DrRich at The Covert Rationing Blog hosts grand rounds this week. He gives very detailed abstracts and although he tongue-in-cheek suggests you read this quickly. To do so you’ll have to be a really fast reader. I particularly enjoyed the article by Amy Berman about her experiences with the health care system as a breast cancer patient. Enjoy.
Reading The Rotarian magazine this month I was mesmerized reading the article Living with Landmines, and especially about anti-personnel mines. Landmines are essentially broken down into two types. One are mines to blow up vehicles, in particular to blow up tanks. The other type is to injure and maim people, in theory enemy soldiers, but in reality anyone who steps on or triggers the mines, often years after their intended use.
In war it is just not possible to retrieve mines that have been laid as battlegrounds can be fluid and evacuations of positions can be necessarily rapid and unplanned. Mines from many long past wars remain in the ground and a danger to residents of these countries. As a consequence of this worldwide an estimated 15,000-20,000 people (UN data) are killed or maimed by mines annually. Many anti-personnel mines are triggered by pressure of as little as 11 pounds, less than the weight of a toddler running across the ground. In 2008 over 60% of casualties form landmines were civilians, and of these about a third were children.
I am not a dove, anti-military, or totally naïve about the facts of war. I was in the Army for 7 years, admittedly as a physician, but have a general understanding that in war people get hurt and killed, and that there are incredibly effective tools to accomplish these tasks in warfare today. I also consider myself a proud American. I understand there are times when military force is needed to maintain our republic. Given this, I am not proud that the United States is one of the 37 countries that have not signed the Ottawa Treaty (156 countries have signed the treaty) that bars the use, production, stockpiling or production of anti-personnel mines. We join countries including China, Iran, Russia and Pakistan in the minority of countries not agreeing to the Ottawa Treaty terms. These are not countries with whom I like believe the US shares values on human rights and the value of life. Admittedly the US abides with most of the provisions of the treaty. Still we continue to stockpile approximately 10 million mines. There may be some military explanation for this position, but as far as I’m concerned it is lame.
Mine clearing remains a huge worldwide problem. There are an estimated 10 million land mines in both Cambodia and Afghanistan, and apathy to the issue is one of the major obstacles to faster progress in the search for and removal of mines. Princess Diana was a vocal supporter of anti-mine programs, and is credited with posthumous influence in getting the Ottawa Treaty signed. Her death left supporters of mine eradication without a glamorous supporter. In a bizarre comment a prominent candidate for congress from New Mexico recently discussed using land mines to protect the US – Mexico border. Thankfully he was not elected, but just the idea that an educated US citizen running for public office would of placing anti-personnel mines on US land is so horrifying that this issues clearly lacks the level of public awareness it deserves.
If enough American citizens express outrage this could be easily corrected. Let’s stop the apathy and demand that our government do the right thing. I find it impossible to believe that our country can justify the use of anti-personnel mines in warfare today. The US has not used landmines since 1991. If we are not considering use they there is no reason not to sign the treaty and get rid of the stockpiles. For a haunting video photo collection check out this You Tube.
Contact your congressman today, talk about this with your friends, and make it clear that you consider the US not getting rid of our anti-personnel mines as unacceptable. I just sent letters to Senators Murray, Maria Cantwell and Congressman Adam Smith. You can easily do this too.
Let me know what you think by leaving a comment.
No surprises here that energy drinks and children are not a good mix. Enjoy this first guest post by Maria Rainer as she discusses energy drinks side effects and children in a review of an article from Pediatrics.
The Adverse Effects of Energy Drinks on Children: A Pediatrics Review
by Maria Rainier
As any parent can observe, the caffeine from a single can of soda often results in a significant and noticeable energy spike when given to children. If this is the case, the effects of energy drinks on young people must be incredibly powerful – maybe even detrimental.
This is no longer supposition. Sara M. Seifert and a cohort of doctors have recently published a study whose objective was to review the effects of energy drink consumption among children, adolescents, and young adults while identifying the consequences. The researchers found that energy drinks have no therapeutic effects, that 30-50% of adolescents and young adults consume them regularly, and that 46% of the 5448 U.S. caffeine overdoses in 2007 were reported for individuals under the age of 19. The study has been made available to the public due to its high significance and its potential to inform parents about the severe health problems that can result from energy drink consumption.
