Saturday, October 20, 2012

Brain Freeeeeeeze (Marin IJ)

It’s popsicle-o-clock at the Ballard house and everyone is content… until a horrible shriek reverberates through the home. The perpetrator is three-year-old Holden and his tribal yell quickly morphs into a plaintative wail of “brain freeeeeeeeezzzzze.” In a moment, the pain (for all of us) recedes and our daughter, removing her hands from her ears, asks, “Dad, what causes ‘brain freeze?’” Until recently I would have answered: “Popsicles.” But now, thanks to new evidence, I can instead tell her, “vasodilatation of the anterior cerebral artery.”

This past April, Jorge Serrador of Harvard Medical School and colleagues reported the results of a small study suggesting an explanation for the bodily processes (physiology) involved with brain freeze (known in medicalese as sphenopalatine ganglioneuralgia.) Now, I know what you might be thinking – with autism unexplained and cancer uncured, aren’t there greater priorities for medical research than a painful yet benign experience like sphenopalatine ganglioneuralgia? And, you would be absolutely right. However, there is a bit more to it, and some have long posited that the physiology of brain freeze might be related to that of other (less temporary) conditions – such as post-traumatic and migraine headaches. In fact, prior studies have suggested that migraine sufferers are more likely than other folks to experience brain freeze. So, with that in mind, let’s get back to the research at hand.

Serrador and colleagues recruited thirteen healthy adults willing to suffer through brain freeze in the name of science (and I’m guessing there were other inducements as well). While researchers monitored the blood flow in their brains with transcranial Doppler (ultrasound), the volunteers sipped ice water through straws pressed against their upper palates. Then, they raised their hands to signal the freeze and thaw of brain freeze. Brain blood flow under these conditions was then compared with that of the same volunteers sipping warm water. The results of the study were presented at the Experimental Biology 2012 conference in San Diego and were notable in that the researchers observed that one particular artery, the anterior cerebral artery, dilated rapidly and flooded the brain with blood in conjunction with the freeze sensation. Soon after this vasodilatation occurred, the same vessel constricted (tightened) as the volunteers' pain receded. Now, remember, this was a small study and it’s results have yet to complete the rigorous peer review process associated with manuscript publication. Nonetheless, there do seem to be some important implications in these findings.

1)     Migraine headaches. These are thought to be caused by abnormal dilation of arteries in the brain, and many existing treatments attempt to modulate this process. These results then, support this concept and may lead to greater focus on migraine treatments that prevent dilation in the first place. And, for people with friends or family members with migraines, this study provides us with a way to relate to their pain. For some with migraines, the headache must certainly feel like one long brain freeze. Ouch.

2)     The suddenness of sensation matters. We’ve all heard about the frog that will jump out of a pot of boiling water but will stay in a tub slowly brought from ambient temperature to a boil. One of the aspects of brain freeze that makes it so uncomfortable is the rapidity and severity of its onset. This principle is worth keeping in mind for other situations. Take, for example, removing a bandage. The conventional wisdom is that pulling it off quickly is better, as it gets the pain over and done with. But some researchers, such as Dan Ariely, the author of the fascinating book Predictably Irrational, contend the opposite; the quicker the pain the more severe the pain, and thus the greater the overall discomfort. So perhaps very slowly removing a band-aid is actually more comfortable than yanking it right on off. That’s a topic to be exposed more thoroughly some other time.

3)     Now, I can turn Holden’s occasional freezathon into a spelling lesson for his sister. Ok, here we go, let’s try “sphenopalatine ganglioneuralgia.” S...P...H…

On Breast Cancer Risk (Marin IJ)

Establishing cause and effect is one of the trickiest aspects of medicine. So-called “causality” can be elusive, especially once you move beyond connect-the-dots type circumstances (exhibit A; Mom cuts finger with bagel knife = bleeding Mom.)

Here in Marin, we worry and wonder a lot about breast cancer. Why does a particular woman get breast cancer? How does another woman avoid it? These are difficult and often unanswerable questions. Unlike the knife and finger example, there are a litany of possible reasons why an individual might develop breast cancer. And, even if we expand the question to what increases the risk of breast cancer across a broad population, satisfactory answers are slippery. It is with this in mind that we should view the recent evidence regarding breast cancer in Marin County.

It is well documented that Marin has historically had an abnormally high rate of new breast cancer cases. In particular, data from the late 1990s demonstrate breast cancer rates some 15% higher than those found across the rest of the state. Multiple culprits – lifestyle, hormones, toxins, and genetics – have been proposed and studied, without the emergence of a single smoking gun.

A study recently published in the Journal of the American College of Surgeons has proposed yet another possible cause – genetic differences in Vitamin D receptors. The study, conducted by Dalessandri and colleagues, examined the DNA of 164 Caucasian women living in Marin and diagnosed with breast cancer between 1997-1999. They compared their genetic profiles with those of 174 breast-cancer-free matched controls and found that women at statistically high risk for breast cancer were 1.9 times more likely to have a specific difference (called a variant) in the gene which dictates how the body utilizes Vitamin D (the Vitamin D receptor). Vitamin D has received quite a bit of attention for its possible benefit in deterring certain types of cancers and animal models have demonstrated that it has a beneficial effect on breast cancer tumor growth. Thus, differences in how Vitamin D is processed by its receptors is a logical explanation for why certain women (in Marin and elsewhere) would be at higher risk for developing cancer.

But before you march out to determine your Vitamin D receptor profile, let’s put these findings in proper prospective. First of all, this was a small “pilot” study and should be considered preliminary evidence. Medical practice and investigation is ripe with prominent associations that have not borne out in larger studies; oat bran and heart disease, and (who can forget?) vaccines and autism, and on and on. In fact, there are more disproven associations in medicine than proven ones.

A much larger study of Marin Women (the “Marin Women’s Study” with 14,000 participants is ongoing and analysis of their DNA samples (there are some 8500 available) should provide more robust data on Vitamin D receptor variants and genetic risk. Furthermore, the genetic data from Dalessandri’s study is from fifteen years ago – during a time when breast cancer rates were peaking – especially in Marin. While multi-factorial, we know that this peak was due, in part, to combined post-menopausal hormone (estrogen and progesterone) therapy – a known risk factor for developing breast cancer, and a treatment more common (at the time) in Marin than elsewhere in California. Thus, we must be careful to extrapolate the findings regarding breast cancer risk from a prior generation to today’s milieu. Finally, one must always be particularly fastidious when reviewing the results of studies that focus on a specific proprietary drug (remember Vioxx?) or test. While this study was funded by state, county and charitable sources, the results quite prominently affect the fortunes of genetic testing company InterGenetics Incorporated, which is marketing OncoVue® - a “genetic-base, breast cancer risk test.”  Thus, while interactions between genes and the environment is certainly a promising field, the jury on Vitamin-D receptors and breast cancer is most definitely still out.

Where then, does this leave us with breast cancer causality? Well remember, this is tricky – proving a clear-cut link between a dietary item, personal habit, or medical treatment and a disease process is fraught with the potential for mis-interpretation. Nonetheless, there are certainly some risk factors that we can confidently delineate. Some genetic risk is clearly proven – and a family history of breast cancer is a known red flag – especially if due to a known BRCA mutation. In terms of risky environmental exposures, an Institute of Medicine committee report released last year summarizes these quiet nicely as “hormone therapy that combines estrogen and progestin, exposure to ionizing radiation…excess weight among post-menopausal women and alcohol consumption.” Other environmental agents – chemicals such as bisphenol A (BPA) – have been implicated and are biologically plausible but at this time unproven. Mary Mockus, a surgeon at Kaiser-Permanente San Rafael and a member of the collaborative Marin Women’s Study team, thinks that the ‘toxic soup’ present in higher socioeconomic areas like Marin County is likely to play some role in the higher breast cancer rates, but that we are unlikely to ever identify one clear cut perpetrator. And, this then, fits quite well with what we know about causality in medicine.

Thus for Marin women, the best advice for preventing breast cancer is probably the best advice for preventing many diseases; sleep well, get regular exercise, know your family’s medical history and discuss individualized screening plans with your doctor…don’t smoke, avoid excesses of alcohol, drugs and ionizing radiation, and eat plenty of green leafy vegetables. And a healthy Vitamin D level (ask your doctor!) won’t hurt either. 

Cannabinoid Hyperemesis (Marin IJ)

Every once in a while in medicine a new discovery comes along that, on its face, seems to make no sense at all. What if I were to tell you that a popular drug – one that’s been sampled by two out of every five Americans and is renowned for its relaxation and anti-nausea properties – could actually cause severe bouts of nausea and vomiting among long-term users? These symptoms are worse in the morning and seem to be most effectively relieved by a long hot shower. Hmmm, smells a bit skunky, right? But, recently published reports seem to confirm the phenomenon. And, you might be more than a bit surprised by the culprit: THC.  

Cannabinoid hyperemesis (THC associated vomiting) was first described in 2004 but remains a relatively unknown and underappreciated malady. A recent case series by Douglas A. Simonetto and colleagues at the Mayo Clinic in Rochester, MN, compiled data on 98 patients with this condition – and in the process they’ve put it on the map as a medical diagnosis.

The accumulating evidence about cannabinoid hyperemesis gives us this typical patient profile: a chronic cannabis user under the age of 50 who develops periodic and severe abdominal pain associated with nausea and vomiting that tends to be worse in the morning and to improve with hot showers or baths.

For example, in Simonetto’s report (published in February 2012 in Mayo Clinic Proceedings), the study team reviewed 1,571 charts of patients seen at their institution between 2005 and 2010 and identified 98 that met their criteria for cannabinoid hyperemesis (long term cannabis users with recurrent vomiting not explained by any other medical illness). Of these, each one was under the age of 50 and the vast majority (95% of those for whom data was available) used cannabis at least twice a week. Of the 57 patients for whom the effect of hot water immersion was documented, 51 (91%) reported relief. Most patients (86%) also reported abdominal pain. From these results, the authors have proposed specific criteria for the diagnosis of cannabinoid hyperemesis – including most of the above characteristics. As to the cause of the paradoxical vomiting due to cannabinoids, several theories have been proposed, including the inhibitory effects of cannabis on peristalsis (the wave-like impulses that propel food through the intestines). It may also be that chronic use changes the effects of cannabinoids on THC receptors in the brain. More investigation is needed, however, and as of now we can only speculate as to why hot showers are such an effective treatment (it could be because hot water draws blood supply away from the gut and to the skin). Despite the uncertainty, this new evidence does have a couple important implications for how we think about cannabinoids.

      1)   Today’s cannabis is not the same as your father’s puff the magic dragon. In particular, synthetic and oral cannabinoids can lead to much higher and prolonged exposure to THC or similar compounds – and this would, presumably, increase the risk of cannabinoid hyperemesis syndrome. In particular, “herbal incense” products like Spice and K2 can cause effects – including prolonged psychosis – that were rarely observed from marijuana alone in the era of dirt grass and flower power. Thus, while the evidence is accumulating that cannabinoids may be helpful in the treatment of a number of uncomfortable medical conditions – including those that cause nausea and vomiting! – one must be careful with the amount and delivery of the drug. Like any drug, cannabis is not risk- or side effect- free.

2)  If you are a long-term cannabis user suffering from severe bouts of nausea and vomiting, there may be simple treatments. First, try a nice, long, hot shower. (I fear I may be setting myself up for public stoning here, but this may help explain why, for years, Fairfax’s medical marijuana clinic was located right next to a Frogs Hot Tubs). But I digress…  the second (and medically advised) treatment for cannabinoid hyperemesis is to stop using cannabis. In Simonetto’s case series, of those reporting have quit cannabis, six out of seven (86%) had complete resolution of symptoms.

In medicine, like in life, it is always good to constantly question and challenge assumptions. The long-standing assumption about cannabis is that it’s main danger is as a “gateway” drug – and that it is otherwise quite safe and side effect free. We are starting to learn that this is not exactly true.  

Monday, August 20, 2012

The Stick of the Issue (Marin IJ)

A Kiwi grade-schooler amazed his classmates with a remarkable feat of attraction. He suspended a spoon from his navel, held, as if floating, by an invisible attachment. An American preteen was the envy of her BFFs because she had a tongue bolt – achieved without the pain of piercing. How did they do it? Gorilla strength glue? Superhuman powers? Neither, actually, but rather a stalwart force present all around us but not usually within us. Fans of AMC’s Breaking Bad will recognize this force as the same one that Walter White used to destroy the evidence police had linking him to methamphetamine production. More mundanely, most of us will recognize it as the molecular reaction that secures photos and to-do lists to our refrigerators. Magnetism. And although magnets are part of our daily lives, they are not always harmless – in fact can exert very powerful and destructive forces on the human body. You may not have heard about it yet, but around the globe there’s a mini magnet problem. Here in the U.S., you might even call it an epidemic, with reports of magnet ingestions in children ages 0 to 17 having increased by approximately tenfold over the last ten years and resulted in hundreds of injuries and at least one known death.  
How can swallowing a magnet be worse than swallowing a marble or a bead? The stick of the issue has to do the remarkable force with which some magnets are attracted to one another – a force that can cause a lot of damage to gastrointestinal tissue when magnets travel through the gut to reunite with one another. Recently, a clinical report in the Lancet described two children (one aged 18 months and the other 8 years) with toy magnet ingestions. Both kids required surgeries  - one for significant intestinal injuries caused by the magnets’ compressive “pull” forces  – which can be up to 1300 Gauss (by comparison, a typical refrigerator magnet exerts only 50 Gauss) – against the bowel wall.
A few months ago, the case of a ten-year old girl who ingested two toy magnets she had used to make her own “tongue piercing” received national news attention. While she avoided the pain of a real tongue piercing, she ended up short her appendix in the process. In Portland this past March, a three-year-old nearly died after swallowing 37 magnets. Inside her abdomen, the balls snapped together to form a ring – and tore at least four holes in her gastrointestinal tract.  
In these instances, the common and concerning characteristic was the ingestion of multiple neodymium (“rare earth”) magnets. These neodymium magnets are a relatively new product – they were invented by General Motors in 1982 – and are five to ten times more powerful than traditional magnets. Still, solitary magnets, even of the neodymium variety, tend to pass through the gut without major incident. But multiple magnets, or magnets paired with other metal objects in the gut, pose a unique problem as, like young lovers, they have an insatiable desire to find and press up against each other. Some describe such magnets as “kissing magnets.” And, like love-struck fools, kissing magnets will do anything to stay together, even, for example, pushing right through the linings of internal organs. If you can picture your anatomy; imagine two different loops of bowel with a magnet in each – straining to reach each other. As the magnets are drawn together they bring the loops of bowel tightly together and create connections or holes between them (known as fistulas or perforations). So, if you have kids, magnets are no toy.
For some time, pediatricians and consumer product safety groups have been warning about the dangers of kissing magnets. In fact, in 2008 the Consumer Product Safety Commission (CPSC) issued new standards for children’s products and toys containing magnets. The standards require that the magnets be secured so that they will not fall out of the toy or become unattached.
Despite this, we’re hearing about more and more kids swallowing magnets – especially neodymium magnets used as “stress relief” desk toys for adults. You may have seen these “Buckyballs” at your local Brookstone or thought of getting a set for your spouse. The magnets are generally sold in groups of 100 to 1000 and are replete with enticing shapes and colors. Although the products are labeled and designed for adults and contain prominent safety warnings, they can easily find their way into the hands and mouths of children. And while youngsters with developmental delay are known to be at higher risk for ingesting objects, many kissing magnet reports – such as a couple of those mentioned above – have occurred in developmentally normal children. As such, the CPSC has just recently filed suit to prevent the sale of Buckyball magnets by retailers.
But, whether such products stay on the market in the long-term or not, parents, caregivers and teachers should be aware of the risks. Thus, here are some helpful tips. First, be aware of the potential complications of magnets – just because they are small doesn’t mean they aren’t capable of exerting a lot of Gauss. Second, for those who might enjoy Buckyballs or related products – keep them at work rather than at home. Third, if you suspect that a child has ingested magnets, get him or her evaluated early – magnets show up quite clearly on x-ray but a child’s symptoms won’t show up until later – when the damage is already done. Medical providers and parents should be sure to report all cases of magnet ingestion. You can visit to report (anonymously if you prefer) injuries related to magnets or other products. Accurate accounting of cases can help with efforts to educate the public and maintain safety in consumer products.

If you still feel a strong need to impress and amaze your friends… forget the spoons, tongue bolts, and Buckyball shapes. I suggest a different type of magnetism – one of personality – not potential perforation. 

Saturday, July 7, 2012

From your Kiwi Correspondent Part VI

Over the last half year, I’ve been scrutinizing health-specific differences between Kiwi and American societies. This has been a bit of a brain-buster and I don’t feel that, to borrow a Kiwi phrase, I’ve got it “properly done and dusted.” Just when I was getting discouraged, however, I found something about health in New Zealand that’s clearly superior to back home – the Kiwis have healthier honey!

Specifically, I’m referring to manuka honey produced by bees collecting nectar from the manuka bush (Leptospermum scoparium). This bush, which is quite plentiful throughout New Zealand, is rather ordinary looking – something like what you might expect if you crossed an azalea with rosemary. But, similar to the mold of penicillin, the manuka bush has surprising properties hidden behind its mundane appearance. Before arriving in New Zealand, I’d heard about manuka honey, but (being naturally skeptical about “natural” treatments with unnaturally ambitious claims) I’d quickly set it aside in the “I’ll research that later” bucket. It wasn’t until a couple parents of pediatric burn patients asked me whether I recommended manuka honey as a topical treatment that I actually began that research.

When I did, I first confirmed what I already knew – that for centuries, people have utilized all types of honey for therapeutic purposes. In fact, before antibiotics were developed, honey was a common dressing for infected or non-healing wounds. But, and this was news to me, starting around about 170 years ago when the European honeybee was introduced to New Zealand (interestingly, the native New Zealand bees did not forage from the manuka bush), Kiwis began to notice that honey made from the nectar of the manuka was distinct. First of all, it was darker and richer in color and second it did not taste very good – which is why many combs of manuka honey were tossed away as useless.

Later, folks noticed a third difference – manuka honey used for medicinal purposes seemed to work better than other honey varieties. So, starting several decades ago, researchers began to investigate what makes manuka honey different. In the early 1980’s, Peter C. Molan, a biochemist at The University of Waikato in New Zealand, conducted a simple yet elegant experiment that illustrated the antibacterial activity of manuka honey. He added the enzyme catalase (present in human saliva, blood, and other tissues) to two different types of honey – traditional clover honey and manuka honey. In doing so, he disabled the hydrogen peroxide in both honeys – an important step, as up to that point, scientists credited hydrogen peroxide alone with giving honey its antibacterial properties. In Molan’s experiment, the peroxide was nullified and (as predicted) the clover honey stopped killing bacteria while the manuka honey’s antibacterial activity was unaffected.

This discovery sent Molan and others on a 25-year quest to discover the biochemical ingredient in manuka that provides this non-peroxidase antiseptic action. Ultimately, a team from Germany stumbled across the answer – a substance called methylglyoxal. Meanwhile, back in New Zealand, Molan established the world’s first Honey Research Unit and unearthed many other honey secrets. Fast-forward to 2012, and Molan has compiled compelling evidence that honey is a lot more than Winnie the Pooh’s cure for a rumbly tumbly. “The only reason for being a bee,” Pooh once said, “is to make honey, and the only reason for making honey is so I can eat it.” Molan would disagree. Based on work from his laboratory and others, Molan ascribes the following therapeutic attributes to honey… (Below is a summary of published and unpublished work.)

• Honey stimulates white blood cells’ immune response
• Honey has pre-emptive antioxidant activity – it can stop potentially cell-damaging free radicals from forming.
• Honey removes pus and dead tissue from wounds.
• Manuka honey has these benefits as well unique antibacterial activity that is more persistent in its interaction with wound bacteria.

Additional purveyance of the literature demonstrates in vitro evidence of manuka honey’s unique action against methicillin-resistant staph aureus (MRSA). A study out of Wales by Jenkins and Cooper (Journal of Antimicrobial Chemotherapy, December 2011) found that not only does manuka honey effectively kill MRSA at low concentrations (6% weight/volume) on agar but also that it down regulates the gene (mecR1) thought to be responsible for the germ’s resistant properties. Furthermore, the investigators found in microarray analysis that a combination therapy of oxacillin and sub-inhibitory concentrations of manuka honey showed significant synergistic effects against MRSA. This, then, raises the possibility that cephalosporins combined with topical manuka honey might be a viable strategy for treating skin MRSA infections.

So, if you haven’t already, you are likely to hear more about the medicinal uses of honey, in particular, manuka honey. The FDA has now approved manuka honey (in wound dressings) and there surely are marketers out there salivating over taglines. But before you put manuka on the honey-do list, there are some not-so-sweet caveats and they start with the cost. At one Bay Area natural food store, one would need to spend $23.98 for 8.75 ounces of high-end manuka honey. And, such honey is only a tad cheaper here in the source land. Then, there is the variability in therapeutic activity. Honeybees haven’t yet agreed to be standardized and the potency of their honey differs on a batch-to-batch basis. There are rating systems in use, but they are not fully reliable.

Still, honey is good stuff and may be useful from head (an proven treatment for hair loss) to toe (foot ulcer dressings). And while it’s clear that manuka honey is special honey, the question is, at this point, is manuka worth the money?

To find out whether manuka could live up to expectations, I visited Dr. Peter C. Molan, the founder of the Honey Research Unit at the University of Waikato and the world’s foremost expert on the medicinal qualities of honey.

I sat with Molan in his 60’s era lab, as graduate students finished up experiments around us. Molan is an oak of a man – tall and sturdy with sharp blue eyes – but warm and generous with his time and thoughts.

“Honey took over my life,” he explained, while his students worked on separating milk caseins. “I used to do other things; it all started out as a hobby. Now I’ve been studying it for forty years.” And in those forty years, Molan has become influential and ardent in his beliefs about the medicinal benefits of honey.

Molan’s passion is based both on science and personal experience. Scientifically, Molan points to the molecular makeup and antibacterial activity of all honey as well as the specific non-peroxidase properties of manuka honey. He also explains the physiologic benefits of manuka honey as anti-inflammatory and anti-oxidant  – including the inhibition of phagocytosis in wounds, especially burns. Personally, Molan calls upon the examples of friends, family, and strangers to whom he’s recommended honey over the years and the stories they’ve brought back to him. For example, Molan’s wife used manuka honey to treat a severe scald burn and one of his friends has successfully tempered his sour stomach by having a spoonful of honey every night before his wine. 

But, there is melancholy in Molan when he speaks about manuka – he laments the reluctance of the medical world to buy into therapeutic honey. “Evidence based medicine – everyone says they support it – but in reality they only buy into something they have a rationale for. ” Even in New Zealand, manuka honey is not considered a frontline treatment for wounds by the district health boards – due primarily to cost considerations (the exception being Molan’s home district of Waikato.) Another frustration for Molan is the commercialization of the manuka honey market – in particular the manipulation of rating systems and widespread disingenuous marketing. For example, says Molan, there is now honey being sold as “Active Manuka Honey,” but the “activity” the seller is referring to is the antibacterial activity (due to hydrogen peroxide) that is present in all honey, not the non-peroxide type of antibacterial activity that is unique to manuka honey.

When I ask Molan the critical question – is manuka honey worth the money – he hesitates for a moment. “If you look at the total cost,” he responds, “which means taking into account the time to healing, and thus the total number of dressings needed and the cost of the staff time and facilities – there is a huge saving to be made by using manuka honey if it is used in a ‘best practice’ method.”

Molan is certainly the world expert on this topic, but he also has a bit of an insular view as well as a potential conflict of interest (which he readily admits) as the owner of patents on honey, including on a manuka honey impregnated wound dressing. So, he may not be completely seeing the comb for the bees.

Here then, is the bottom line on what I have concluded about honey, and in particular manuka honey.

*Honey, any honey, might be beneficial for simple sunburns, superficial burns, heartburn-like sour stomach, and cold symptoms.

*The level of scientific proof on these benefits is mixed, although the risk of use is probably pretty low – although it is still prudent to follow the advice of the American Academy of Pediatrics and avoid feeding honey (any raw honey) to children under the age of one due to the small risk of contracting botulism.

*For open wounds and severe burns, manuka honey is almost certainly superior to regular honey – but if patients are buying it over-the-counter, it will be both expensive and fraught with the potential for misinterpretation of activity. Also, be aware, as a Kiwi plastic surgeon told me, that honey applied to open wounds may sting quite a bit.

*Gamma irradiated manuka wound dressings hold promise, especially for pressure wounds and complicated burns that are not healing with standard treatment and dressings (like hydrocolloid or silver-impregnated dressings.) In this regard, the American market is still evolving.

So, there you go, as crystal clear as a manuka mud bath. Indeed, if the therapeutic use of honey interests you (or your patients), it appears you will just have to stay tuned to see how both the science and the business sort themselves out. Until then, as Pooh says “Oh yes, I'm rumbly in my tumbly. Time for something sweet.”

Saturday, May 26, 2012

Notes from New Zealand; Green Prescriptions

I recently received this media statement from the Kiwi Health Minister, promoting the green prescription program. This can be the most important prescription a doctor writes for their patient...

"Many keen for green prescribing

The benefit to patients from following doctors’ orders for regular exercise is highlighted in a publication launched today by Health Minister Tony Ryall.
“Last year GPs and practice nurses issued 32,028 people with a Green Prescription to become more physically active, an increase of 5,868 people since 2008. Over 80 per cent of GPs in the country have issued Green Prescriptions.

The internationally recognised Green Prescriptions are a health professional’s written advice to encourage and support patients to exercise regularly as part of a total health plan. The main activities prescribed are walking, swimming and gym exercises.

“The top three reasons people are given a Green Prescription are weight problems, high blood pressure and risk of stroke or diabetes.

“A survey this year shows 73 per cent of people noticed improvements in their health six to eight months after receiving their Green Prescription.

“The online publication tells 10 patient stories - each one showing how regular exercise has had significant benefits in the person’s life.

“It also includes a story from our own Olympic great Sir Peter Snell who describes regular physical exercise as the closest we can get to immortality – and after reading the patient stories it’s easy to understand his enthusiasm.

“Since receiving his Green Prescription, Northland man Andrew Riwhi-Moiha has lost 22 kilograms, reduced his blood pressure and no longer needs to take as much diabetes medication.

Health Minister Tony Ryall says the National Government’s Green Prescription initiative is getting more New Zealanders active and significantly improving their health.
The patient stories can be read or watched on the Ministry website.

Wednesday, May 2, 2012

From your Kiwi Correspondent Part V

Here in New Zealand, I often reflect on October 2010. You may recall that month; the fall colors were black and orange and the season was flush with fearful beards and late-inning “torture.” During those pennant-winning weeks, the cauldron of Giants baseball fever hovered between bubble and froth and our community had cohesion of purpose unlike I’d seen before.
So why is it that half-a-world away (where virtually no one knows the difference between a slider and a curveball) I’m consistently reminded of the 2010 World Champs? Well, it’s because the fervour of fall ’10 is replicated daily in New Zealand but for a much different sport: rugby. 

New Zealand has been a rugby nation since shortly after its incorporation into the Crown territories in the early19th century. The British, you see, were intent on avoiding the opulent mentality that plagued prior empires, and so chose a formidable and stoic sport to promote throughout their colonies. I don’t know how successful this tactic was elsewhere, but in New Zealand the game – and its paradigm – took root.. According to Dr. Robin McConnell, in his profile Inside the All Blacks, rugby “shapes New Zealand social history and everyday life .” Case in point -- it’s been five months since the New Zealand national team won the Rugby World Cup on home turf, yet the All Blacks remain ubiquitous. Flags, some homemade, fly from car antennas and balconies, babies don All Black onesies, and bottles of the nation’s top selling beer (Steinlager) declare “All Blacks…25 Years of Unconditional Support.” Looking for front-page news? Any snippet  about a present or former All Blacks player will do. Did you know that the legendary Michael Jones is helping to bring a Carl’s Jr. franchise to New Zealand?

The All Blacks are a national team and rugby a national sport in New Zealand – and we really have nothing comparable in the U.S., especially in terms of unity of loyalty. Given size and diversity differences between the two countries, this may not seem a fair comparison but it nonetheless raises the question of whether this shared passion for, and culture of, rugby pervades Kiwi life beyond the pitch? And in particular, does it help make Kiwis happier and healthier?

If you ask my wife, rugby is defined as a sport played by short men wearing too short shorts around gigantic thighs. But to others, it is defined by discipline, masculinity and stoicism. It is the type of sport in which a player (true story) might insist on playing most of a match with one testicle hanging torn from his scrotum. Stories like this are common and lead one to believe that the stoicism of Kiwis is unparalleled – an observation that finds some support in medical studies on pain tolerance. It could be that rugby plays a role in the Kiwi approach to death and dying [which is?]– one that, anecdotally at least, is more accepting than that of many other countries. Additionally, the national morale may be boosted by shared enthusiasm over rugby, which, in turn, can benefit the collective welfare. Indeed if you were to ask psychologist Jonathan Haidt, author of The Righteous Mind, Kiwi rugby culture might represent a classic case of sacredness of the group - “People who worship the same idol can trust one another, work as a team and prevail over less cohesive groups.” 
But some argue that any such benefits are greatly overwhelmed by rugby’s culture of rowdiness, drunkenness and intolerance. In fact, just as there are Kiwis who live for rugby, there are those who detest it. One blogger, in a piece entitled “NZ Rugby Morally Bereft,” writes that rugby “promotes machocism, alcoholism, violence, sexism and colonialism. Rugby has also created a crippling crisis in our health sector.” There is certainly truth to the first statement – the only rugby match I’ve ever attended hosted a highly intoxicated crowd, and I won’t even attempt to describe the experience of visiting a stadium urinal. But while injuries are common, I can’t believe that they are a crippling crisis. Rugby may have a higher injury rate than many other sports, and concussions (especially under-reported concussions)  are of particular concern, but the rates of devastating injuries such as spinal cord injury are actually not that high. A review of nationwide injury claims related to rugby from 1999-2007 reports an average of 743 a year, most of them limb and soft-tissue injuries, with a rather (given the nature of health expenses) modest yearly cost of $5.3 million

One of the few academics that has closely studied and written about the cultural and societal effects of Kiwi rugby is Brendan Hokowhitu, an associate dean at University of Otago. He shares a rather bleak assessment of the health effects of the sport. “I wouldn't say there is anything historically at least positive about New Zealand rugby culture and health,” he wrote. “Rugby was very much part of the establishment and was as such quite oppressive of women and alterity  [cultural freedom] in general.”

So the All Blacks culture does have a black side. But, to reiterate, the cohesiveness of the culture certainly has positive effects regarding national identity and group mentality. New Zealanders consistently score highly in international surveys of happiness and a nationwide social survey of 8,000 Kiwis found very high levels of people feeling like they “belong to New Zealand.” Another survey, of about 6,000, conducted by psychologist Marc Wilson of Victoria University of Wellington, found that Kiwi respondents with stronger identification to rugby reported being happier, more optimistic and having higher self-esteem. The beneficial effects of happiness on health are both obvious and well documented, and should not be underestimated. I wonder if the rugby in rugby culture could be replaced with a group activity with fewer downsides? Could a less dangerous and less rambunctious diversion replace rugby? Golf is popular here – so perhaps the All Greens might substitute. When it comes to group identity, however, such a change is much easier to talk about than to make. It’s a bit like asking a Giants fan to take up an L.A. Dodger habit.

Thursday, April 19, 2012

From your Kiwi Correspondent Part IV

For a week after arriving in New Zealand, Holden, my three-year old son, was truly out-of-sorts. He was consistently cranky, refused to walk the city sidewalks, and frequently directed abusive behaviour towards his sister and the hotel furnishings. Disturbed, we convened a family summit on how to make him right. Holden suggested “bad guy” toys and his sister proposed gummy worms, but ultimately we settled on the parental preference: pharmaceuticals. My wife, based on prior experience, was concerned that Holden had an ear infection and I was concerned both about waking up at four in the morning and also about lugging a 30-pound child to and from the immigration office to complete visa paperwork. So, we agreed on a compromise – a liquid painkiller called Auralgan for his ears. We decided on this despite the lack of evidence that Holden actually had an ear infection and despite a strong suspicion that moving halfway around the world might have a significant psychological impact on a three-year old. 

I was pleasantly surprised to find a local pharmacy that carried Auralgan but taken aback when the pharmacist began to quiz me about my choice. She was (rightfully) dubious about Holden’s diagnosis, and it wasn’t until I explained that I was a physician (and that I believed in the placebo effect), that she finally relented and allowed me to pay $20 for a small bottle of medication. 

Afterwards, it occurred to me that this interaction would have gone quite differently back home, where purchasing over-the-counter medications usually only elicits questions like “Do you have a Rite Aid Saver Card?” I soon started noticing other differences, as well.  One was quite striking – the absence of drug advertising. No billboards for antacids, no magazine spreads for cholesterol pills, and no wacky television commercials with beavers, Abraham Lincoln and insomnia prescriptions.  At work in the Emergency Department, I noticed a simpler approach to prescriptions – fewer choices, shorter medication lists, fewer narcotics, and for the children: “play therapists” to supplement pain control during procedures. Among all patients, I heard far fewer concerns about the meds they could or could not afford to purchase.
In short, it became clear that medications are less prominent in Kiwi society than in America. Why might that be? Well, first off, while direct to consumer pharmaceutical advertising is legal in both countries, it is uncommon in New Zealand with Kiwi television ad time being reserved for truly important products like Marmite (did you hear that there’s a shortage?) Americans, however, cannot avoid drug ads – U.S. pharmaceutical companies spend over $5 billion a year on them and the typical American will spend around sixteen hours each year watching television snippets for drugs. But, more importantly, the structure and incentives regarding prescription medications are distinct. In the U.S., a premium is put on choice and novelty, at the expense of, well, expense. Sure, there are drastic differences between insurers and public assistance programs, but as a nation we spend a lot of money on prescription drugs – something like $300 billion dollars, which works out to about 13% of all health care costs (the highest rate in the world.) 
In New Zealand, there is a smaller pharmaceutical budget and unified approach under a national formulary. Created in 1993 in response to rapidly rising drug prices, the Pharmaceutical Management Agency (PHARMAC) recognizes that for some common conditions there are a handful of medications that perform equally as well, and some of these are cheaper generic brands. For example, a patient with high cholesterol has many choices of “statins” – Lipitor, Mevacor, Crestor, etc. – that all work through the same molecular mechanism. In circumstances such as this, and with the input from multiple physician-staffed committees and sub-committees, PHARMAC negotiates with the makers of those medications to get the best value for the money. The result is that a narrow list of medications (often just one) becomes the subsidized choices for that condition and when patients are prescribed one of these they pay a nominal pharmacy charge (between $0 and $3). So, rather than seven statins to choose from, the Kiwis have just three (which seems enough to me).

Of course, if a customer truly desired a different statin, he or she could almost surely pay more to get it. Many large U.S. insurers function in a similar manner regarding formulary and non-formulary medications. But because PHARMAC is negotiating for an entire market of 4.5 million people, they have a reasonable chance of striking a good deal with the drug makers. And financially, at least, PHARMAC has been a success. PHARMAC reports saving $4.7 billion since year 2000, whilst increasing its purchasing power threefold since 1993. This success has allowed the organization to expand funding of specialized and novel medications (for exceptional circumstances). An example is the funding of a new blood thinner called dabigatran for the treatment of atrial fibrillation (this by the way may turn out to be a mistake, but more about that another time.) 

Although the cost efficiency is difficult to argue with, not everyone is keen on the PHARMAC model or its decisions. A recent funding switch regarding glucometers for diabetics is an example. Some worry that the newly subsidized glucometer will not work well for everyone and thus not be worth the projected ten million dollars in savings. In the words of one parent to TVNZ…

"We are sheep farmers in a rural area. If I have to call for an ambulance for my daughter the first thing they are going to ask me is what her blood sugar levels are. If I haven't got an accurate meter to tell them, the consequences will be drastic." 

But despite flares like this, in general, it does not seem like having fewer pharmaceutical choices bothers the average Kiwi. I asked an Auckland pharmacist if her customers seemed happy with the medication choices they had. “Well, sure they do,” she replied, “but they don’t have much of a choice about that, now do they?” And I must admit that, as a physician, it is sometimes rather nice to have a short and sweet list of prescribing options. This approach seems to lessen the risk of gratuitous medication prescribing and there is less emphasis on pharmaceuticals – with the Kiwi perception of health being, if you will, less drugged out.
This is not to say that one approach or perception is necessarily superior to the other – indeed the Kiwi approach would probably not be possible without the American one. Pharmaceutical companies need markets for new drugs, after all, and we all benefit from them staying in the business of making lifesaving treatments such as vaccines, insulin and antibiotics. 

So, you may be wondering, did those eardrops help little Holden? We’ll never know the answer. Ultimately, his mom and I demurred and went with bad guy toys and gummy worms instead. And I am happy to report that this worked quite well. Could it be that those who haven’t been fully indoctrinated into the “pill for every problem” lifestyle might be onto something? Maybe we can all do with a little more “play therapy.”

Monday, March 19, 2012

From your Kiwi Correspondent Part III

Imagine that you’ve driven your car off the road and into a Eucalyptus tree and busted up your ankle. During the subsequent ambulance ride, what thoughts might pop into your head?

“Thank goodness no one else was hurt.”
What in the heck were those possums doing?”
“I’ve never liked Eucalyptus trees.”
“How in the world am I going to pay my medical bill?”

A Marin County resident could conceivably have some, or all, of these thoughts. But here in New Zealand, at least one of these notions would be quite unusual. And no, it’s not the one about possums – they are as plentiful as sheep around these parts. Rather, it is the bit about medical costs. You see in New Zealand, accident and injury-related medical care is fully compensated – regardless of insurance or fault. More about that soon, but first, for those who may have missed my last column, a quick catch-up…I’m in the midst of a six-month stay in Auckland, grappling with how Kiwi perceptions of health and wellness differ from American ones. Now, I recognize (disclaimer alert!) that perceptions of health are diverse and that this endeavor hazards broad generalizations. Perhaps my query is as unanswerable as the age-old “nature versus nurture debate.” Nonetheless, there are identifiable differences in geography, culture and statute that would seem to shape how health is perceived in these two countries.

Let’s return to the example of medical care for the wounded. We all know that some injured patients in the U.S. just cannot pay for healthcare, but that eventually (probably in an ER) they are likely to receive treatment anyway.  Everyone else picks up the tab for this through higher insurance premiums and other cost shifting. Of course, in some cases, it’s not that simple. For example, some uninsured patients might be able to pay their medical bills, but risk bankruptcy in the process.

Injuries are handled quite differently in New Zealand under a system called the Accident Compensation Corporation (ACC). First enacted in 1974 and revised many times since then, the ACC hinges on a crucial trade off – free medical care for injuries (regardless of fault) for all citizens and non-citizens alike in return for higher taxes and, importantly, forfeiture of the right to sue for damages.

Here’s how it works… let’s say an American tourist tries Zorbing – a “sport” in which you are rolled down a hill inside a large plastic sphere that looks like an overfed yoga ball. This American then suffers an unscheduled tumble into the path of a campervan. When he is taken to the Accident and Emergency (aka, the ER), the physician will complete an ACC form, verifying that he has sustained a valid injury and that his medical care will be paid for by the ACC. In return, said American cannot sue the Zorbing company, the driver of the campervan, the physician who treats him, or anyone else. He can, however, take solace in the fact that if any of these parties has acted negligently, they may be criminally prosecuted (as opposed to sued).

This system, it seems to me, helps mitigate fear. I’ve noticed this on many levels but it’s most pronounced with the children. There is a tool bench at my son’s preschool and it’s equipped with actual carpenter-worthy hammers, screwdrivers, nails, and Philips heads for actual building projects (take that Bob the Builder!) The kids go shoeless much of the day – they take their kicks off when they arrive at school and  (maybe) put them back on when they leave (of course the lack of poisonous snakes or spiders helps make this a safer proposition than it might be elsewhere). Trampolines and “bouncing pillows” are common, as are the injuries they cause. Kids play rugby, without helmets, which does not seem like a good idea to me. For young adults, the fearlessness manifests in adventure sports such as white water river sledging (river rafting on a boogie board). But it’s in professional life where diminished fear may make the most substantive difference. Kiwis I’ve spoken to are amazed at the thought of staying in a bum job just because it offers good health coverage. An American physician who spent a decade in New Zealand put it this way, “we [Americans] have to buy protection against the health care system that could make us poor. They have freedom from that fear.” Of course, these are perceptions, not hard facts, and fear (especially the type that softly itches at you each day) is a hard thing to measure objectively.

