November 23, 2011 | 8:18 am

Reflections on Gratitude

Posted by Albert Fuchs, M.D.

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For each new morning with its light, For rest and shelter of the night, For health and food, For love and friends, For everything Thy goodness sends

Thanksgiving By Ralph Waldo Emerson

It’s been a difficult year for many of my patients. Some have had catastrophic health challenges. Many businesses are still struggling. Some marriages are fraying. Many of us are very unsure of what comes next.

When things look irredeemably hopeless, when I have nothing but bad news to give, when I really wish someone else was the doctor for one day, that’s when I am reminded what an extraordinary job I have. I am privileged to be a part of people’s lives at their scariest, most personal, darkest times. I hear their anxieties, their confessions, and their secrets. I do my best to help, and to assemble a team of specialists to do the many things I can’t do. But ultimately all help fails.

And the one thing my patients teach me again and again when things are at their worst is gratitude. I hear about the love of family, the comfort of happy memories, the joy of looking back without regrets. In the most desperate situations when I would expect panic or grief, I hear gratitude.

Tomorrow is the day to remember all of our abundant blessings. We all have so much to be grateful for. This year I’m especially grateful to my patients for allowing me to make a living doing what I love, and for reminding me constantly of the importance of gratitude.

As is my annual tradition, I hereby lift all my patients’ dietary restrictions for one day. I wish you happy feasting in homes filled with cheer and joy! Happy Thanksgiving!

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.

November 18, 2011 | 5:54 pm

Yoga Or Stretching Helps Chronic Back Pain

Posted by Albert Fuchs, M.D.

Everyone hates stress, and for good reason. Stress makes us miserable. Perhaps for that reason, stress is blamed for virtually every disease for which the cause is still unknown. Later, when we discover the true cause, we find that it is unrelated to stress. We thought stress causes stomach ulcers before discovering the bacterium that is the true culprit. We thought stress caused heart attacks before a study comparing high-stress to low-stress individuals showed that this wasn’t true. Stress causes gray hair? Nope. Genes cause gray hair. Irritable bowel syndrome is probably the next disease on this list. We’re close to sorting out what causes it, and when we do, we can stop blaming stress.

So stress causes misery, which is bad enough, but we should be careful not to scapegoat it for other ills.

A study in the Archives of Internal Medicine last month adds another illnesses for which stress may not be relevant.

Chronic back pain is common and has no universally effective treatment. Lots of patients swear by yoga, and for many with chronic back pain it seems to improve their symptoms. Is this simply because the exercises stretch their backs and legs, or is the breathing and meditative component also helpful? After all, countless people attest to the stress-lowering properties of yoga. Shouldn’t less stress decrease chronic pain?

To test this question, researchers enrolled over 200 patients with chronic back pain and randomized them to three groups. One group attended weekly yoga classes. A second group attended weekly stretching classes. A third group was given a self-care book teaching exercises for low back pain and was asked to follow the book’s instructions independently. All the patients had their functional status and pain levels measured by periodic questionnaires.

As expected, the yoga group did better than the self-care group. But surprisingly, the yoga group did no better than the stretching group. This suggests that the benefit for back pain from yoga is entirely related to the stretching, with no additional improvement from the meditation and breathing exercises.

That’s not to say that the breathing exercises and the meditation don’t feel good, which might be reason enough to do them.

So chronic back pain may be another illness that doesn’t have as much to do with stress as we thought. But stress makes us unhappy and strains our relationships. That’s reason enough to find ways of managing stress.

The holidays are around the corner, which for some of us are particularly stressful. So when you’re feeling very anxious and want to tell a loved one who is annoying you “You’re giving me an ulcer,” remember that he’s not. Take a deep breath and say something like “You’re not giving me an ulcer, a heart attack, or gray hair, but I wish you’d stop anyway.”

Learn more:

Yoga, stretching both ease chronic back pain: US study (Reuters)
Yoga May Help Low Back Pain. Mental Effects? Not So Much (Wall Street Journal)
A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain (Archives of Internal Medicine, 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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November 11, 2011 | 10:14 am

Difficult to Digest Carbohydrates Implicated in Irritable Bowel Syndrome

Posted by Albert Fuchs, M.D.

Irritable bowel syndrome (IBS) is a chronic condition marked by abdominal pain, bloating, and alternating constipation and diarrhea. There is no specific test for IBS and other more serious diseases like celiac disease and inflammatory bowel disease can cause similar symptoms. The good news is that when a doctor has ruled out these more serious diseases and diagnosed IBS the patient can be assured that her illness is chronic but not progressive or life-threatening. The bad news is that IBS symptoms can be quite miserable, and at their worst can interfere with work and life activities.

Myriad treatments are used for IBS, and as with any disease with myriad treatments, that means that none of them are consistently effective. I wrote five years ago about a trial that showed modest success using antibiotics for IBS but even that trial did not show an improvement in the majority of patients.

A new theory proposed by researchers in Australia holds that IBS is caused by certain sugars that are difficult to digest. These sugars pass undigested through the small intestine and are fermented by bacteria in the colon. This releases carbon dioxide which causes bloating and pain, and draws water into the colon which causes diarrhea.

These carbohydrates are called FODMAPs, which stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols, which just means small sugars that can undergo fermentation.

FODMAPs are present in lots of foods. (This Wall Street Journal article has a handy table with a list of foods high in FODMAPs and low in FODMAPs.) So eliminating them entirely requires some drastic dietary changes. Nevertheless, the Australian researches published a study in last month’s issue of the Journal of Human Nutrition and Dietetics in which patients were randomized to standard care or to a FODMAP-free diet. About half of the patients in the standard group had symptom improvement, compared to about three quarters of those on a FODMAP-free diet.

Gastroenterologists who are promoting this theory recommend that patients try a FODMAP-free diet for six to eight weeks and then slowly reintroduce FODMAP-containing foods to determine what quantities they can tolerate. Unlike food allergies, complete abstinence is not necessary. It’s just a matter of reducing the FODMAPs below whatever threshold causes misery.

Some caveats are necessary. The study was quite small, and it was not blinded since it’s impossible not to know whether your diet is being restricted radically. So the results should be treated as suggestive but preliminary. Still, for those with severe IBS symptoms a FODMAP-free diet may be worth a try. It may be inconvenient but it’s certainly safe and the worst that could happen is that it won’t work.

Learn more:

When Everyday Foods Are Hard to Digest (Wall Street Journal)
Very Restricted Diet May Reduce Symptoms of IBS (WebMD)
Irritable Bowel Syndrome (National Library of Medicine information page)
An Oral Antibiotic Reduces the Symptoms of Irritable Bowel Syndrome (my post in 2006)
Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome (Journal of Human Nutrition and Dietetics, abstract available without subscription)

Tangential Miscellany

If you appreciate the right to speak as you wish without fear of censorship or punishment, the right to wave a sign declaring your displeasure with how much income the top 1% earn, the right to occupy public places and protest Wall Street and be generally tolerated, if you value these rights, then thank a veteran. Happy Veterans Day.

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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November 4, 2011 | 8:27 am

Ivacaftor – a Breakthrough in Cystic Fibrosis Treatment

Posted by Albert Fuchs, M.D.

One of the implicit themes we were taught in medical school is that an understanding of the basic science of a disease informs and guides treatment of patients. The general philosophy that we absorbed was that an understanding of the molecular or cellular defects in a disease would explain the abnormal organ physiology which would explain the patient’s abnormal signs and symptoms. This understanding of the abnormality at a molecular or cellular level would also help discover medications that corrected or ameliorated this abnormality. Just as physics forms the foundation of chemistry which leads to organic chemistry and then to cell biology, we were led to believe that understanding physiology would form a foundation for understanding medicine.