The Effects of Common Energy Drink Ingredients
Based on a review of research conducted on the subject of children and energy drink consumption, as well as energy drink manufacturer websites, Seifert and her colleagues identified a list of common additives and their medical effects. The main offenders are caffeine, guarana, taurine, l-carnitine, ginseng, and yohimbine. Together, they have a frightening set of negative side effects that occur when they are ingested in excessive amounts. Unfortunately, excessive ingestion is almost a certainty when children consume energy drinks that are meant for adults. The effects of caffeine alone can include tachycardia, arrhythmia, nervousness, abdominal pain, vomiting, hallucinations, and even more serious problems like seizures, cerebral edema, and paralysis. Ginseng toxicity presents with headache, vertigo, mania, rashes, insomnia, irritability, and a host of other symptoms that can seriously impede a child’s ability to function normally. Yohimbine also causes tachycardia and, in some cases, death.
Other Dangers
Energy drinks, unlike sports drinks or fortified water beverages, are not meant to hydrate the body. Their purpose is to rapidly increase energy and performance, but that typically means a rapid increase in heart and respiratory rates as well as blood pressure. This can be a result of the additives in energy drinks, but it can also be traced to the large amounts of sugar and the interaction of so many potentially dangerous ingredients. Another unseen threat is dehydration. Rather than replenishing fluids, energy drinks deplete them, increasing thirst and potentially causing excessive consumption of the products in question.
Energy Drinks and Children
Because children are so much smaller than adults, the amount of caffeine that they can safely consume is significantly diminished. According to pediatric nutritionist Tara Harwood in an ABC interview, adults should consume less than 400 mg of caffeine daily while children should adhere to a limit of less than a quarter of that amount. Unfortunately, many energy drinks are nonspecific about the amount of caffeine they contain, so it can be difficult for parents to identify acceptable drinks for their children. The best practice is to avoid them entirely, especially since some drinks have limits set on them by their own manufacturers. Redline, for example, has a package warning indicating that it is not to be sold to anyone under the age of 18. Despite purported self-regulation, energy drinks are categorized by the FDA as nutritional supplements, so their manufacturers are not legally required to adhere to caffeine regulation or package documentation specifications.
The recommendations from the doctors who completed the study are that pediatricians stay apprised of the situation, that communities promote risk awareness, and that long-term research objectives be made to identify safe dosage limits, the effects of chronic use, and the effects in at-risk populations.
Bio: Maria Rainier is a freelance writer and blog junkie. She is currently a resident blogger at First in Education where she writes about education, online degrees, and what it takes to succeed as a student taking online programs remotely from home. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.
Insensible water loss should probably be called immeasurable water loss. As a resident we all learned to order I&O (Intake and output of fluids) and daily weights as a way to monitor the change from day to day in our hospitalized patients fluid status. Rapid weight gain, especially combined with a higher fluid intake than urine output was often a clue that we needed to watch for problems associated with fluid retention like congestive heart failure, pulmonary edema, and edema. We also learned in med school, and this was apparent in clinical care of patients, that everyone loses fluids constantly in ways other than urine formation and output. Some of these ways are measurable using not-too-inconvenient or impractical means. We could measure or roughly estimate fluid lose in emesis, diarrhea, blood loss, drainage of body fluids from various drains placed, and still we knew that these cannot account for all of the water a patient ingests or has infused.
The water loss of patients that is not able to be measured in any practical way is commonly referred to as insensible water loss, or fluid loss. Although there are numerous means of insensible water loss, respiration is by far the largest in patients who are not sweating profusely. Each breath of air we inhale usually contains less than 100% humidity. The air is humidified in the nose, sinuses, and upper airways so that the air that reaches the lungs, and is subsequently exhaled is essentially 100% humidity at body temperature. The carrying capacity of water for air goes up rapidly as the body temperature goes up, so respiratory loss of patients with fever is higher than the respiratory loss of afebrile patients.
Sweating is another means of insensitive water loss. Sweating obviously varies with ambient temperature, body temperature, physical activity and other variables. We often see patients who are ill in the hospital or at home have profuse diaphoresis and the water loss from this may be significant.