There are certainly downsides to the ACC scheme – a 2% earner’s levy (income tax) which caps at approximately $2000/year/person as well as the potential for both fraud and reckless behavior. As to the latter, Kiwis are certainly adventurous, but not particularly reckless. The roads are safe and well-policed and fatal motor vehicle accidents rare (396 in all of 2008) and less frequent (per vehicle) than in the U.S.  And, while I see far more unhelmeted cyclists here than at home, I also note far fewer folks texting while behind the wheel. Any freedom that an individual might feel to act carelessly seems to be more than counterbalanced by a public health incentive (financial and otherwise) to prevent severe injuries. The only truly reckless activity I’ve heard about is as a coed rugby squad called the Nude Blacks (if that isn’t explanation enough, there are YouTube videos.)

“Normal fear protects us; abnormal fear paralyses us,” so wrote Marin Luther King Jr. True enough, but what is “normal,” and how much is it defined by the social contract of the society in which we live?

It would seem that American society creates certain “abnormal” fears that may not exist in New Zealand. And this might help explain differences between the two peoples in regard to how they view their health. It does not, however, explain what the heck those possums were doing in the the road.

From your Kiwi Correspondent Part II

Soon after arriving in Auckland for a six-month sojourn, I picked up the local paper (The New Zealand Herald) and was surprised to read this from columnist Paul Holmes…  

“Now, my health. It seems to have been a matter of speculation since last Sunday and I don't want you to think I'm on my last legs, so here's what happened…It was all to do with damage done by radiotherapy during the first days of the prostate cancer treatment a decade ago…
In mid January, my bladder shut down. That is to say, its ability to drain itself was blocked by an enlarged prostate strangling the urethra. So I could not pee. Meantime the bladder continued to swell and believe me, this must be one of the most painful conditions in the world. The immediate solution is to insert a catheter to drain the bladder, a moment of immense relief. And you walk round with the bag attached to your leg until they can do what I call a re-bore.
Sounds weird and unpleasant I know, but it's happened to me now a few times over the years and you kind of get used to it.
But it's what can happen after prostate cancer. Like any cancer, it is a nasty, unpredictable thing, and its effects can hang round for years and change your life forever.”

I read this, and then re-read it to be sure. Did a prominent newspaperman just describe a personal and painful medical condition in a public and matter of fact manner? Why, yes, he had. And it occurred to me that one would be hard pressed to read such an account in the mainstream American media. This in turn had me asking, are we Americans a bit squeamish about our health? You certainly don’t see much about bladder blockage on the opinion page of the New York Times, but it’s not just that. Rightly or wrongly, many Americans would prefer to keep matters of reproductive and mental health (among others) in a black box. For instance, I would wager that there are precious few (if any) U.S. neighborhoods that feature billboards urging men to…“Give it a shot, there’s a 1,000,001 reasons to be a donor.” Sperm donor, that is. Such billboards are abundant here in Auckland. You also are unlikely to find your local paper running a feature on male cosmetic surgery, entitled “Beauty and the bloke.”

What you will find in the U.S. is a large number of people addicted to prescription narcotics. But while the U.S. is facing an unprecedented epidemic of prescription drug mis-use and abuse (prescription narcotic-related deaths numbered 14,800 in year 2008), what there is of Kiwi statistics on the topic suggests it is nary a problem here. The most recent published report I could find documents 92 prescription drug abuse deaths in the whole of New Zealand for the entire 2001-2002 time period. Why the difference? From my observations so far, and from what people tell me, it seems that Kiwis with chronic pain are better able to manage their pain with a regiment of Tylenol and the occasional happy hour. Or it could have something to do with the fact that hydrocodone is not available here in New Zealand. When I asked a Kiwi physician about this drug, she replied “No, haven’t heard of it. Related to morphine is it?”
But, there could be more to it. Limited investigation, some of it quite dated, suggests that there are cultural differences between Americans and Kiwis when it comes to pain perception and disability. A comparison study (Carron et al, 1984) of one hundred some chronic low back pain in each country indicated that “despite nearly similar between-country reports of pain frequency and intensity, the U.S. patients, both at pre- and post-testing, reported greater emotional and behavioral disruption as a correlate of their pain.” A more recent qualitative study (Dean et al, 2011) of rural Kiwi workers with low back pain observed a return-to-work ethic in spite of pain driven by a “‘can do’ attitude to work, managing [low back pain] within the context of having job control and flexible work practices.”

Am I saying that Americans are prudes and wimps when it comes to health? No, I have no such authority and we Americans would have no such monopoly. Besides, who’s to say that health squeamishness is a detrimental trait? I’m just pondering why there appears to be a health-minded difference between New Zealanders and Americans?

Over the next half dozen or so columns, I will explore various angles and nuances of this question – incorporating stories and observations from New Zealand and relating them, when applicable, back to the U.S. system. In the process, I hope not to, as a Kiwi might say, “Make you a whole lot of knackered,” which translates loosely to “bore you to sleep.”

To start this endeavor off, we must address size and population density. New Zealand is a country roughly half the size California with only 4.5 million people. By way of comparison, the San Francisco Bay Area registers just about this many all by itself.

As Don, a rather sharp-tongued tour guide told us… “Four-point-five million, that is not so many that you couldn’t fit them all in your backyard and still have room for a game of golf.” To put this in perspective, topics make it into The New Zealand Herald that would surely be drowned out by other news in the U.S. For instance, it’s front section news that a woman “abducted” a newborn baby from its mother – after asking and receiving permission to take the baby for a stroll. Articles also appear regularly about hospital food and clothing. The sticky stripe socks are, by the way, considered a smashing success! 

New Zealand, however, does have a high profile epidemic in progress. A nationwide surge of late night chip (French fry) cooking–induced house fires (1,005 of them in 2008-2009) prompted the Kiwis to launch a public service campaign called “Don’t drink and fry.” If you have a moment, pull up the TV ads on YouTube, they are richly entertaining. Somewhat remarkably, this campaign seems to have contributed to a nearly 40% decrease in frying fires in 2009-2010.

So size matters – both in the nature of what’s news and what demands public health attention. But, there is more to this topic of comparative squeamishness than that. Next time, I will explore the role of fear – in particular the fear of losing health coverage or not having it all – and how this impacts a culture’s approach to health and wellness.