Sunday, 31 October 2010
A method of assessing a newborn's health.
[After anesthesiologist Virginia Apgar (1909-1974) who devised it.]
This is a judging world and we get evaluated right from birth (Apgar score) to death (how many people came to the funeral). In 1953, Dr. Virginia Apgar devised a quick way to measure the health of a newborn child. She assigned 0, 1, or 2 points for each of the five criteria: heart rate, respiration, muscle tone, skin color, and reflex response. The Apgar score is typically calculated at one minute and five minutes after birth. Ten years after the debut of the Apgar score, Dr. L. Joseph Butterfield introduced an acronym as a mnemonic aid for the term: Appearance, Pulse, Grimace, Activity, Respiration. Also see backronym.
"The baby, a 6-pound, 14-ounce boy, appeared so healthy that doctors who delivered him gave him an Apgar score of 9 on a scale of 1 to 10."
Delthia Ricks; Congenital Malaria Case is First For NY; Newsday (New York); Apr 23, 2005.
Oh to have a lodge in some vast wilderness. Where rumors of oppression and deceit, of unsuccessful and successful wars may never reach me anymore. -William Cowper, poet (1731-1800)
Magnolia Cardona-Morrell email, Lucie Rychetnik email, Stephen L Morrell email, Paola T Espinel email and Adrian Bauman email
BMC Public Health 2010, 10:653doi:10.1186/1471-2458-10-653
Published: 29 October 2010
The clinical effectiveness of intensive lifestyle interventions in preventing or delaying diabetes development in people at high risk has been established from randomised trials of structured, intensive interventions conducted over the past two decades in several countries. The challenge is to translate them into routine clinical settings. The objective of this review was to determine whether lifestyle interventions delivered to high-risk adult patients in routine clinical care settings are feasible and effective in achieving reductions in risk factors for diabetes.
Data sources: MEDLINE (PubMed), EMBASE, CINAHL, The Cochrane Library, Google Scholar, and grey literature were searched for English-language articles published from January 1990 to August 2009. The reference lists of all articles collected were checked to ensure that no relevant suitable studies were missed. Study selection: We included RCTs or before-and-after (with or without a control group) studies of lifestyle interventions with the stated aim of diabetes risk reduction or diabetes prevention conducted in routine clinical settings and delivered by healthcare providers such as family physicians, practice nurses, allied health personnel, or other healthcare staff associated with a health service. Outcomes of interest were weight loss, reduction in waist circumference, improvement of impaired fasting glucose or oral glucose tolerance test (OGTT) results, improvements in fat and fibre intakes, increased level of engagement in physical activity and reduction in diabetes incidence.
Twelve from 41 potentially relevant studies were included in the review. Four studies were suitable for meta-analysis. A significant positive effect of the interventions on weight was reported by all study types. The meta-analysis showed that lifestyle interventions achieved weight and waist circumference reductions after one year. However, no clear effects on biochemical or clinical parameters were observed, possibly due to short follow-up periods or lack of power of the studies meta-analysed. Changes in dietary parameters or physical activity were generally not reported. Most studies assessing feasibility were supportive of implementation of lifestyle interventions in routine clinical care.
Lifestyle interventions for patients at high risk of diabetes, delivered by a variety of clinical health care providers in routine clinical settings, are feasible but appear to be of limited clinical benefit one year after intervention. Despite convincing evidence from structured intensive trials, this systematic review showed that translation into routine practice has less effect on diabetes risk reduction.
Saturday, 30 October 2010
Vitamin D Has Retinopathy Link
By John Gever, Senior Editor, MedPage Today
Published: October 20, 2010
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
* Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
* Note that the study cannot determine causality, and that whether vitamin D supplementation can reduce the risk of diabetic complications is not known.
CHICAGO -- Diabetic retinopathy may be added to the list of conditions potentially related to vitamin D insufficiency, a researcher said here.