What physicians call “third spacing” of fluids is a shift of body fluids into an area neither inside cells nor in the vascular system. Inflamed tissues can swell leading to a shift of significant amounts of body fluid into areas where the fluid does not support the vascular system. In some cases this can be rapid and in large volume, leading to shock and vascular collapse. An example is acute pancreatitis where large amounts of edema can occur rapidly in the inflamed tissues in the abdomen and retroperitoneum. Another situation is when the small bowel stops functioning to move the fluid contents through to the colon where fluids are generally reabsorbed. In this situation, called an ileus, large amounts of fluid can accumulate in the gut, another third space where fluid can be lost to the vascular system. These situations can require significant IV fluids to maintain blood pressure, renal perfusion, urine output, and to support the patient’s metabolism.
For the kidneys to function well they require water to excrete as urine. The kidneys of a healthy person can concentrate urine only to a certain degree, after which they cannot both continue to function and preserve water needed in the body. With inadequate fluid intake to replace urine loss, insensitive fluid losses, and fluid functionally lost in third space accumulation, a person becomes unable to maintain blood pressure and renal perfusion at a level that supports kidney glomerular filtration. When this happens the kidneys can acutely fail, in a condition called acute tubular necrosis. If this is brief and good fluid resuscitation occurs, the kidneys can recover. If prolonged renal failure from acute tubular necrosis can be permanent.
A need for water that is not obvious is that the requirement for water actually increases with increased nutrition. The waste products of the burning of calories, especially high protein foods, requires water for the needed urine output. Although tiny amounts of water are actually produced as end products of the burning of carbohydrate foodstuffs, in general increased caloric intake requires a modest increase in water intake for homeostasis.
In summary of the fluid taken in by oral route or from IV fluid infusion either accumulates in the body or is lost from the body in one way or another. We refer to the losses as sensible, i.e. through ways we can measure, or insensible through ways like respiration, water loss in the stool, and sweating. Functional loss of fluids into body areas outside the vascular system and outside the body’s cells is called third space losses. Although this is fluid that eventually may become absorbed into the vascular system and utilized, it is functionally lost for use to maintain normal bodily functions.
So when you are looking at whether you are taking in enough water the best single indicator is your urine output. If you are not voiding at least 2-3 times a day in moderate amounts, you need to drink more. If our patients are not putting out 30-50 ml of urine an hour, we want to try to figure out why not, and try to take measures to remedy the situation.
In case you had no noticed I’ve started a fan page on Facebook for DrPullen.com and you can follow this blog there, and I’ll post other relevant but generally briefer info there, so become a fan and don’t miss a post from this medical blog or other cool stuff. Just click on the facebook icon on the right side of this blog or on the hyper-link above.
I stumbled across a beautiful story while I was looking for a topic for this weekend’s post when I came across an interesting interview in the NY Times Tara Parker-Pope section about the author of a book I’m reading right now for my book club, Unbroken: A World War II Story of Survival Resilience and Redemption by Laura Hillenbrand. I was amazed to learn than Ms. Hildenbrand has a severe form of chronic fatigue syndrome, and is housebound. She writes as an occupation, but also as a way to live outside her body. The article touches briefly on her love story too. She has now written about two of the great runners of the 1930′s, Seabiscuit and Louis Zamperini. I sometimes feel reading is almost like going on vacation, or living in another situation. Right now life as a WWII Japanese POW is one I’m glad I missed. See a couple of prior articles about chronic fatigue syndrome called:
XMRV and CFS – Hope Ahead of Evidence
XMRV and Chronic Fatigue Syndrome, The Drama Continues
I believe there is some unifying underlying cause of CFS that is yet to be convincingly discovered, be it XMRV or something else.
Enjoy the Article:
February 4, 2011, 2:15 PM
An Author Escapes From Chronic Fatigue Syndrome
Laura Hillenbrand, the best-selling author of “Seabiscuit: An American Legend,” is known for her exuberant storytelling and dynamic characters. Her newest book, “Unbroken: A World War II Story of Survival, Resilience and Redemption,” is a riveting tale of the life of an athlete and war hero, Louis Zamperini.
