be worried.

Actually, he conducted the wrong kind of test and misinterpreted the results. (If you’re interested in the scientific details this scathing article in Forbes has a great review.) Oz was widely criticized, including by other physicians. The FDA released a very reasoned update reminding us that apple juice is safe. The FDA regularly tests apple juice for arsenic and has been doing so for years. So Dr. Oz was forced to back-pedal and reassure us that he’s not worried about drinking apple juice. Phewf! That’s a relief.

This week Oz published an op-ed in the Chicago Tribune explaining that he was simply trying to “raise an alarm” about food safety and that “we need more stringent restrictions on arsenic in fruit juice”. Huh? He said he has no concerns about the safety of juice. There’s no evidence that arsenic levels in juices (or in any other food or beverage) are dangerous and no evidence that anyone is getting arsenic toxicity from their diet. Other than that, he has a good point, or at least a very popular show.

But why did his ploy work? Why did he get so much attention? Why didn’t the couple of million people (!) who watch his show search the CDC or FDA websites about arsenic, yawn slowly, and move on to a different subject? Why didn’t they discover on their own that the scariest thing about apple juice is the calories? Overweight people shouldn’t touch the stuff. After decades of drinking fruit juices daily they might suffer the complications of diabetes, but they would still have no effects from the arsenic. Why would we take the word of a TV entertainer and thoracic surgeon about food safety instead of the opinion of people with PhDs in biochemistry who spend their careers keeping food safe? Like me, Dr. Oz last studied biochemistry as an undergraduate. The only thing his training prepares him to answer about apple juice is “How long before my heart surgery can I have anything to drink?”

For better or for worse, we’re hard-wired to pay attention to scary stuff. So a reasoned explanation that everything is OK will never get as much attention as a bogus warning that you’re poisoning your children. As an open society we are being challenged to learn to give credibility to those who have earned it and ignore those who have abused our trust. Can we do it?

To all of us celebrating Rosh Hashanah next week I wish a year of good health in which all bad things arrive only in safe doses. Posting will resume in two weeks.

Learn more:

Why You Should Trust the FDA (And not Dr. Oz) (Forbes) If you read only one article about the arsenic in apple juice story, read this one.

Apple Juice Is Safe to Drink (FDA Consumer Update)

Oz Gets Taken to Task Over Apple Juice (Neurologica Blog)

Why we raised an alarm on apple juice (Dr. Oz’s op-ed in The Chicago Tribune)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

September 16, 2011 | 2:55 pm

Contaminated Cantaloupes Responsible for Listeria Outbreak

Posted by Albert Fuchs, M.D.

My regular readers know I have a bit of an obsession with food-borne illness. Why? Because it’s such a difficult and old problem. (Obviously germs have been contaminating food and sickening animals long before people were around.) Modern sanitation and farming have made our food much safer, but occasional outbreaks remind us that our current methods are still imperfect.

This week an outbreak of the bacterium Listeria has sickened over 20 people in seven states. (California has not been affected.) Two people have died.

The outbreak has been traced to cantaloupes grown in Jensen Farms, in Colorado. The FDA has announced a recall on cantaloupes from that farm. (California is not one of the states to which the cantaloupes from Jensen Farms were distributed.)

The Centers for Disease Control (CDC) has an information page on Listeria infection with some handy common-sense tips for preventing illness, including:

• Thoroughly cook raw beef, pork, or poultry to a safe internal temperature.
• Rinse raw vegetables thoroughly under running tap water before eating.
• Keep uncooked meats and poultry separate from vegetables and from cooked foods and ready-to-eat foods.
• Do not drink raw (unpasteurized) milk, and do not eat foods that have unpasteurized milk in them.
• Wash hands, knives, countertops, and cutting boards after handling and preparing uncooked foods.
• Consume perishable and ready-to-eat foods as soon as possible.

Follow the link for more suggestions.

Technology has made our food supply much safer, but we still have room for improvement.

Learn more:

FDA warns about cantaloupe linked to illness, deaths (LA Times)

FDA Ties Listeria to Cantaloupes (Wall Street Journal)

Multistate Outbreak of Listeriosis Linked to Rocky Ford Cantaloupes from Jensen Farms (CDC update)

Listeriosis (CDC information page)

Jensen Farms Recalls Cantaloupe Due to Possible Health Risk (FDA recall notice)

My previous posts about food-borne illness:

When the Stool Hits the Sprouts

Germany Struck by Major Food Poisoning Outbreak

Your Food Is Pretty Safe, But it’s Not Getting Safer

Would You Like Some Salmonella With That?

Gamma Rays are Good for Your Veggies

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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September 9, 2011 | 4:51 pm

Primary Care Doctors Want a Raise from Medicare

Posted by Albert Fuchs, M.D.

Imagine that you manufacture and sell ottomans. You are very proud of the excellent ottomans that you make. You trained for many years at great expense to become an expert ottoman maker. But as your career progresses, you find yourself generally dissatisfied with how many ottomans you have to make every day to make a living, and you think that your ottomans are worth more than you’re getting paid for them.

But what really annoys you are coffee table makers. They get a lot higher prices for coffee tables than you get for ottomans even though you work every bit as hard as they do. And you’re pretty sure that ottomans are much more important to most living rooms than coffee tables. The more you think about it, the more you’re convinced that coffee table makers shouldn’t make as much, and ottoman makers should make more.