A study of 123 diabetic individuals with varying degrees of retinopathy, along with two groups of controls, showed that low vitamin D levels were significantly more common in those with the diabetic complication, according to John F. Payne, MD, of Emory University in Atlanta.
In a poster presentation here at the American Academy of Ophthalmology's annual meeting, Payne also reported that multivitamin use appeared to be helpful in preventing vitamin D insufficiency -- at least as currently defined.
"If you were taking a daily multivitamin, your mean vitamin D [25-hydroxyvitamin D] was about 31 [ng/mL] versus about 22 if you weren't taking a multivitamin," he told MedPage Today. Because 30 ng/mL was the cutoff Payne and colleagues had used to define insufficiency, "now you're up to the optimum level."
But he acknowledged that some researchers have begun to advocate for higher levels of daily vitamin D intake and serum levels of the 25-OH-D metabolite, relative to current norms, as necessary for health.
Payne and colleagues gathered a total of 221 individuals in five groups: 47 volunteers without diabetes or any eye disease; 51 without diabetes who had uveitis, macular degeneration, or other ocular diseases; 41 diabetics without eye disease; 40 diabetics with nonproliferative diabetic retinopathy; and 42 diabetics with proliferative disease.
Serum 25-OH-D levels were measured from December 2009 to March 2010, which eliminated seasonal effects on vitamin D levels.
Mean levels in the five groups were as follows (P<0.001 for diabetics versus nondiabetics):
* Healthy controls: 28.8 ng/mL
* Nondiabetics with eye disease: 24.7 ng/mL
* Diabetics without eye disease: 23.2 ng/mL
* Diabetics with nonproliferative retinopathy: 21.5 ng/mL
* Diabetics with proliferative retinopathy: 18.0 ng/mL
Vitamin D insufficiency was found in 81% of the proliferative retinopathy group and about 70% of the two other diabetic groups, versus 55% of the two nondiabetic groups (P=0.048).
Black participants, who made up about half the overall sample, had lower mean 25-OH-D levels than whites, at 23.7 versus 29.2 ng/mL -- a difference found in most studies, as melanin in the skin interferes with the vitamin D-boosting effect of sunlight.
But in multivariate analysis, which accounted for body mass index, glycated hemoglobin levels, and two measures of renal function, only the presence or absence of self-reported daily multivitamin use was significantly associated with 25-OH-D level (mean 31.1 versus 22.0 ng/mL).
Vitamin D insufficiency was seen in 44% of those taking daily multivitamins, versus 83% of those not taking them (P<0.001).
Payne said the big unanswered question remains whether vitamin D supplementation can reduce the risk of diabetic complications, or any of the wide range diseases that have been linked to vitamin insufficiency in previous studies. These have included breast cancer, heart failure, multiple sclerosis, GI infections, and age-related cognitive decline, among others.
He noted that in this cohort, there was not a significant relationship between reported multivitamin use and the presence or severity of diabetic retinopathy.
Payne added that a randomized, placebo-controlled trial of supplements might be impossible because withholding them from patients known to have vitamin insufficiency could be considered unethical.
"We may have to go about getting that data a bit differently than we normally would," he said.
Nevertheless, Payne recommended that patients and physicians should consider vitamin D supplements in the meantime, since they are safe and could very well be helpful.
The study was supported by Research to Prevent Blindness and the National Eye Institute.
Payne and colleagues declared they had no competing financial interests.
Primary source: American Academy of Ophthalmology
Payne J, et al "Vitamin D insufficiency in diabetic retinopathy" AAO 2010; Abstract PO223
According to a new study, regular consumption of sugar-sweetened beverages is linked with a clear and consistently greater risk of metabolic syndrome and Type 2 diabetes. Picture: Agency
Friday, October 29, 2010 - Page B02
A NEW study has found that regular consumption of soda and other sugar-sweetened beverages is associated with a clear and consistently greater risk of metabolic syndrome and Type 2 diabetes.
According to the Harvard School of Public Health (HSPH) researchers, the study provides empirical evidence that intake of sugary beverages should be limited to reduce risk of these conditions.
The study appears online Wednesday in the journal Diabetes Care and will appear in the November print edition.
"Many previous studies have examined the relationship between sugar-sweetened beverages and risk of diabetes, and most have found positive associations but our study, which is a pooled analysis of the available studies, provides an overall picture of the magnitude of risk and the consistency of the evidence," said lead author Vasanti Malik, a research fellow in the HSPH Department of Nutrition.
Consumption of sugary drinks, the majority of which are sodas, has increased substantially in the US and across the globe and previous scientific studies have shown consistent associations with weight gain and risk of obesity.
However, this study is the first meta-analysis to quantitatively review the evidence linking sugar-sweetened beverages with type two diabetes and metabolic syndrome.
Metabolic syndrome is a group of risk factors, such as high blood pressure and excess body fat around the waist, that increase the risk of coronary artery disease, stroke and diabetes.
The researchers, led by Malik and senior author Frank Hu, professor of nutrition and epidemiology at HSPH, did a meta-analysis that pooled 11 studies that examined the association between sugar-sweetened beverages and those conditions. The studies included more than 300,000 participants and 15,043 cases of Type 2 diabetes and 19,431 participants and 5,803 cases of metabolic syndrome.
The findings showed that drinking one to two sugary drinks per day increased the risk of Type 2 diabetes by 26 per cent and the risk of metabolic syndrome by 20 per cent compared with those who consumed less than one sugary drink per month.
Drinking one 12-ounce serving per day increased the risk of Type 2 diabetes by about 15 per cent.
"The association that we observed between soda consumption and risk of diabetes is likely a cause-and-effect relationship because other studies have documented that sugary beverages cause weight gain, and weight gain is closely linked to the development of Type 2 diabetes," said Hu.
While a number of factors are at work in the development of Type 2 diabetes and metabolic syndrome, sugar-sweetened beverages represent one easily modifiable risk factor that if reduced will likely make an important impact, say the researchers. "People should limit how much sugar-sweetened beverages they drink and replace them with healthy alternatives, such as water, to reduce risk of diabetes as well as obesity, gout, tooth decay, and cardiovascular disease," said Malik.
Wednesday, 27 October 2010
DIABETES AS A SOCIAL ILLNESS
Generational Trauma, Exile, Desperation, Marginalization as causes of Diabetes
Sudah Yehuda Kovesh Shaheb
M.D, M.Sc, M.S
Visiting Professor of Medical Anthropology, University of Havana, Department of Philosophy, La Habana, Cuba
Consultant Endocrinologist to various Indian tribes in the USA.
The often stressed paradigm, based firmly on the biomedical model of body as a machine, uses terminology to blame the indigenous peoples and the peoples of emergent economies for their increasing rates of suffering from Diabetes.
I would like to demonstrate, with various examples from around the world that trauma, exile, oppression, alienation lay at the roots of the endemic Diabetes, which is only a symptomatic representation in the body of the sufferer, of spiritual disruption, marginalization and poverty. The solution, treatment and especially prevention of this epidemic should focus on the root causes, rather than the eradication or hiding symptoms, this reflected in the lack of successful national diabetes programmes in richer countries such as USA, UK or Australia, where rates of Diabetes continue to soar despite latest technology, increasing number of Endocrinologists, Diabetologists, Nutritionists and Educators, and increasing amount of money spent on Diabetes.
Models, with practical advice to translate culturally relevant tools to comprehend social illnesses and their treatment in community and clinical settings will be alluded to, such as the successful programme of prevention of obesity among the indigenous children among some Plains Indian tribes.
If you are interested you can get in touch with me
Cambodia 30 years Later..
Foetal Origins of Adult Disease
The Barker Hypothesis
A leading Academic Nephrologist was once asked: is there a physiological explanation for the susceptibility of renal disease among the native populations?
