October 23, 2009 | 8:57 pm

Vaccines: Fighting Fear with Information

Posted by Albert Fuchs, M.D.

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Diversity of opinion is a mark of any free society.  Whenever I hear the latest conspiracy theory, see a commercial for a ghost-investigating “reality” show, or hear the latest quack cure advertised on radio, I remind myself that the spread of wacky fringe ideas is a consequence of liberty.  And, though I wish my fellow citizens would develop a bit of skepticism, I wouldn’t want anyone preventing them from hearing, watching or believing all that nonsense.

So it’s a major victory when facts finally win out in the court of public opinion—rare but sweet instances when science scatters away panic, rumor and superstition.  This seems to be happening about vaccines.  The fact that vaccines are very safe and that they save lives is gaining popular traction.  This is very encouraging.

It means that people who believe that organic food has health benefits (it doesn’t) or that vitamin C helps treat colds (it doesn’t) are at least rejecting the fear-mongering of the anti-vaccine movement.  A recent article in the Atlantic (link below) is another step in spreading the truth.  It’s not long.  Please read it.

Of course, none of that matters because the Mayan calendar predicts the end of the world in 2012.  I better stock up on vitamin C.

(Thanks to my friend, Tom, for pointing me to the Atlantic article.)

Learn more:

The Atlantic article: The New Pandemic of Vaccine Phobia

My previous posts about vaccine refusal:

Vaccine Refusal: Turning Back Two Centuries of Progress

U.S. Measles Cases at Highest Numbers Since 2001

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 despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

October 16, 2009 | 7:14 pm

A Dose of Realism about Advanced Dementia

Posted by Albert Fuchs, M.D.

Dementia isn’t one disease.  Like cancer, dementia is a family of different diseases that have important similarities.  The diseases that cause dementia all lead to progressive memory loss and brain dysfunction.  Dementia is caused by Alzheimer’s disease, vascular dementia, Parkinson’s disease and several other rarer brain disorders.  The different diseases that cause dementia cause different symptoms initially and have different treatments.  But unfortunately all the treatments are temporary and only slow the progression of dementia.  Advanced dementia has the same constellation of symptoms regardless of the cause – profound impairments in memory, language and mobility.

Dementia is a progressive incurable fatal illness. I learned that in my residency over ten years ago, and the newer treatments haven’t changed this fact.  On average, patients survive for 4.5 years after diagnosis, but some live as long as a decade.  There are incurable cancers with better survival rates.

Even though the poor prognosis of dementia isn’t news, apparently the word hasn’t spread.  An important study in this week’s New England Journal of Medicine studied the prognosis of patients with advanced dementia and followed the care they received, their family’s expectations and their medical complications.  Over 300 patients with advanced dementia who were admitted to nursing homes were followed.  They all were unable to recognize family members, had minimal verbal communication, were completely dependent for all daily living activities, were incontinent and were unable to walk independently.

The results of this study were depressing.  Over half of the patients died within 18 months.  In their last 3 months of life over a third had distressing symptoms like breathlessness and pain.  Only a fifth of the patients were referred to hospice care.  Despite their terrible prognosis, over a third of the patients underwent a hospitalization, emergency room visit, tube feeding or intravenous feeding.  The one bright point was that patients whose families understood the poor prognosis of dementia were less likely to receive intensive intervention.  Though the study doesn’t state this, I pray this translated to earlier hospice referral and better symptom relief.

As we all live longer and as we are better able to treat and prevent heart disease and some types of cancer the incidence of dementia will increase.  Families deserve honesty about the course of this terrible illness, and patients deserve comfort.

Learn more:

Time article:  Redefining Dementia as a Terminal Illness

New England Journal of Medicine article:  The Clinical Course of Advanced Dementia

The source of the statistics about survival after dementia diagnosis is this Medscape article:  Survival After Dementia Diagnosis Depends on Age, Sex, Disability (click on the first search result)

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 despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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October 9, 2009 | 8:13 pm

The Challenge of Trusting Science

Posted by Albert Fuchs, M.D.

Around the turn of the last century medical practice was in a sorry state.  Despite dramatic advances in physics, chemistry and physiology, the day-to-day practice of medicine was still entirely estranged from the scientific method.  Medical training and medical practice was still what it had been for thousands of years – an apprenticeship in which treatments were passed down from teacher to student and applied by doctor to patient for generations without rigorous testing.  At about that time leaders in medical education sought to bring the scientific rigor of other disciplines to medical education and medical practice.  We can’t say that their work is complete.  The rigorous testing of therapies in randomized trials and the deliberate attempt to base clinical practice on the results of those trials (what we now call evidence-based medicine) is only a few decades old.  And even now, many physicians are deeply skeptical of evidence-based medicine, preferring to rely on their own experience or on traditionally accepted treatments.

I have no objection to relying on my experience or my judgment in the many cases for which scientific evidence is lacking.  Every day doctors face clinical situations for which no large randomized trials provide data.  That is the time for experience, improvisation, the art of medicine.  But some physicians resist relying on science even in cases in which studies exist and are clear.  They assert the importance of their autonomy and experience and refuse to follow “cookbook medicine”.  The problem with that approach is that our experience frequently fools us.  We remember best the cases that conform to our biases and expectations, and tend to forget the ones that challenge us.  We overestimate the frequency of dramatic outcomes and underestimate the more common boring cases.  We deceive ourselves to maintain our preconceptions.  That’s why to get at the truth studies have to be blinded and randomized.  The experience of every living person suggested that the sun revolved around the earth.  It was only Galileo’s data that convinced him otherwise.

Though medicine has a long way to go, we’re moving in the right direction.  But there’s another field which is now approaching the scientific revolution that medicine started a century ago – psychology.  Much of clinical psychology remains the transmission from teacher to student of untested but long-used therapy methods.  At the same time, the last few decades have seen remarkable progress in the science of mental illness and psychotherapy.  A specific kind of psychotherapy called cognitive behavioral therapy has been proven in many studies to be helpful for many disorders, especially in the family of anxiety disorders.  This scientific proof is startlingly lacking for many other forms of psychotherapy.  But there is a schism between the scientific findings and the education and practice of psychology.  Most psychologists have not been trained in cognitive behavioral therapy and most do not practice it, relying instead on unproven techniques.

This is not my criticism.  It is the criticism of three psychologists led by Dr. Timothy Baker in the University of Wisconsin who authored an article in Psychological Science in the Public Interest.  (See link below.)  The article details the many evidence-based psychotherapy techniques available and then shows how infrequently these techniques are used in practice.  The editorial that precedes the article is a clarion call for the field of psychology to reform itself if it is to continue serving patients.

I have the pleasure and honor to take care of several psychologists and have psychologists as friends.  (I look forward to their emails about this.)  My intention in this post is not to point fingers or criticize.  It is to highlight an important positive development in psychology and to encourage psychologists to trust science.

Learn more:

Newsweek article:  Ignoring the Evidence.  Why do psychologists reject science?

LA Times Booster Shots:  Do therapists know what they’re doing? Don’t bank on it, 3 psychologists say

Psychological Science in the Public Interest article: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care

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 despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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October 2, 2009 | 7:18 pm

The H1N1 (Swine) Flu Vaccine

Posted by Albert Fuchs, M.D.

Countless of you (well actually, several of you) have asked me in the last few weeks “What about the swine flu vaccine?”  “Should I get it?”  “When will it be available?”  “Is it safe?”  “Does it not herald the coming of the zombie apocalypse?”  Well, your long wait for answers is finally over.

So far the H1N1 infection has caused symptoms very similar to garden variety seasonal flu, except that diarrhea and vomiting have been more common and that most hospitalizations have been in people younger than 65.  Remember, this is overall not a worse disease than the regular flu, though some groups have been particularly vulnerable.

Physicians will begin receiving shipments of the H1N1 vaccine later in October.  The H1N1 vaccine is prepared the same way as the regular influenza vaccine, so it has the same side effects and is just as safe.  Fortunately (despite conflicting reports a few months ago) one dose of the vaccine is sufficient.

The vaccine is recommended for the following five groups.

• Everyone 6 months through 24 years of age
• People who live with or care for infants younger than 6 months of age
• Pregnant women
• Healthcare workers
• People 25 years through 64 years of age with health conditions associated with high risk for medical complications from influenza

If you’re in one of the above groups, see your doctor later this months and get the vaccine.  If you’re not, don’t.  Our office expects to receive the vaccine in the next few weeks.

Learn more:

Centers for Disease Control recommendation for H1N1 vaccination

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 despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

1 Comments — Leave your comment

September 25, 2009 | 1:59 pm

Reservations Regarding Resveratrol

Posted by Albert Fuchs, M.D.

Resveratrol is a chemical found in the skin of red grapes, berries, plums and peanuts.  It is being widely promoted as the latest antiaging wonder drug.  Fortunately, to separate research from hype, this issue of The Medical Letter reviewed the current knowledge on Resveratrol.

Resveratrol has shown some interesting benefits in animal experiments.  In obese mice, it increased insulin sensitivity and longevity.  In non-obese mice it did not improve survival but increased other markers of good health.  In simple organisms, such as yeast, resveratrol increased lifespan by up to 70%.  (My guess is that this is fabulous news for yeast, but not as good if you’re a human with a yeast infection.)

Studies of resveratrol in humans are lacking, so little can be said with confidence about either benefits or side effects.  The authors of The Medical Letter conclude

Resveratrol appears to produce some of the same effects as calorie-restricted diets that have reduced the incidence of age-related diseases in animals. Whether it has any benefit in humans remains to be established.

So I remain squarely in the pro-aging camp, and hope we all stay healthy and safe enough to grow old.

Tangential miscellany:

I’m proud to announce that I have been elected Fellow of the American College of Physicians.  If you’re curious what that means, see the link explaining FACP below.

Learn more:

The Medical Letter review of Resveratrol (by subscription only)

My previous posts on antiaging:

Growth Hormone Doesn’t Help Healthy Older Adults

DHEA and Testosterone Don’t Help Elderly Patients

American College of Physicians website:  FACP - What do these letters after your doctor’s name mean?

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 despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

0 Comments — Leave your comment

September 18, 2009 | 6:37 pm

A New Blood Thinner May Outperform Coumadin

Posted by Albert Fuchs, M.D.

Atrial fibrillation is a very common abnormal heart rhythm affecting 3 million Americans.  The most dangerous complication of atrial fibrillation is stoke, which can happen when a blood clot forms in the fibrillating heart chambers and travels to the brain.

Blood thinners have been the mainstay of treatment for atrial fibrillation.  They reduce the risk of stroke by preventing blood clots.  Warfarin (marketed under the brand name Coumadin) is the most effective available oral blood thinner, but taking it is fraught with difficulty.  The appropriate dose varies widely between individuals because of genetic differences, and even in the same individual the correct dose varies from one time to another.  The only way to dose warfarin correctly is to check blood tests periodically and adjust the dose based on the results.  Too much warfarin and the risk of dangerous bleeding increases; too little and the risk of stroke from atrial fibrillation is undiminished.  This need for frequent lab monitoring and the many interactions that warfarin has with foods and with other medications make it one of the least convenient and potentially most dangerous medicines in common use.  But for atrial fibrillation warfarin is the best we have.

An important study in this week’s New England Journal of Medicine compares a new blood thinner, dabigatran, with warfarin.  Over 18,000 patients with atrial fibrillation were randomized to either warfarin or to two different doses of dabigatran.  The lower dose of dabigatran was as effective at preventing strokes as warfarin, but was safer, causing fewer incidents of major bleeding.  The higher dose of dabigatran was as safe as warfarin (i.e. equal numbers of major bleeding) but prevented more strokes.

That by itself would be encouraging enough, but the major advantage for many patients will be that dabigatran does not require laboratory monitoring and has much fewer interactions with other medications.  It is taken twice a day at a fixed dose, making it dramatically simpler than taking warfarin.

Dabigatran should be available in the US in 2010.

Learn more:

Wall Street Journal article:  New Blood Thinner Matches Warfarin

New England Journal of Medicine article:  Dabigatran versus Warfarin in Patients with Atrial Fibrillation

New England Journal of Medicine editorial:  Can We Rely on RE-LY?

Tangential miscellany:

To my Jewish readers I extend wishes for a sweet and healthy year.  To my readers who, like me, are astronomy geeks: happy fall equinox!

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 despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

2 Comments — Leave your comment

September 11, 2009 | 5:41 pm

The Facts on Red Yeast Rice

Posted by Albert Fuchs, M.D.

Many of my patients ask me whether they should take red yeast rice to lower their cholesterol.  This week’s issue of The Medical Letter has a very handy review of red yeast rice which I summarize below.

Red yeast rice is a food that is produced by fermenting rice with a specific species of yeast.  It has been used in Chinese cooking and medicine for centuries.  It contains many molecules that are similar to statins, the family of medicines including Liptor, Zocor and Crestor.  In fact one of its ingredients is lovastatin, the medication in Mevacor, the first statin approved in the US.

Statins have been repeatedly proven to prevent strokes and heart attacks, but statins also sometimes cause muscle or liver inflammation, a side effect also present in red yeast rice.

Because it is sold as a food supplement, not as a medication, the quantity of active ingredients in red yeast rice formulations is not standardized and varies widely.

The article concludes that red yeast rice has many of the benefits and side effects of statins but unlike statins, its ingredients are not standardized.  The bottom line is that “generic lovastatin would be safer and cost less”.

Learn more:

The Medical Letter review of Red Yeast Rice (by subscription only)

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 despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

0 Comments — Leave your comment

September 4, 2009 | 1:09 pm

National Cholesterol Education Month

Posted by Albert Fuchs, M.D.

The CDC says that September is National Cholesterol Education Month, and who am I to argue?  So here is a dollop of education about cholesterol.

• High cholesterol is a major risk factor for strokes and heart attacks.  Other risk factors include
  • smoking,
  • age,
  • high blood pressure,
  • diabetes and
  • having a first-degree relative who had a heart attack in middle age or younger.
• High cholesterol doesn’t feel like anything.  The only way to know if your cholesterol is high is to have it checked.
• High cholesterol can be safely and effectively lowered with dietary changes, exercise and medications.
• Lowering high cholesterol with a family of cholesterol medicines called statins has been proven to prevent strokes and heart attacks.

So if you haven’t had your cholesterol checked in years, or if you know your cholesterol is high and you’ve been desperately ignoring it, get back to your doctor and get her advice.

Learn more:

The CDC webpage for National Cholesterol Education Month

Tangential miscellany:

My last post, Rational Rationing, generated lots of email responses and led to very stimulating discussions.

This month The Atlantic published a terrific article on the problems of our current healthcare system written by media and technology executive David Goldhill.  (Thanks to Timo K. for pointing me to it.)  It’s a very well researched and very personal analysis of what’s wrong and how to fix it.  I urge you to read it.  How American Health Care Killed My Father

Have a happy and safe Labor 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 despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

0 Comments — Leave your comment