Simple scientific questions require simple scientific answers; doctors want unequivocal guidance to their practice so that they do not fumble in the dark. But it is easier to ask questions than to answer them, as two papers published in the same week in the New England Journal of Medicine and the Journal of the American Medical Association attest.
The question asked by the two papers was the optimum level of oxygenation in the blood of pre-term infants. In the past it was rather naively supposed that if oxygen were necessary, then more of it must be better; but premature infants who were exposed to high levels of oxygen developed a condition known as retinopathy of prematurity, often leaving them blind or severely impaired visually.
The two trials, one from Britain, Australia and New Zealand, and the other from the United States, Canada, Argentina, Finland, Germany and Israel, sought to establish whether a higher or lower level of oxygen saturation of the blood was better for infants born very prematurely. The results were different, if not quite diametrically opposed.
The first trial found that babies treated so that their blood oxygen saturation was higher had a lower death rate at 36 weeks than those treated so that their levels were lower. 15.9 per cent in the high saturation group died compared with 23.1 per cent in the lower. You would have to treat 14 babies with the high oxygen saturation to save life more than treating them at the lower level.
Does practice really make perfect? Does it even lead to improvement? One feels instinctively that it should, that the more experience a physician has, the better for the patient. Much of the skill of diagnosis is pattern-recognition rather than complex intellectual detection, and it follows that the longer a physician has been at it, the quicker he will recognize what is wrong with his patients. He has experience of more cases than younger doctors to guide him.
But the practice of medicine is more than mere diagnosis. It often requires manual dexterity as well, and the ability to assimilate new information as advances are made. These may decline rather than improve with age. Too young a doctor is inexperienced; too old a doctor is past it.
A recent paper, whose first author comes from the Orwellianly named Department of Veterans’ Affairs Center for Health Equity Research and Promotion, examined the relationship between the years of an obstetrician’s experience and the rate of complications the women under his care experienced during childbirth. The authors examined the records of 6,705,311 deliveries by 5,175 obstetricians in Florida and New York. No one, I think, would criticize the authors for the smallness of their sample.
They examined the rate of serious complications such as infection, haemorrhage, thrombosis, and tear during or after delivery, divided by obstetrician according to his number of years of post-training experience. Reassuringly, and perhaps not surprisingly, experience reduced the number of such complications decade after decade. The rate of complications was 15 percent in the first ten years after residency; it declined by about 2 percent to 13 percent in the first decade thereafter, by about 1 percent in the subsequent decade to 12 percent, and by half a percent in the next. In other words, improvement continued, but less quickly as the obstetricians became more experienced; the authors appear not to have continued their study to the age at which the rate of complications started to rise again (if indeed there is such an age).
Having recently returned from Madrid, I confess that I saw little evidence of the Mediterranean diet being consumed there (apart, that is, from the red wine): though, of course, Madrid is in the middle of the peninsula, far from the Mediterranean. Perhaps things are different on the coast. Nevertheless, at over 80 years, Spain has one of the highest life expectancies in the world.
Is this because of the much-vaunted Mediterranean diet? Spanish research recently reported in the New England Journal of Medicine provides some – but not very much – support for the healthiness of that diet.
The researchers divided 7000 people aged between 55 and 80 at risk of heart attack or stroke because they smoked or had type 2 diabetes into three dietary groups. One group (the control) was given dietary advice concerning what they should eat; the two other two groups were cajoled by intensive training sessions into eating a Mediterranean diet, supplemented respectively by extra olive oil or nuts, supplied to them free of charge.
They were then followed up for nearly five years, to find which group suffered from the most (or the least) heart attacks and strokes. The authors, of whom there were 18, concluded:
Among persons at high cardiovascular risk, a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events.
The authors found that the diets reduced the risk of the subjects suffering a heart attack or stroke by about 30 percent. Put another way, 3 cardiovascular events were prevented by the diet per thousand patient years. You could put it yet another way, though the authors chose not to do so: 100 people would have to have stuck to the diet for 10 years for three of them to avoid a stroke or a heart attack. This result was statistically significant, which is to say that it was unlikely to have come about by chance alone, but was it significant in any other way?
The unexamined life, said Socrates, is not worth living; but sometimes I wonder whether the too-closely examined life is not worth living either, for examination uncovers dilemmas where none existed before.
Two articles in a recent edition of the New England Journal of Medicine ask the question of whether employers should, or have the right to, refuse to employ smokers, as increasing numbers do in the 21 states that permit such discrimination against them.
As is by now no secret, smokers are more likely to suffer from many types of illness than non-smokers, and their health insurance is therefore considerably more expensive than that of non-smokers. They impose costs on their employers which weigh upon all workers, smokers or not. (The authors do not take into account that smokers not only contribute to taxes by their habit but, by dying early, reduce pension costs.)
The authors worry that refusal to hire smokers would be discriminatory against people of lower social class, since it is among the latter that smoking is most prevalent. I am not sure that this is right: the majority of people in all social classes now do not smoke, while people who apply for jobs at any particular level are likely to be of the same social class. Except in the case where there is only one applicant for a job, then, it is likely that there will always be an applicant of any given social class who does not smoke. The discrimination remains against smokers, therefore, and not by proxy against members of lower social class.
Twenty-seven years ago I found what seemed to be the only functioning storm-drain in Tanzania, in East Africa, and fell down it, severely injuring a knee in the process. The journey to the mission hospital in the back of a pick-up truck over sixty miles of rutted laterite road was one of the more agonising experiences of my life.
I had an arthroscopy when I returned home several weeks later — I could not even hobble until then — and the orthopaedic surgeon told me that unless I did physical therapy every day for a very long time it was inevitable that I should be crippled by arthritis within twenty years.
It was equally inevitable that I would not do physical therapy every day for a long time; and here I am, twenty-seven years later, without so much as a twinge from my knee. My faith in the predictive powers of orthopaedic surgeons has been somewhat dented.
That was why I read with interest a paper in a recent edition of the New England Journal of Medicine comparing physical therapy with surgery for meniscal tears in the knees of people with osteoarthritis. To cut a long story short, there was no difference in outcome, an important finding, since 465,000 people undergo operations for precisely this situation every year in the United States alone.
Actually, the uselessness of operation had been established before — the uselessness from the patients’ point of view, that is. Two previous trials had compared real with sham operations, and with no operations at all, and found no difference in the outcome two years later. One might suppose that, in the light of these findings, the 465,000 operations still performed annually constituted something of a scandal.
The clinical trial reported in the NEJM is, like all such trials, not definitive. The follow-up period was only 6 months, relatively few patients were recruited to it, and some patients initially allocated to physical therapy had an operation nonetheless for reasons that are not entirely clear. Moreover, the trial is only that of operation versus physical therapy; strictly speaking, there should also be a comparison with patients who had no treatment at all.
Week 6 of my second 13 week season; low carb diet and more exercise, tracking my weight, blood glucose, and body fat. You can follow me at my 13 Weeks Facebook page for daily updates, and you can join Fitocracy (free!) and follow my daily exercise, and maybe even start tracking your own.
So let’s just end the suspense right away: yes, I am feeling a lot better this week.
At one point or another, the draft of last week’s column started with the line “Okay, ‘despair’ may be a little strong…”. I cut it because as I thought about it, I realized despair was the right word. Look it up and we find “Noun: The complete loss or absence of hope. Verb: Lose or be without hope: ‘to despair of ever knowing’” (via Google.) That’s exactly what I was fighting against — the feeling that there was nothing to be done, that there was no real hope. That’s the real enemy of any attempt to change, or to do anything extended really — that moment of no hope, when you don’t see the end in sight. It’s not just diets, either — it happens to me in writing, when I hit the point at which I think “oh, this is awful, no one will want this.”
That’s why I started this on the basis of a 13 week “season” — it was long enough to see some real changes, short enough to be bearable. Even so, about the fifth and sixth weeks of the first season, I’d reached the point where I was wondering if it was going to really do any good.
So look at the results this week: my 7-day average weight is down 3 pounds, my 7-day average blood sugar is down 16 points. What happened? I don’t know for sure, but I can tell you one thing I did differently, based on a lot of suggestions from others who’ve done the low carb thing. I broke training. I got out of the no carbs jail for a couple days. I had my ice cream, and I had some congee (zhou, Asian rice porridge). I didn’t go real far off the overall diet except for violating the carb rules, and based on calories I was actualy doing fine.
So now I’m back on the low-carb diet. What did I learn?
First, yes, you can break the diet for a day or a few days and get back on. What’s more, for me at least, if you do it with rice and ice cream, you don’t get sick like I did after Thanksgiving.
Second, your body can get used to anything. In weight training, they tell you to change routines fairly often if you want to keep making gains. The trick is to watch what happens. I broke the rules a little bit, up to maybe 100g of carbs one day, and didn’t have my blood sugar go nuts, didn’t gain back lots of weight. (Right now, I’m on a little bit of a bounce, but I’m basically up to where I was complaining about not being able to break in the downward direction.)
And third — there’s a new-ish idea in the nutrition world: orthorexia. It means an unhealthy fixation on a healthy diet. Maybe, just maybe, an occasional 4 oz cup of ice cream (26g carbs) is good for you.
|Date||7 day Weight||7 day Glucose||7 day Bodyfat||Sum Fitocracy Points||Weekly Fitocracy Points|
|Δ since 2-1||-2.64||-14.57||-3.00%||N/A||N/A|
For a long time doctors were subject to contradictory imperatives with regard to AIDS. On the one hand they were enjoined to treat it as they would treat any other disease, without animadversion on the way in which the patient had caught it; on the other hand they had, before testing for the presence of HIV, to seek special permission of the patient and to ensure that he or she had had counselling before the test was taken – quite unlike the testing for any other disease, syphilis for example. So AIDS was at the same time a disease like any other and also in a completely different category from all other diseases.
It cannot be said that pre-test counseling is universally popular among patients. There was an Australian clinic that famously offered the test with “guaranteed no counseling” and it did not lack for clients. For quite a number of years, however, HIV-test counselling has provided a living for the kind of people who like to hover around the edges of human catastrophe.
However, the recommendation by the United States Preventive Services Task Force (USPSTF), reported in an article in a recent edition of the New England Journal of Medicine, that henceforth the screening of adults for HIV infection should be routine will, if adopted, put paid to all such pre-test counseling. One cannot counsel scores or hundreds of millions of people.
Seven years ago the USPSTF came to a different conclusion on the question of screening for HIV, believing that the benefits were insufficient to recommend it. Since then, however, evidence has accumulated that treating people early in the course of their infection not only prolongs their life but reduces spread of the infection.
For some reason that I have never quite fathomed, immunization against infectious diseases has from its very inception in Jenner’s time been one of the most viscerally feared and bitterly opposed of all medical techniques. Perhaps people felt that to immunize was to interfere sacrilegiously with the course of nature, and that people, especially children, had the duty to die of infectious diseases just as Nature “intended.” Perhaps they felt that, if it worked, it would allow the survival of the unfittest. At any rate, few medical procedures have been as persistently, minutely, and fervently examined for harmful effects as immunization has.
In general, the results have been disappointing for those who wished to show that immunization was invariably followed by Nature’s retribution, particularly in the neurological sphere. Scare has succeeded scare without ever being confirmed, though those who hold to the anti-immunization faith refuse to abandon it. Now, at last, there seems to be evidence of a genuine association between a certain type of immunization and a neurological condition.
That association is that between the immunization of children with an anti-influenza virus and narcolepsy, a condition characterized by chronic, excessive daytime sleepiness and a tendency to cataplexy, that is to say a loss of muscular tone triggered by strong emotion. It was first observed in Finland and Sweden; subsequent studies in other European countries and in Canada failed to find an association, but a further study, this time in England, and reported in the British Medical Journal, confirmed that the Finnish and Swedish findings.
In October 2009, children at risk of pulmonary complications during a pandemic of influenza were immunized against it with a vaccine against the causative virus. Most of the children immunized suffered from asthma (interestingly, one of the theories to account for the recent rise in the proportion of children suffering from asthma and other allergic conditions is that, having been immunized against all the common childhood infectious diseases, their immune systems have not developed as Nature “intended”).
Week 4 of my second 13 week season; low carb diet and more exercise, tracking my weight, blood glucose, and body fat. You can follow me at my 13 Weeks Facebook page for daily updates, and you can join Fitocracy and follow my daily exercise.
I haven’t published new charts recently, so I think it’s time. Here’s the first one, my weight.
OH, NOOOOOES! My weight is going up! I’m a failure! Eeeek!
Well, maybe not, although certainly if all I was tracking were my weight I’d be mildly hysterical. (And I have to admit I get qualms looking at it this time, even though I swear I’m not primarily interested in my weight. But 50 years of dieting doesn’t go away quickly.)