Ms. Hillenbrand’s ability to transport her readers to another time and place is all the more remarkable in light of the fact that she is largely homebound, debilitated by chronic fatigue syndrome, or C.F.S. read more
A scotoma is a strange name for a common problem. A scotoma, pleural is scotomata, is an area of diminished or absent vision that is surrounded by an area of normal or near normal vision. It comes from the Greek work for darkness. Patients with scotomata usually comment that there is a part of the vision in one eye that is blind or abnormal.
When patients present to the office with these complaints, it’s not difficult to recognize that they have a scotoma. The trick is to figure out what’s causing them, and what can be done. Causes can range from simple transient problems to really serious vision threatening diseases. A scotoma can be an early sign of major problems like MS, or can be symptom so retinal diseases.
By far the most common cause of scotomata is migraine. In migraine patients many times neurologic symptoms precede the headache. One of the most common symptoms is scintillating scotomata. These are described as flashing yellowish lights in the vision. Usually they resolve about the time the migraine headache begins. This is called migraine with aura, or classic migraine. When this history is given by the patient it’s pretty simple to understand and explain the scotomata, and treatment is simply treatment for the migraine. If the migraines are frequent patients may benefit from preventative therapy, and if infrequent abortive treatment to use early in the course of migraine is usually indicated. The scotomata can actually be somewhat helpful in making it clear to the patient that they are starting a migraine, and lead them to early treatment to prevent the severe migraine.
Here is an simulated You Tube of a Scintillating Scotoma as an aura to a migraine headache:
Other scotomata can be causes by more serious problems. Anything that causes a part of the retina to not function can cause a loss of part of the visual field. Examples are macular degeneration, blockage of a blood vessel in the retina, and demyelinating diseases like multiple sclerosis. Tunnel vision is a type of scotomata where the central vision is preserved and the peripheral vision is lost. Reinitis pigmentosa, a congenital cause of vision loss can present with a peripheral ring scotoma. Patients with diabetes who have laser treatment of abnormal blood vessel growth can have scotomata in the areas where the retinal vessels have been coagulated.
If you suspect a scotoma you can close the unaffected eye, and fix your vision on something to hold the eye still. Then move an object like the eraser on a pencil, or your thumb around the field of vision. You should notice the loss of vision when the object enters the scotoma.
If you suspect a scotoma you should definitely seek medical attention to find out what’s wrong and to see how to manage the problem. Most of the time unless the problem is scintillating scotomata with migraine, an ophthalmology consultation is going to be needed. Your opthalmologist is likely to do formal visual field testing, a dilated fundoscopic exam, and possibly brain and optic nerve imaging with MRI to try to determine the cause. Sometimes more sophisticated ways to look at the circulation of the eye is needed.
If nothing else today you’ve learned a cool new word that is also used in by psychologists to describe a mental blind spot as in the the inability to see something that is obvious because of a psychological block.
I recently wrote an article for Live Right – Live Well, an online magazine about anti-microbial soap and anti-microbial gels as hand sanitizers. The bottom line is that alcohol kills bacteria and viruses better than anti-microbial soaps that contain triclosan. Use soap and water to get dirt and particulate matter off your hands. Use alcohol containing hand sanitizing gels to kill germs. Here is the original article.
The Best Way to Kill Germs
With cold and flu season in full swing, you may be wondering if washing with antibacterial soaps and using hand sanitizers are better ways to keep germs at bay than washing with regular soap. I see sick patients every day, so I’m attentive to the latest research and have my own ways of preventing the spread of bacteria and viruses. Here’s my take:
Regular vs. Antibacterial Soap
First let’s look at the question of regular versus antibacterial soap. Most antibacterial soaps contain triclosan, which kills not only bacteria, but fungi as well. However, most of the illnesses we try to prevent — the common cold, influenza, etc. — are caused by viruses. There is little evidence to show that antibacterial soaps are more helpful in killing germs than plain soap. In fact, a 2003 study sponsored by the National Institutes of Health showed no difference in bacterial counts when washing with triclosan-containing antibacterial soap was compared to washing with regular soap.