So you do the reasonable thing. You fire off a letter to the Central Committee for Living Room Furniture Allocation (CCLRFA) and demand that ottoman prices be raised and coffee table prices lowered.

It sounds like an Orwellian dystopia, but that’s exactly what’s happening in healthcare.

The American Academy of Family Physicians (AAFP) believes that primary care doctors are not being paid enough by Medicare, and that Medicare overvalues services provided by specialists. In any rational marketplace, primary care doctors (or at least some of them) would simply raise their prices. But in the price-fixed world of Medicare, the prices aren’t set by patients or doctors, so the AAFP is left arguing with the CMS (Centers for Medicare & Medicaid Services) about the RUC (Relative Value Scale Update Committee).

Feel free to follow the links below for a mind-numbing look at the arcane world of healthcare reimbursement.

Though I am obviously a primary-care doctor, it’s hard for me to have much sympathy for the AAFP. Forget the fact that the central control of prices has been disastrous everywhere it has been tried, and that Medicare’s task of setting the prices that thousands of doctors receive for hundreds of services is absolutely impossible. With healthcare costs exploding, and with healthcare being one of the few sectors that (because it is heavily subsidized) continues to grow during the economic slump, it seems outlandish that doctors would ask current taxpayers for a raise. It’s actually worse than that. Because of our debt, current expenditures aren’t even paid by current taxpayers but rather by future generations. So the AAFP would like your grandkids to pay your doctor more for your care.

Do I think most primary-care doctors work hard and try to do a good job? Absolutely. Do I think they’re under paid? I have no idea. The only way to accurately value something is in a free marketplace.

If family doctors want to earn what they’re worth, they should work for their patients and find out how much their patients are willing to pay. If they want to start internecine bickering with specialists over who gets to bankrupt the country first, they should renew their membership in AAFP.

Learn more:

Differences in Doctors’ Compensation in the Spotlight (Wall Street Journal Health Blog)

Primary-Care Doctors Push for Raise (Wall Street Journal article)

Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared To Other Countries (Health Affairs, abstract available without subscription)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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September 2, 2011 | 12:16 pm

A Revolution in Atrial Fibrillation Treatment

Posted by Albert Fuchs, M.D.

Atrial fibrillation is an irregular heart rhythm affecting about 3 million Americans. The most serious risk of atrial fibrillation is stroke, caused by a blood clot forming in the abnormally beating heart chambers and traveling to a blood vessel in the brain. For over 50 years the mainstay of atrial fibrillation treatment has been the anticoagulant warfarin (better known by the brand name Coumadin) which effectively decreases the risk of stroke by preventing blood clots.

By the way, medicines that prevent blood clots are frequently called “blood thinners”, but they don’t thin the blood or affect blood viscosity. They prevent clotting. “Anticoagulant” is a more accurate term. Use the word at your next party (ideally while holding a bloody Mary) and your friends will marvel at your verbal precision.

Where was I? Oh, yeah.

Warfarin is probably the least convenient and most dangerous medication in common use. The reason is that the amount of anticoagulation caused by a given dose of warfarin varies wildly from one patient to the next and also varies in the same patient over time. Other medicines and certain foods can increase or decrease the anticoagulation caused by warfarin. Frequent blood tests are therefore required to adjust the dose. Too much warfarin increases the risk of life-threatening bleeding. Too little warfarin raises the risk of stroke from atrial fibrillation.

A group of new medications are now promising to eliminate the dangers and hassles of warfarin. I wrote two years ago about dabigatran (Pradaxa), an anticoagulant which is now on the market and is at least as safe and as effective as warfarin. Since then, another anticoagulant, rivaroxaban, has also been shown in a large trial to be superior to warfarin in safety and efficacy.

This week a third anticoagulant, apixaban, joins the group proven to be superior to warfarin. A study published in the New England Journal of Medicine (NEJM) randomized over 18,000 patients with atrial fibrillation to warfarin or apixaban. The patients were followed for almost two years. The patients on apixaban had fewer strokes, fewer episodes of major bleeding, and less mortality. An accompanying editorial in NEJM proclaims “a new era for anticoagulation in atrial fibrillation”.

Besides the fewer episodes of bleeding and stroke, a major advantage of these new medications is that they are prescribed at a fixed dose and do not require blood test monitoring.

Like many new medications, these new anticoagulants are relatively expensive (though less expensive than having a stroke or a life-threatening bleed). And like many old medications, warfarin is dirt cheap. So the transition away from warfarin may take some time. Nevertheless, its days in use for atrial fibrillation are numbered. Afterwards, it will likely still be useful in another role it has played for many years – as rat poison.

Learn more:

Study Gives Lift to Drug That Cuts Stroke Risk (Wall Street Journal article, see especially the handy chart summarizing the new anticoagulants)

A New Blood Thinner May Outperform Coumadin (My post two years ago about Pradaxa, dabigatran, the first oral alternative to warfarin.)

A New Era for Anticoagulation in Atrial Fibrillation (New England Journal of Medicine editorial, free without subscription)

Apixaban versus Warfarin in Patients with Atrial Fibrillation (New England Journal of Medicine article, free without subscription)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment