Tuesday, February 28, 2012

ADHD kids - What society thinks we do

Best Singer I Know Personally

I once thought of myself as a very good singer...then I met Lucas.

His voice amazed me, and his quirky demeanor led to our rapidly formed friendship. 

A few years ago he auditioned for American Idol.  He didn't even make it past the first audition with the screening judges.
(which is one of the reasons I've never auditioned.  If he didn't make it - I have no chance.)

I thought that since the world didn't get a chance to enjoy his voice on American Idol - I would give him a little shout out here.

SO - Here's a video he submitted to be part of "Magic Valley's Got Talent."


If you want to hear more - Here's his website: Lucas Henry

Saturday, February 25, 2012

The Politics of Diagnosis – A Glimpse

Why diagnose?

In most of medicine – people go to doctors when something is wrong.  Something about them is not “normal” and they want to know what it is, what caused it, and how to fix it.

SO – as “diagnosticians,” doctors over the centuries have observed patients.  We find a group of symptoms that usually seem to go together.  We call that a disease.  We try to find a cause, we try to find a cure, and the purpose behind all of it is to make sick people better, and keep healthy people from getting sick.

We don’t always know what causes disease.  We don’t always have a way to fix it.  But we try.  Sometimes we can diagnose it, fix the problem, and it’s gone forever.  Sometimes we can’t fix the problem, but we can treat the symptoms to make life better.  Sometimes we don’t know the cause of the disease, but we have a lot of educated guesses about stuff that might be causing it – so we try to prevent that. 

And sometimes we really have no idea - so we try everything in the book because we hate the thought of being powerless and being able to do nothing – so we try everything.

Mental illness diagnosis is the same.  Sometimes we know exactly what caused a disease.  We know how to treat it, and it’s fixed.  Often we don’t know the cause, but we know the symptoms, and we know what helps.  

So why does diagnosis matter?  Usually the answer is “Diagnosis dictates Treatment.”  All treatment research is based on diagnosis, so if you don’t know what a person has – there is no research as to how you should treat it.

Unfortunately – “type of treatment” is not always the answer but rather “ability to treat.”  

Example: After Vietnam and Korea, the VA ignored vets with PTSD.  Why???  The diagnosis didn’t exist yet.  Some Physicians saw the symptoms, some wanted to treat them, but they couldn’t.  These soldiers were in the VA system, and as a VA Psychiatrist, you could only treat veterans for a listed number of problems…PTSD as a diagnosis did not exist..so they had to be released to “deal with it.”  The doctor could not get paid, and the patient could not be treated because it was not a diagnosable condition.

Sometimes diagnosis matters because diagnosis opens the door to services, to insurance, to disability, to what the patient needs.

Example: Parents of an autistic child can often find great educational assistance and community programs for their child.  But what if the child doesn’t have “Autism” but rather has “Asperger’s Disorder,” “Childhood Disintegrative Disorder” or “Pervasive Developmental Disorder.”  These children have similar symptoms, but they have no access because the funding and programs are for “autism.”

How do we get help for those kids?  Do we pass new funding bills through Congress to fund every diagnosis?  Do we talk with city councils, schools, and donors to get money for each different disorder?  Or do we just call them all "Autistic" and we’re done?

Next year the new edition of the “Diagnostic Manual” for psychiatry comes out.  The plan is to eliminate all these different names and diagnoses -  and call them all “Autism Spectrum Disorders.”

It could be that they should have been called that in the first place.  They really are one disease with different levels of severity.  Or it could be that we just have a bunch of kids that need help and since nothing else has worked, we’re just going to change the label so they can all get assistance.

Is this a slippery slope?  Are we “fudging the numbers”, or changing the labels to fit programs, and insurance plans?

That’s a discussion for another day (or the comments section).

Wednesday, February 22, 2012

Antidepressants - Publication Bias

In 2008 the FDA decided to look at all the published data about antidepressants.  They found that 51 studies had been published.  They looked back at their own records about how many studies had been done on antidepressants, and found the number to be much higher - 74.