It is possible that they have a lesser number of nephrons, 800 000 per kidney rather than the usual one million, which may predispose them to later kidney disease.
In the kidney, maternal dietary imbalance may lead to developmentally induced deviations from the optimal ratio of body mass to nephron number. A relative deficiency in the number of nephrons is thought to create an increased risk of inadequate renal function and hypertension in later life31,53 and, ultimately, a predisposition to renal failure and a potentially reduced life span.54 The severity of the hypertension in rodent models appears to depend on sex, with males having higher risk.43 The molecular mechanisms are incompletely understood. In the rat, the intrarenal renin–angiotensin system appears to be critical for normal nephrogenesis and may be altered by maternal dietary imbalance, both during the neonatal stage55 and at later time points.56
There is no doubt in my mind that Renin Angiotensin System is important, from a clinical stand point. One is able to protect the life of the individual by protecting the kidney by Angiotensin Converting Enzyme Inhibition ( such as Lisinopril, Enalapril )
Other studies have implicated reduced activity of the antiapoptotic homeobox gene product paired box 2 (Pax-2) in reduced number of nephrons57,58
The propensity of all native peoples: American Indians, Australian Aboriginals, Polynesians could be a genetic protective or genetic modified mechanism.
In all hunting and gathering societies, the intake of meat was sporadic but when it did occur, large amounts of meat were eaten. It is well known that meat, products from the meat, increases renal flow and that an expansion of existing glomerular filtration would become necessary, thus a decreased number of nephrons could balloon themselves periodically to accommodate the sporadic event. When the sporadic events become regular, as the native communities adjust to a European Diet, there may be weakening of this mechanism, leading to a propensity for renal dysfunction ( this is just my theory!)
or have suggested that hypertension in later life caused by maternal dietary imbalance results from up-regulated sodium transport in the distal nephron, possibly triggered by increased oxidative stress.59
the Normal Blood pressure is a point of contention. The current 130/90 was formulated by Insurance Actuaries in Connecticut, and is possibly suited for Europeans, even that I am not sure. Certainly Asians and indigenous people have a normal BP readings in the range of 120/70 and we should aim at that. Overweight possibly is the single most common reason for an increase of BP of about 5 mm Hg.
Nutritional stress in pregnant rats reduces the growth of the endocrine pancreas during organogenesis and increases beta-cell apoptosis,60 leading to hyperglycemia and impaired insulin secretion when the offspring become adults. Glucocorticoids may be involved in inducing phenotypic changes and have been shown to inhibit the transcription factor pancreatic and duodenal homeobox 1 (Pdx-1) in beta-cell precursors, which may affect the resultant number of beta cells.61 In the adult male rat offspring of mothers on a protein-restricted diet, low birth weight is associated with reduced expression of components of the insulin signal-transduction pathway in skeletal muscle (including the protein kinase C zeta isoform, the p85 regulatory subunit of phosphoinositide-3 kinase, and the insulin-sensitive glucose transporter type 4 [GLUT4]).62 Similar abnormalities have been reported in infants of low birth weight,62 and together with the developmentally induced reduction in skeletal muscle mass,3 these abnormalities might contribute to later insulin resistance.
I have seen a number of cases, of young men presenting with Hyperglycaemia, who are thin and presentation mistaken for Type 1 Diabetes. Unlike ketosis prone Type 2 Diabetes, these young people do not revert to normal or not able to get by using oral hypoglycaemic agents.
Review of the histories of these patients revealed two common features:
Intra Uterine Pancreatic Insult
Adult Pancreatic Insult.
Both with excessive alcohol.
It is possible that the intrauterine pancreas were insulted with alcohol and stunted ( other chemicals possibly could do the same), and limping by the glucostasis when further insult to the pancreas decrease their ability to maintain homeostasis of Glucose.