Hand-sanitizing Gels
Gels are becoming increasingly popular. They’re used when washing is inconvenient or unavailable, and sometimes they’re used to replace washing altogether. Unlike the use of antibacterial soaps, there’s considerable evidence that using alcohol-containing gels to sanitize hands kills both bacteria and viruses more effectively than washing.
So to stay healthy this cold and flu season, keep the following in mind:
Dr. Edward Pullen is a certified family physician in Puyallup, Wash. In addition to practicing full-service family medicine since 1983, he blogs at DrPullen.com.
Thanks for reading this medical blog. Leave a comment and contribute to the discussion.
After nearly 25 years of nutrition counseling, I think I ‘m starting to get the hang of it! Here is my view of the clients I meet with. Which one are you?
Busybodies – Busybodies eat for one reason and one reason only—to fuel their activity. These individuals eat as a means to the end and often eat on the run when their stomach starts to growl. Busybodies are lucky in some ways, because their diet is not influenced by their emotions and food is not overemphasized for them. However, it can be hard to pay attention to the nutritional quality of the foods that are eaten when you’re just grabbing at whatever is most convenient. In addition, these people have a tendency to go for too long of a period of time without eating and can suffer medical repercussions because of this.
Feelers – Feelers are usually very emotional, and not all of these emotions are negative in nature. These people are often capable of extreme happiness and joy, as well as the negative connotations that are attached to “emotional” people. When most people hear the term “emotional eater,” they tend to conjure up images of sad people eating too much ice cream as a way of escaping pain. What about the relaxed, happy person who eats too much on vacation as a way of celebrating? This, too, is emotional eating. The good news is that feelers are often capable of enjoying food more than other people, if they approach eating in a healthy manner. The bad news is that these people are prone to eating too much. They enter into an endless cycle of eating too much, then promising to do better the next day, and then berating themselves when they don’t.
Independents – Independents live in the moment and don’t really care about following rules or keeping up with the status quo. Independent eaters are the most likely of all of the personality types to overeat during holidays or other celebrations. They often are very good at coming up with new and inventive ways to make food taste good, a quality that is useful in altering recipes to make them more healthful. Unfortunately, independents aren’t always good at controlling their cravings and may “splurge” a bit too often.
Improvers – Improvers always strive to better themselves and push their loved ones to do the same. The desire to succeed is the first step in living a healthy lifestyle, and this personality type has no problem with this. Improvers have a tendency to take nutrition advice and research findings at face value, and at times, they are quite gullible. Improvers have a tendency to cut healthy foods from their diet, if the newest fad diet recommends doing so.
Organizers – Organizers like to plan their upcoming weekend by mid-week and always have an itinerary planned for every vacation. Highly organized people like to think of themselves as being well prepared for every possibility. Organizers are exceptionally good at planning their menus and at making certain to have a healthy lunch packed the night before. The problem is that highly organized people have a tendency to be inflexible and may beat themselves up emotionally for eating a food that they deem to be “bad.”
Nutrition matters and so does realizing some of our negative and positive lifestyle patterns! Send an e-mail to Brooke at NutritionAuthority.com to obtain your FREE password to take the on-site “Lifestyle Patterns Quiz‟ under the “nutrition‟ tab. Every little tidbit of information we learn about ourselves helps us to better see the “real‟ YOU in the mirror, better enabling us to maintain healthier living.
This is the question on everyone’s mind and the question I am asked numerous times every day. Each time I think about who’s asking the question, and decide on which answer to give. Is this a question that begs the same answer as, “How are you today?” If so should I answer with the equivalent of, “Fine thanks, and you?” Is this a factual question from a concerned person? If so the answer is that she feels quite well, but is in the early stages of recurrence of her ovarian cancer. We’re hoping that starting chemotherapy now will lead to her continuing to do well. Thanks for asking.” Is this a close friend or family member who wants to have a conversation about how she is doing physically, emotionally, and spiritually? If so I often don’t have the emotional energy or time to give them the information and love they deserve, so sometimes I beg off. Other times I appreciate the opportunity to talk. It mostly depends on circumstances.