Where were the missing 23 studies?  (Those 23 studies had 3,449 patients who went through full drug trials, and their results were never published)

Why weren't they published?

The FDA looked at the 51 studies that were published and the looked at the publication itself to see how the drugs were represented.  The graph below shows the result of that analysis:

(White Boxes above the red line are studies that showed that the drug worked.  Black Boxes below the red line are studies that had negative or mixed results)

Basically this says that out of the 51 studies, 48 showed that the drug had a positive effect.  That's 94% of all studies showing a positive result!
There were only 3 studies that showed that the drug had negative or mixed results. 
THEN, the FDA looked all 74 the trials that had been done, without looking at the publications.  They analyzed the data themselves to see what they would find.  Were the unpublished studies mostly positive, or negative?  Were all the published studies portrayed accurately?
The graph below is their result when they FDA analyzed the data from all 74 trials themselves:

Yep.  It turns out that 36 studies showed mixed or negative results.  Only 38 studies were positive.  The positive results dropped from 94% to 51%
All 23 missing studies showed negative or mixed results.  13 of the published studies were misrepresented in the publication to make them look like they had a positive result.

What does this say about "double-blinded, placebo controlled, randomized control trials?"  What does is it matter that the studies are done correctly if they are misrepresented or selectively published?

This is only part of the depressing news about anti-depressants.  More to come...

Source: New England Journal of Medicine Article

Monday, February 20, 2012

Quotes from all 44 U.S. Presidents

George Washington
"Few men have virtue to withstand the highest bidder."

John Adams
“The Revolution was effected before the War commenced. The Revolution was in the minds and hearts of the people; a change in their religious sentiments of their duties and obligations. This radical change in the principles, opinions, sentiments, and affections of the people, was the real American Revolution.”

Thomas Jefferson
"One man with courage is a majority."

James Madison
“Knowledge will forever govern ignorance; and a people who mean to be their own governors must arm themselves with the power which knowledge gives.”

James Monroe
“National honor is the national property of the highest value.”

John Quincy Adams
“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”

Andrew Jackson
“Any man worth his salt will stick up for what he believes right, but it takes a slightly better man to acknowledge instantly and without reservation that he is in error”

Martin Van Buren
“It is easier to do a job right than to explain why you didn’t.”

William Henry Harrison
“There is nothing more corrupting, nothing more destructive of the noblest and finest feelings of our nature, than the exercise of unlimited power.”

John Tyler
"Wealth can only be accumulated by the earnings of industry and the savings of frugality."

James K Polk
"Public opinion: May it always perform one of its appropriate offices, by teaching the public functionaries of the State and of the Federal Government, that neither shall assume the exercise of powers entrusted by the Constitution to the other."  

Zachary Taylor
“I have always done my duty. I am ready to die. My only regret is for the friends I leave behind me.”

Millard Fillmore
“May God save the country, for it is evident that the people will not.”

Franklin Pierce
“Frequently the more trifling the subject, the more animated and protracted the discussion.”

James Buchanan
“The test of leadership is not to put greatness into humanity, but to elicit it, for the greatness is already there”

Abraham Lincoln
"Do I not destroy my enemies when I make them my friends?"

Andrew Johnson
"The goal to strive for is a poor government but a rich people."

Ulysses S Grant
"My failures have been errors of judgment, not of intent."

Rutherford B Hayes
"Nothing brings out the lower traits of human nature like office seeking."

James Garfield
“If the power to do hard work is not a skill, it’s the best possible substitute for it.”

Chester A Arthur
“Men may die, but the fabric of our free institutions remains unshaken.”

Grover Cleveland
“A government for the people must depend for its success on the intelligence, the morality, the justice, and the interest of the people themselves.”

Benjamin Harrison
"We Americans have no commission from God to police the world."

William McKinley
“That’s all a man can hope for during his lifetime – to set an example – and when he is dead, to be an inspiration for history.”

Theodore Roosevelt
"Speak softly and carry a big stick."

William Howard Taft
“The world is not going to be saved by legislation.”

Woodrow Wilson
“We are citizens of the world. The tragedy of our times is that we do not know this.”

Warren G Harding
“I have no trouble with my enemies. I can take care of my enemies in a fight. But my friends, my goddamned friends, they’re the ones who keep me walking the floor at nights!”

Calvin Coolidge
“We cannot do everything at once, but we can do something at once.”

Herbert Hoover
"A splendid storehouse of integrity and freedom has been bequeathed to us by our forefathers. In this day of confusion, of peril to liberty, our high duty is to see that this storehouse is not robbed of its contents."

Franklin D Roosevelt
“The only limit to our realization of tomorrow will be our doubts of today.”

Harry S Truman
"You can not stop the spread of an idea by passing a law against it."

Dwight D Eisenhower
"I never saw a pessimistic general win a battle."

John F Kennedy
"And so my fellow Americans, ask not what your country can do for you; ask what you can do for your country."

Lyndon B Johnson
"You ain't learnin' nothin' when you're talkin'."

Richard Nixon
“A man is not finished when he is defeated. He is finished when he quits.”

Gerald Ford
“A government big enough to give you everything you want is a government big enough to take from you everything you have.”

Jimmy Carter
“The best way to enhance freedom in other lands is to demonstrate here that our democratic system is worthy of emulation.”

Ronald Reagan
"We are a nation that has a government—not the other way around. And that makes us special among the nations of the earth."

George Bush
“Any definition of a successful life must include serving others.”

Bill Clinton
"We need a spirit of community, a sense that we are all in this together. If we have no sense of community, the American dream will wither."

George W Bush
“America will never seek a permission slip to defend the security of our people.”

Barack Obama
“No one is exempt from the call to find common ground.”

Saturday, February 18, 2012

Best Oil Change Ever

     After successfully completing many "fix-it" tasks I decided to do something I haven't done in about 10 years - change the oil.  I used to do it with my dad - and it was no big deal.

     I went to the store and bought an oil pan, the filter, 5 quarts of oil, and a funnel. I figured I was good to go. When I used to change it with my dad we also put a huge metal sheet under the oil pan to collect any oil that spilled, and coveralls for me so I wouldn't get dirty.

     I remembered that when I worked with dad we usually didn't spill any oil, and the precautions were unneeded.

     Yes you can feel free to laugh now.

     So - first thing I realized, obviously a mechanic with power tools changed the oil in the van last time, because I had to use a ridiculous amount of torque to get the oil plug loose. When it finally budged, I moved the oil pan underneath it. The plug was on the side of the oil pan, so I moved the oil pan so it would catch the oil if shot out up to 18 inches. I removed the plug the rest of the way, and watched the oil over shoot the pan by at least a foot. I slid the pan back to collect the oil, but I already had a pretty good puddle on the garage floor.
I let the oil drain for about 5 minutes, then put the plug back in and went to loosen the filter. Yeah - couldn't get that undone with a barehand.

     So I put on my leather gloves to get a better grip. As soon as the filter was loose hot oil came spilling out over my glove, and soaked through to my hand.  I knew taking the glove off or wiping off the oil would do no good because all the burning would be done before I could get the glove off - so I just let it burn...OUCH!
(I should let the car sit for more than 15 minutes next time before I change the oil.)

     Anyway, I gingerly removed the filter, and the rest of the oil change went pretty well.  New filter, 5 quarts of oil - and I was good to go.

     Now I needed to dispose of the used oil in the pan. I figured - pour it into the now empty oil containers form the 5 quarts I just put in.

First problem - the funnel tip barely fit into the quart containers I was trying to refill.
Second problem - The quart containers are skinny and tall, and empty, which makes them prone to tip over.

     So - I held the quart container between my feet, secured the funnel in place between my knees, and held an oil pan with 5 quarts of oil in my hands.

     The first quart - no problem
     Second quart- a few drops of oil splashed onto the floor.
     Third quart- I poured too much oil into the funnel at once and it suddenly stopped going down. As I crouched to see why, an air bubble from the quart container escaped up through the funnel and splashed oil up onto my face, glasses, etc...