The thing is, that weight in general isn’t really our primary interest. I asked whether weight itself was a primary concern over at my Facebook page, and got a lot of different interesting answers; almost none of them included weight. “Feel better”, “better health”, “more attractive”, “sexier” all did show up. Now a couple of people with bad knees and backs did say weight in itself was a problem, but for most people it’s more a symptom of something else that troubles them. Certainly so with me — blood sugar, health in general, and as I realized during the first 13 weeks, simply feeling ugly and disgusting were my major issues.
What people use as a proxy for all this is weight, of course, and especially with daily weighings, this can be very disheartening.
What’s worse, I’ve been at least as diligent with the diet — in the last full week, according to LostIt!, I’ve been 8200 kcals in deficit, with an average of about 9g carbs a day net of fiber. Being diligent with the diet isn’t so awful, but still I’d sure like a chocolate bar or a plate of spaghetti sometimes. In anything, I’m doing better with the diet plan that in my first 13 weeks.
Add to that I’ve been pretty diligent with the exercise — not every day but at least five days a week (I’ve got more to say about the exercise, below) so I’m lots more active than I was in the first 13 weeks — and probably more than I’ve been in the last 13 years.
But still, I’m actually gaining weight.
I read the article in the New York Times entitled “Taking a Stand for Office Ergonomics” (thanks to the reader who sent it to me):
But a closer look at the accumulating research on sitting reveals something more intriguing, and disturbing: the health hazards of sitting for long stretches are significant even for people who are quite active when they’re not sitting down. That point was reiterated recently in two studies, published in The British Journal of Sports Medicine and in Diabetologia, a journal of the European Association for the Study of Diabetes.
Suppose you stick to a five-times-a-week gym regimen, as I do, and have put in a lifetime of hard cardio exercise, and have a resting heart rate that’s a significant fraction below the norm. That doesn’t inoculate you, apparently, from the perils of sitting.
The research comes more from observing the health results of people’s behavior than from discovering the biological and genetic triggers that may be associated with extended sitting. Still, scientists have determined that after an hour or more of sitting, the production of enzymes that burn fat in the body declines by as much as 90 percent. Extended sitting, they add, slows the body’s metabolism of glucose and lowers the levels of good (HDL) cholesterol in the blood. Those are risk factors toward developing heart disease and Type 2 diabetes.
“The science is still evolving, but we believe that sitting is harmful in itself,” says Dr. Toni Yancey, a professor of health services at the University of California, Los Angeles.
It seems like everything we do these days is harmful. I’m just waiting for the government to demand that all offices come equipped with something like this FitDesk. Don’t get me wrong. I actually have this FitDesk and use it occasionally but you can bet that contrarian that I am, if someone told me to use it, I might just stop. Sitting might be bad for you, but so is a constant barrage of negativity from the media telling you that everything you do is somehow bad for you and then using the information to implement policies that restrict people’s individual choices.
According to an article in The Times of India, researchers from UC Berkley, the University of Rochester, and the Rochester Institute of Tehcnology have discovered that adults with lazy eye respond positively to video game-based treatment. Doctors previously thought the condition, amblyopia, to be untreatable once a patient reached maturity.
Now, however, things have changed:
In collaboration with Daphne Bavelier, PhD, of the University of Rochester and Jessica Bayliss, PhD, of Rochester Institute of Technology, Levi has been working on a new approach using video games for visual training.
The goal is develop a new type of action game that will combine the fun and excitement of video games while targeting the visual skills needed to improve visual performance in the weaker eye.
Initial clinical studies suggest that video games may improve several aspects of visual performance. In one recent study, this approach to perceptual learning led to recovery of three-dimensional stereo vision in adults with established amblyopia–even after decades without normal binocular vision.
And games not only assist patients. Doctors, too, have noted the advantage of using them for their medical training:
A reported 98 percent of medical students surveyed at the University of Michigan and University of Wisconsin-Madison liked the idea of using technology to enhance their medical education, according to a study published online in BMC Medical Education.
For example, a virtual environment could help medical students learn how to interview a patient or run a patient clinic. In the survey, 80 percent of students said computer games can have an educational value. (University of Michigan, 2010.)
Take note. Now, whenever some sanctimonious fool tells you to shut off the Wii or Xbox or Playstation, tell them: “I can’t. Doctor’s orders.”