First we just got back from a great vacation. We left for Maine on my birthday, Sept 2, and spent a terrific week with my family at the camp on McGrath Pond in Oakland, ME where I spent every summer of my childhood. We ate lobster, got to know my nieces much better, and just enjoyed ourselves. We also visited close college friends and their girls and new son in law at Little Sebago Lake after picking up our daughter from the Portland airport. We mostly slept through the rain effects a hurricane, and swam every day. My Mom and Dad are doing pretty well, and it was a great visit.
After a week, we left for Rome, and on arrival after a red-eye flight from Portland, ME through Philidelphia and on to Rome. We dropped our bags at a hotel in town and walked to the Coliseum. It was daunting to walk where the ancient Romans walked, and our sweat may be mingled with that of Caesar, as it was very warm that afternoon. That night we visited the Spanish Steps in the city lights, and had our first of many great Italian meals. We had our first 3 hour-four course meal. I could get used to that style of eating. A good bottle of red and lots of time to talk make a great meal really memorable. The next day off to Tuscany, a week at Borgo di Vagli, a 14th century hamlet far from anything, and a week of day trips to Florence, Assisi, Cortona, the Adriatic Sea, and Montepulciano. Our trip ended with a day back in Rome, a whirlwind tour of the Vatican Museum and St. Peter’s Basilica, and a 20 hour, one stop flight home. Overall it was a trip to remember. Here are some of photos to get a flavor.
Borgo di Vagli
Looking Down into the Collis
Spanish Steps at Night
The last week has been a whirlwind of catching up, getting ready for Kay to start chemotherapy again, and preparing emotionally to start the fight again.
So, “How’s Kay.” The real answer is complicated. Physically she is still feeling quite well. She got through the initial phase of her PARP inhibitor study without any complications. She still feels strong, is exercising regularly, and feels about 95%+ in terms of health. She has been more fatigued for the last month or so, and feels slightly full in the upper abdomen, where we suspect the remnants of her cancer are hiding, although no imaging has found it yet. Spiritually she stays strong. She feels and needs continued prayer support. Emotionally the situation is much more complicated. She finds it hard to dive back into chemotherapy when she feels so good. Last time we were desperate to start chemo, because we could literally see and she could feel the cancer destroying her. Chemo was clearly her friend at that time, and she could honestly call the port on her chest wall, “My life sustaining port.” Now we are treating a cancer that is only making itself known by a number we see on paper as her CA-125, and by this vague fatigue. The number today was 58, continuing its upward march, and the reason to start the chemo. She really is dreading losing the sense of normalcy that we have enjoyed for the last 9-10 months. She fears being on chemotherapy the rest of her life and never feeling fully strong and healthy again. She asks me how long until I’ll become the, “Finder of things again.” Chemo causes her to lose just a tiny bit of her sharpness for remembering where things are and she seems to misplace more stuff. The joke is that chemo knocks out part of the second X chromosome that somehow allows women to see things other than at eye level. We’ve had our share of tears over this anticipation of loss. Kay has had trouble sleeping, and I could sleep all the time. Still overall we are emotionally holding up pretty well, and feel ready for the battle.
This week Kay had her first infusion of the first course of her chemotherapy for the cancer recurrence. We did our old hypnotherapy regimen in the morning and the infusion went uneventfully. Sometimes I think her judgment is impaired, as she is now out for a walk with friends, just 90 minutes after arriving back home. She thinks fresh air is going to do her well. I suggested rest, but … This chemotherapy regimen is a much more time intensive schedule than last time. She will get Carboplatin, Gemcitabine, and the PARP inhibitor on day 1, the PARP inhibitor on day 4, Gemcitabine and the PARP inhibitor on day 8, and the PARP inhibitor on day 11 of each 21 day cycle. She dreads spending four half-days getting chemo every 3 weeks. Still, Kay being Kay, she has a mother-daughter road trip in her plans for the first “off week,” and they are going somewhere fun together. She is hoping, probably realistically, not to lose her hair this time, though we just looked at some pretty cute photos of Kay without hair. We are both praying for great success in suppressing and possibly eliminating the cancer this time. We know that cure is not likely at all, but miracles happen. Now that’s more than most people expect when they ask, “How’s Kay?”
Check out Musings of a Dinosaur for the weekly Grand Rounds this week. This solo Family Physician uses a baseball theme to outline the best recent healthcare posts. DrPullen.com has the honor of throwing out the first pitch.