     I was not amused
     Fourth quart - I was now perturbed and wanted to just get this job over with. I put the quart container between my feet, funnel between the knees, and began to pour the oil. I realized that all the remaining oil would fit in this container, and that I was almost done.  I began pouring faster as I was so anxious to be done.  I then remembered my error from last time - pouring too fast. I quickly stopped pouring and as I did my knees shifted. The funnel slipped off the container and began pouring oil all over my jeans and down my left leg. My instant reaction was to shift back right which then tipped the quart container over so it was pouring oil onto my right shoe.

     I still had the oil pan in my hands, so I could do nothing but stand there and let the oil soak into both feet, running down into my socks and beneath my heels.  I stood there with my eyes clenched shut using every Mormon curse word to describe how much I LOVE CHANGING THE OIL.

     After buying a bag of kitty litter (to soak up the oil), buying a new set of leather gloves, cleaning up myself and clothes with 1/2 a roll of paper towels, and showering, it turned out that I had spent 2 hours and $25 to change my oil by myself. Last time I checked it took 15 minutes at the shop and only cost $20.00.

     Yeah - We'll see if I ever change my oil again. Hope you all had a good laugh.

Wednesday, February 15, 2012

Prologue (to my medical murder mystery)

             Marcus Donovan squeezed his eyes shut so tight that his vision blurred when he opened them again.  His eyes slowly came back into focus, and he stared at the man in the mirror.  When had the bags formed under his eyes? He couldn’t remember. For that matter, he couldn’t remember when the stomach ulcers had developed, or the spare tire around his mid-section, or the gray hairs at his temples.  His eyes were bloodshot, and the alcohol wasn’t helping. 
            He couldn’t go back.  He often pondered now what life might have been like with Rachel.  He imagined what their kids would have looked like.  He tried to imagine himself driving a mini-van with 3 kids in the back.  It was hard to imagine, his life was too different.
            He hadn’t had many regrets in life; he was always working too hard and running too fast to bother with the past.  He knew how long patents lasted, and that thought was paramount.  Once you got one product on the market, you had to start working on the next, or you would fall behind.  Someone else would copy your idea, and then sell it for cheaper than you ever could, to cover costs.  That’s why he had to be smarter than the rest, always a step ahead, and he always had to do everything exactly by the book.  Litigation was rampant in his business, and that was the only way to survive.
            This time was different.  He had made a mistake.  He had been sure everything was going to work.  He had done the research himself, he had developed it himself, and set up the experiments.  Then he had started making promises, a little too early.  His company had already signed government contracts, and already started receiving payment.  The ball was rolling, but the ball was defective.  He had made sure all quality controls were double blind studies so that no one could claim bias or data manipulation.  No one who did the tests could see the results, and vice-versa; no one except him.  He was the gatekeeper, the supposed “control” among all the variables.  He was the only one who could ensure everything was accurate, and therefore he was only one who could manipulate things without getting caught.
            His conscience had finally caught up with him.  Was he going to get fired?  There was really no question there.  Was he going to jail? Probably.  Once he went public the company was through.  They had spent over 5 years on development; the amount invested was now reaching billions.  Yet tomorrow it would all be for naught. 
            Marcus walked into the kitchen and went through his evening ritual.  He pulled out his half empty bottle of Chateau Margaux 1995.  He poured a glass and sniffed once before drinking.  He loved the smell of blackberry and the deep ruby color of his $800 wine.  After finishing the glass he sat in his overstuffed recliner and turned on ESPN.  After a few sips of his wine he began drinking larger and larger glasses till he eventually put his lips to the bottle and downed the rest.  He was sick of the mundane sports highlights and he was finally feeling the alcohol settle on his brain.  He wished the bottle had been full so he were a little more drunk before doing this, but no amount of alcohol could stop the crushing avalanche he was about to unleash.  He pulled his laptop out of the drawer and prepared to send his e-mail to his CEO, shareholders, and six different newspapers.  He felt a tingle on his lips and didn’t think much of it.
            As the computer booted up, he noticed his tongue was starting to go numb.  He put his laptop on the coffee table and went to look in the mirror.  As he walked he felt lightheaded.  His limbs began to give out on him, and he fell to the floor.  He pushed on his temples, trying to relieve the developing headache.  As he thought his head was clearing he suddenly felt his stomach burning.  He felt like he was going to vomit.  He now regretted all the coffee and alcohol.  His stomach ulcer was acting up, and the alcohol was finally getting to him.  He felt nauseated once again, and decided he better get himself to the bathroom before the vomited all over his plush carpet.
            He tried to get up, but his legs were no longer numb, they were paralyzed.  He started becoming nervous, and decided he’d better call out for help.  He tried, but his lips wouldn’t form the words.  He couldn’t even manage enough breath to scream.  This was no stomach ulcer, he realized.  What was going on?  He felt himself shake and convulse a few times, then he was still.  He was still conscious, but could do nothing.  He couldn’t flex a muscle in his body, even his eyes had trouble moving in their sockets.  His mind was reeling.  Had he eaten something he shouldn’t have?  Had he ingested something on accident?  He knew chemistry, he knew poisons, and he started to think through his symptoms, trying to figure out if he was going to recover, or if this was the end. 
            Was it botulism toxin?  No – then I would be limp, not rigid and paralyzed. 
            Tetanus?  He hadn’t felt the back spasms, and he didn’t remember tetanus causing numbness or tingling.  His mind was starting to fade.  He tried with all his might to move any part of his body, but nothing worked.  He felt like he was being buried alive, but in his own body, not a tomb. 
            Then it hit him, tetrodotoxin, the poison found in pufferfish.  He knew the signs and symptoms because he had to review them once a year.  It was work policy; you had to know what was in every lab, and the dangers of each substance.   Tetrodotoxin was used in the lab next door to his. It takes its effect in less than half an hour, but he had been home longer than that.  So he hadn’t been exposed at work.  He hadn’t eaten any pufferfish tonight; he hadn’t even been near seafood.  Where had he… then he saw the empty bottle of wine. 
            Rage began swelling inside him.  They already knew.  They knew that all the results were wrong, that their product didn’t work, and that he was going to tell all. Now he was going to die  for it.  In less than a minute his diaphragm and all breathing muscles would be paralyzed, then his heart.  All he could do, was think. 
            They’ll make millions!  Everyone will want it, and no one will know that it doesn’t work.  His e-mail had not been sent, the evidence was still hidden away.  The world would have no idea they were vulnerable.  No one would know…until it was too late.

Monday, February 13, 2012

Reducing Salt Intake Could Kill You Faster

Everyone knows you should eat less salt...right?  Salt makes you retain water, it increases your blood pressure, it makes you more likely to have a heart attack or stroke...right?

The Mayo Clinic says the average American eats 3.4 grams per day, and should eat <2.3 grams (and <1.5 grams if you have high blood pressure)

Livestrong reiterates this same information, as does the CDC.  The CDC goes on to states that lowering sodium could save thousands of lives annually because there are 400,000 deaths per year attributed to high blood pressure.

They can't all be wrong...right?

The problem is - they are all assuming they understand cause and effect.  They assume that lower sodium decreases blood pressure, and that lowering blood pressure in that way decreases deaths.

Sadly the ACTUAL RESEARCH does not verify their claims or assumptions.

The latest research, published in July 2011 shows something quite interesting.  It shows that as expected, decreasing salt intake can help the healthy American decrease their risk (a little) of dying by a cardiovascular accident.

That's not the interesting part.  Guess what the data show when you look at patients who have high blood pressure or already have heart failure?

If you already have high blood pressure - decreasing salt intake will have no effect whatsoever on your chances of dying by stroke or heart attack.

If you already have heart failure - lowering salt intake will kill you faster.

SO......if this article and research are accurate that means the CDC, Mayo Clinic, Livestrong, and all cardiologists and family docs should be telling you:

Everyone out there reading this who is healthy - decrease your salt.  (yeah, because that's gonna happen)

Everyone who has high blood pressure - don't change your salt intake at all.

Everyone who has heart failure - Don't you dare decrease your salt intake or you're even MORE likely to die of a heart attack or stroke!