In the rat model of nutritional imbalance, the offspring of rats fed an imbalanced diet during pregnancy later had elevated blood pressure, reduced nephron number, and increased responses to salt loading55 as well as reduced vasodilator function in the systemic arteries.40 Rat pups subjected to hypoxic conditions during gestation appear to have fewer but larger cardiomyocytes than pups exposed to normal oxygen levels and are more susceptible to infarction during periods of ischemia and reperfusion as adults.63 Increased blood pressure in fetal sheep stimulates cardiomyocytes to leave the cell cycle prematurely and hypertrophy,64 which may affect cardiac function in adult life. Cardiac hypertrophy is also evident in lambs born to ewes undernourished during early gestation.65 Chronic fetal anemia alters the developing coronary vascular tree in the near-term sheep fetus, and the remodeled coronary tree persists into adulthood.66 In one study, carotid intima–media thickness at 9 years of age in 216 children of European ancestry whose mothers had energy intake in the lowest quartile during early or late pregnancy was higher than that of children whose mothers had intake in the highest quartile, a finding that implies that maternal nutrition within an unexceptional range during pregnancy can affect the subsequent risk of atherogenesis in the offspring.67
THE ABOVE INFORMATION IS OF EXTREME IMPORTANCE FOR THOSE WORKING IN THE FIELD OF DIABETES IN CAMBODIA. I WOULD LIKE A SOCIAL COMMENTARY OF THE SITUATION DURING THE ERA 30 YEARS AGO, DETAILING THE NUTRITIONAL DEFICIENCIES TO BE ADDED TO THIS.
I BELONG TO A GROUP OF PEOPLE WHO SIXTY FIVE TO SEVENTY YEARS AGO UNDERWENT A MOST BRUTAL HOLOCAUST KNOWN IN EUROPE. WE REMEMBER IT AS SHOAH..
The term holocaust originally derived from the Greek word holókauston, meaning a "completely (holos) burnt (kaustos)" sacrificial offering to a god. Its Latin form (holocaustum) was first used with specific reference to a massacre of Jews by the chroniclers Roger of Howden and Richard of Devizes in the 1190s. Since the late 19th century, it has been used primarily to refer to disasters or catastrophes.
The biblical word Shoah (שואה) (also spelled Sho'ah and Shoa), meaning "calamity," became the standard Hebrew term for the Holocaust as early as the 1940s. Shoah is preferred by many Jews for a number of reasons, including the theologically offensive nature of the original meaning of "holocaust
HOWEVER PAINFUL IT MAY BE, IT IS IMPORTANT TO REMEMBER..
GlaxoSmithKline to pay $750m fine in fraud case
By Robert Weisman
Globe Staff / October 27, 2010
Federal prosecutors in Boston yesterday said British drug giant GlaxoSmithKline PLC agreed to pay $750 million to settle civil and criminal charges that it made and sold adulterated drugs, including the antidepressant Paxil, to Medicaid and other government payers.
The settlement, one of the largest ever in a health care fraud case, burnished the reputation of the US attorney’s office in Boston as the premier federal office for investigating health care fraud. It has been responsible for recovering about $6 billion in health care fines and claims in the past decade, about 25 percent of all recoveries nationally.
“A settlement of this size will help build confidence in the public that health care fraud will be prosecuted,’’ said US Attorney Carmen Ortiz, who oversaw the office’s civil and criminal investigations.
The case began when a whistle-blower, Cheryl Eckard, global quality assurance manager for London-based GlaxoSmithKline, filed a complaint in 2004 under the False Claims Act about the company’s manufacturing processes at a Puerto Rican subsidiary. Eckard, who does not live in Massachusetts, filed the complaint under seal in a Boston court because of the expertise of the US attorney’s office, which decided to intervene in the case, according to her lawyer and Ortiz.
Under the settlement unveiled yesterday, GlaxoSmithKline admitted to operating its SB Phamco Puerto Rico Inc. unit “in a manner that was inconsistent with current good manufacturing practice requirements,’’ P.D. Villarreal, senior vice president and head of global litigation, said in a statement issued by the company.
GlaxoSmithKline, which gained a foothold in the Boston area when it purchased Sirtris Pharmaceuticals two years ago, said it would take a charge of $750 million against its second-quarter earnings to account for the settlement. Its shares edged down 14 cents, or 0.3 percent, to $40.17 yesterday on the New York Stock Exchange.
The settlement covered four drugs manufactured at a Cidra, Puerto Rico, plant that has since been shuttered: Kytril, an antinausea medication; Bactroban, a topical anti-infection skin ointment; Paxil CR, a controlled release formulation of the company’s antidepressant drug Paxil; and Avandamet, a combination Type II diabetes drug.
According to criminal information filed in the case, prosecutors alleged that the manufacturing plant failed to ensure its Kytril and Bactroban products were free of micro-organism contamination. They also alleged the plant’s processes caused the two-layer Paxil CR tablets to split and that Avandamet tablets didn’t always have the mix of active ingredients approved by the Food and Drug Administration.
Under the civil settlement, GlaxoSmithKline agreed to pay $600 million to the federal government and to states based on a percentage of the Medicaid claims they filed for the four drugs, including more than $8 million that will go to Massachusetts’ Medicaid program. Eckard, the whistle-blower, will receive about $96 million.
In a separate plea agreement in the criminal case, the company agreed to pay a $150 million fine. “The success of this whistle-blower case will change the way drug companies run their manufacturing facilities,’’ said New York lawyer Neil Getnick, Eckard’s attorney. “The takeaway for corporate America is that dedicated employees who try to do the right thing can’t be silenced and made to go away.’’
Saturday, 23 October 2010
I was extraordinarily lucky to have had my medical education divided between three countries:
London in England, a medical model still paying attention to the great masters of the past while trying to provide equitable care to all
Australia, where the average person started the conversation with the holidays they just had or the holidays they were planning or dinner parties. I enjoyed the medical model of this country where they very cleverly used the young doctors as pawns, rewarding those who wagged their tails to the drools of the senior doctors, dark skinned doctors assigned jobs that no one wanted and the mediocre white doctors (the grand majority) of them guaranteed a cushy life of suburban life with no great expectations of life, except holidays in Noosa or an occasional medical conference in the USA or Europe. They were a bunch of imitators of American ideals, but without knowledge that American ideals were heading nowhere, and still clinging on to a system assuaged on its colonial origins.
United States of America (there are United States of Mexico, United States of Brasil, America is the name of the continent, and usurped name really on the back of economic might. Their revolution was one of the oldest in the world, their democracy certainly very old, older than France where the revolution arrived a couple of decades later)
Go West, Young Man, said Benjamin Rush, considered the father of the Limitless Western Medicine practiced in the USA with its boundless optimism and endless possibilities that leaves 50 million people without care and another 50 odd million afraid to get sick because of bills and people like Dick Cheney getting extraordinarily good medical care! One cannot help enthused by the eternal determination of the Americans and as such reflected in their medical system as well.
The first week I was at the Washington University School of Medicine to begin my career as an Endocrinologist; I realized that a communication barrier existed: None of the world famous doctors knew anything outside their very limited field; one even asked what Belize is? Not where is Belize? And I had no great interest in the finer aspects of the calcium metabolism of the trabecular bone. This lack of communication was to plague me for the next four years, until the American Indians, Jamaican Rum and Cuban migrants to Miami saved me...I can communicate well to the spirit world of the Indians, I liked the ambience created by the mindless bourgeoisie of Jamaica who had created an incredibly narrow cage for themselves made of Gold and thanks to the streaks of Cuban ness still surviving in the soul of the cuban immigrants, I became interested in the real thing, the island of Cuba, which became my home.
This balance between Knowledge, Dedication to Service and Solidarity and counsel of Ancient People brought a sense of balance, approaching something close to what one could call Harmony in life...
It was evident to me, I was not destined to be a doctor with a plush office full of waiting patients, No one would be willing to pay large sums of money to a doctor who specialized in talking about the society and the sicknesses it creates, no drug company would pay a first class ticket to Paris with a hotel room at George V to a doctor preaching Natural remedies, Ayurveda and meditation and Yoga whenever possible, in ADDITION to the limited mechanism and aetiology oriented medications supplied by the drug companies. I once asked my good Friend Daniel A, who is the President of the Diabetes Association in his country, Tell me Daniel, why are they treating you to Paris (first class tickets for two and a week at George V), his answer was frank enough: I prescribe more Vytorin (a drug not shown to be that superior to cheaper version to combat high cholesterol levels) than anyone else in my country. Go in peace, Daniel, you are my Family but can’t say that of another leech of the society, who manage to sneak into the private practice world of Medicine in Miami from an impoverished south American country, after a suitable absence of years and presence of accoutrements of superficiality, I met him at an Endocrine Society meeting, his first question was: what happened to our dreams? I am still living it, my dear friend; it is you who has given up. Then and there I made a point of never getting in touch with him again, a usurper of morality and leech on his own country where he was educated and sucking the innocent in Miami dry. He seemed very angry and disappointed at his friends, but he told me he had a plush office.
Because I have travelled, more than my share, I always maintain Frequent Flier status that brings smiles to the Airlines, and I am faithful to just one airline, so often rewarded with upgrades on transcontinental flights. Once sitting next to me on a flight from Madrid to New York was a young American man, of African descent, who couldn’t wait to open his computer as the flight took off. To be polite, I asked him, where were you in Spain? Valencia, he answered, but quickly added hoping to sore bonus points, but had no time to see anything and I only ate American type food at the hotel. I watched this pitiful specimen of the powerful nation on earth, seeing him work, for the six hours, while I drank champagne and delightful wines from around the world, danced in my head to music from Cabo Verde and reading Alvaro Mutis once again extolling the virtues of Maqroll el Gaviero. As we were disembarking, as a departing gesture to this most hospitable country I told him, why don’t you buy a plot in the cemetery and lie down and wait for death to arrive...
I don’t think he who prides in his hard work appreciated this comment from a champagne drinking, music listening book worm from the other side of the world.
No one could write more elegantly about the Pleasures and Sorrows of Work than the philosopher of everyday life, Alain de Boton. I am quoting the last page of his book in its entirety. He brings to light my own thoughts lying dormant, which I would have liked to have said to a good friend in New York, Istanbul born, and London Educated, an accountant, working for a prestigious accountancy firm which is rather a household name around the world, along with its competitors. In fact, one of the chapters on Alain de Boton’s book is about Accountants, this time he was given the opportunity to spend time with accountants at Ernest and Young, at their Head Quarters, and had a chance to interview the CEO, but Alain de Boton is a literary anthropologist who does participant observation and translates them into brilliant language, English, which we all love.
His words on Work follow, dedicated to those who take their slot in life far too seriously, a state of mind not congruous with good health.
Work does not by its nature permit us to do anything other than take it too seriously. It must destroy our sense of perspective, and we should be grateful to it for precisely that reason, for allowing us to mingle ourselves promiscuously with events, for letting us wear thoughts of our own death and the destruction of our enterprises with beautiful lightness, as mere intellectual propositions, while we travel to Paris to sell engine oil. We function on the basis of a necessary myopia. Therein is the sheer energy of existence, a blind will no less impressive than that which we find in a moth arduously crossing a window ledge, stepping around a dollop of paint left by a too-hasty brush, refusing to contemplate the broader scheme in which he will be dead by nightfall.
The arguments for our triviality and vulnerability are too obvious, too well known and too tedious to rehearse. What is interesting is that we may take it upon ourselves to approach tasks with utter determination and gravity even when their wider non-sense is clear. The impulse to exaggerate the significance of what we are doing, far from being an intellectual error, is really life itself coursing through us. Good Health encourages us to identify with all human experiences in all lands, to sigh at a murder in a faraway country, to hope for economic growth and technological progress far beyond the limits of our own lifespan, forgetting that we are never more than a few rogue cells away from the end.