It turns out that this beautiful philosophy is usually wrong.

One reason is that we don’t understand human physiology in nearly enough detail to understand all the mechanisms that malfunction in any disease, or to predict the effects of any treatment. A single mammalian cell is more complex than the most complicated systems engineered by people, and our understanding of the molecular mechanisms that allow cells, tissues, organs and people to function is incomplete. Just to take one example, everything we knew about how estrogen works suggested it should prevent strokes and heart attacks. It doesn’t.

Another reason that medicine is disconnected from basic science is that understanding the molecular basis of a disease frequently gets us no closer to finding a treatment. The best-known example of this is sickle cell anemia, a disease in which the abnormal gene is known, the abnormal hemoglobin molecule produced by this gene is known, the abnormal way this hemoglobin folds is known, the way this abnormal folding disrupts red blood cells is known, and the way the abnormal sickle-shaped red blood cells make people sick is known. And we are still frustratingly far from a treatment directed at the basic defect.

So medicine is usually a deeply pragmatic practice, largely separated from the basic sciences. We know what works because of trials in which medications are actually tried on patients (and first on animals), not from our understanding of molecules, cells or organs. And those medications are usually found serendipitously, not by design. The basic sciences may give us a vocabulary and an intellectual framework, but they rarely give us an actual treatment.

This week, we have a very happy exception.

Cystic fibrosis is the most common fatal genetic disorder in whites, affecting 30,000 people in the US. The gene responsible for it was discovered in 1989. In healthy people, this gene codes for an ion channel – a protein on the cell surface that controls the flow of charged atoms, like chloride and iodide, into and out of cells. In people with cystic fibrosis this protein malfunctions or is absent.

This inability of cells to pump ions where they’re supposed to go leads to an inability to secrete water (which follows the ions). This leads to many of the clinical manifestations of cystic fibrosis. Airway secretions are too dry because airway linings cannot secrete enough fluid. This creates thick mucus that is difficult to cough up, obstructs airways, and predisposes to lung infections. Pancreatic secretions are also too thick, destroying the pancreas.

Patients frequently lose weight because of recurrent infections and because of malnutrition caused by pancreatic failure. They develop progressive decrease of their lung function and eventually succumb to respiratory failure or infection. Forty years ago the median survival age was 11. Now, with better treatment of infections and drugs aimed and loosening secretions, median survival is 37.

Ivacaftor is a medicine that was designed specifically to treat cystic fibrosis. It is a molecule that was designed to keep dysfunctional ion channels open. That means it is only useful for the 4% of cystic fibrosis patients with the specific mutation that causes ion channels to be present, but not working. This week The New England Journal of Medicine published a study testing the effects of ivacaftor in cystic fibrosis patients with this specific mutation.

167 patients were randomized to ivacaftor or to placebo. The differences between the two groups were striking. The ivacaftor group gained weight, had improvement in lung function, and had fewer respiratory exacerbations. The benefits started within two weeks of treatment and persisted for the duration of the trial. And the trial found no serious side-effects.

It’s hard to overstate the significance of this development. For newborns with this specific mutation, ivacaftor may completely reverse their disease. There is reason to hope that if the disease is treated prior to permanent lung and pancreas damage, people will live entirely normal lives apart from taking a pill twice a day. Obviously, more work must be done to substantiate this, as well as to find similar treatments for the cystic fibrosis patients with other mutations.

This is a breathtaking improvement in the care of a disease that was recently a death sentence, and it is a beautiful demonstration that understanding a disease at the molecular level can actually lead to an effective treatment.

Learn more:
Cystic fibrosis drug ivacaftor offers patients new hope (LA Times)
A CFTR Potentiator in Patients with Cystic Fibrosis and the G551D Mutation (New England Journal of Medicine article)
Therapy for Cystic Fibrosis — The End of the Beginning? (New England Journal of Medicine editorial)

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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