I am getting to enjoy reviewing medical research literature more and more.  Each time I go to research conferences I learn more and more about how the conventional wisdom and even medical advice is completely wrong.
If anyone is curious - the source for this information is pretty much the best source there is.  It's almost universally agreed that the Cochrane Database is THE database for information.

Sunday, February 12, 2012

A Mormon President?

This week I read two interesting viewpoints on "Mormons"

The NY Times article

Obviously I have an inherent bias - but I honestly found this article to be very short sighted and immature.  When Mr. Williams said "Mormons see the world, but they don't get it" I wished he could have a mirror.  I believe he is just as deceived and blinded as any Mormon ever was.

Searching the blogosphere I found this response.  It isn't nearly as concise, but at least it seems to take more than a shallow glance at the subject.

Saturday, February 11, 2012

Medications Likely Do You No Good

You might freak out when you realize how likely it is that your medication will do you no good.
There’s a very important term in medicine that is often ignored, it is “Number Needed to Treat.”
It means, how many people have to take the medication for one of them to avoid the bad outcome.

For example – why do people take Lipitor?
 - So they don’t have a heart attack or stroke and then die or become seriously impaired.
What does Lipitor do?
 - It lowers cholesterol
Why lower Cholesterol?
 - To avoid clogging arteries.
Why avoid clogged arteries?
 - To prevent a heart attack or stroke
Why prevent a heart attack or stroke?
 - to prevent death or serious impairment.
How many people have to take Lipitor to prevent one of them from dying or becoming seriously impaired?
 - 500. 

Okay – forget death or impairment, let’s just talk about a heart attack
How many people have to take Lipitor to prevent one of them from having a heart attack?
- 100.  Yeah.  One hundred people have to take Lipitor for 3 years in order to prevent one heart attack.

And Lipitor isn’t the worst drug, not by far.

Zetia is also taken to lower cholesterol – but it’s NNT is so high it isn’t shown to prevent any heart attacks at all.  Over 1000 people have to take it just to avoid heart disease.
How about aspirin?  Its NNT is 350.

Well what about exercise?  What is exercise’s NNT for preventing a heart attack? 
 - 3.  For every three people who exercise regularly, one of them will be saved from having a heart attack.

All of these number are speaking about healthy people, but it’s still poor even for those who already have disease.
Take people who already have heart disease or have had a heart attack.  How many of them have to take Lipitor to prevent one heart attack?  20.

You’ve had a heart attack, is it worth the 1 in 20 chance to pay for and take a pill every single day?
You just have high blood pressure, is it worth the 1 in 250 chance then?  Is it worth $500-$1000 per year to take a pill that has a 1/250 chance of helping you?
Okay  - forget the money.  What about the side effects?  Lipitor can cause diarrhea, muscle pain, nausea, headache, etc…  Is it worth it to take a pill knowing that the only effect it will most likely have is negative?
Remember, Lipitor is one of the BEST drugs that way.  It's side effects are fairly mild and what it prevents is fatal.  Even so, with such a small chance of benefit, is it worth it?

My point is this.  Medications cost money and they have side effects.  They work, but not nearly as well as most people think.  They bring peace of mind, they correct lab values, and for a small number of people, they prevent a bad outcome.
I am not callous or disinterested.  I prescribe medications every day with this knowledge.  I know my own family history and I’m going to be watching my cholesterol levels like a hawk the rest of my life.  Nevertheless, it is disheartening to know that for the HUGE majority of people taking medication, it will have no positive effect in their life whatsoever.

Friday, February 10, 2012

Climate Change Science is Crap

Does it seem to anyone else like climate change scientist are just sitting in a room using a magic 8 ball to predict the earths future? (assuming you don't think they are politically motivated)
Their science is about that accurate.  Here's the latest example:
They estimated ice melt in the Himalayas 2 years ago. They just got the actual results published yesterday.
They overestimated the ice loss by 1250%
Not 12%, not 100%, 1250%.

My point isn't that we shouldn't work to reduce pollution, my point is that climate change science is crap. 
Nature Research Article
(I didn't link to the Fox News article because I figured it's better to read the original research rather than someone else's interpretation)