To see ourselves as the centre of the universe and the present time as the summit of history, to view our upcoming meetings as being of overwhelming significance, to neglect the lessons of cemeteries, to read only sparingly, to feel the pressures of deadlines, to snap at colleagues, to make our way through conference agendas marked “11:00 am to 11:15 a.m.: Coffee break” , to behave heedlessly and greedily and then to combust in battle-may be all of this, in the end, is working wisdom. It is paying death to much respect to prepare for it with sage prescriptions. Let is surprise us while we are shipping wood pulp across the Baltic Sea, removing the heads of tuna, developing a nauseating variety of biscuit, advising a client on a change in career, firing a satellite with which to beguile a generation of Japanese school girls, painting an oak tree in a field, laying an electricity line, doing the accounts, inventing a deodorant dispenser or making an extended-strength coiled tube for an airliner. Let Death find us as we are building up our matchstick protests against its waves.
If we could witness the eventual fate of every one of our projects, we would have no choice but to succumb to immediate paralysis. Would anyone who watched the departure of Xerxes’ army on its way to conquer the Greeks or Taj Chan Ahk giving orders for the construction of the golden temples of Cancuen or the British colonial administrators inaugurating the Indian postal system, have had it in their hearts to fill their passionate actors in on the eventual fare of their efforts?
Our work will at least have distracted us, it will have provided a perfect bubble in which to invest our hopes for perfection, it will have focused our immeasurable anxieties on a few relatively small scale and achievable goals, it will have given us a a sense of mastery, it will have made us respectably tired, it will have put food on the table. It will have kept us out of greater trouble.
Finished writing in Paris 17 22
August 14, 2009
From memory I think on this day Paquistan became independent and on the 15th august, India became independent form the British rule in 1947..
Happy Independence Day!
Monday, 18 October 2010
Why Most Published Research Findings Are False
John P. A. Ioannidis
John P. A. Ioannidis is in the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece, and Institute for Clinical Research and Health Policy Studies, Department of Medicine, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, United States of America. E-mail: firstname.lastname@example.org
Competing Interests: The author has declared that no competing interests exist.
I try to keep up with what is happening in my chosen fields of Study: Endocrinology as well as Medical Anthropology, in addition to my craving to know what is happening in this world (I try to read BBC News, The Economist regularly and scan through the internet in search of interesting news items).
I see a medical tendency to exaggerate, and this exaggeration is related to the interest the author has in increasing his prestige or income or career opportunities.
Always look for the Competing Interests.
I am not interested in reading about the Lack of Effect of Oral Medications in Type 2 DM from a professor who has financial relationship with Insulin producing drug companies.
If one researcher has many relationships with many drug companies, the chances are his research results would be WRONG.
I will highlight this article by Dr Ioannidis who has done a favour to all or us by highlighting how often biased results are published and gain in popularity.
Corollary 1: The smaller the studies conducted in a scientific field, the less likely the research findings are to be true.
Corollary 2: The smaller the effect sizes in a scientific field, the less likely the research findings are to be true. Power is also related to the effect size. Thus research findings are more likely true in scientific fields with large effects, such as the impact of smoking on cancer or cardiovascular disease (relative risks 3–20), than in scientific fields where postulated effects are small, such as genetic risk factors for multigenetic diseases (relative risks 1.1–1.5) . Modern epidemiology is increasingly obliged to target smaller effect sizes . Consequently, the proportion of true research findings is expected to decrease.
Corollary 3: The greater the number and the lesser the selection of tested relationships in a scientific field, the less likely the research findings are to be true.
Corollary 4: The greater the flexibility in designs, definitions, outcomes, and analytical modes in a scientific field, the less likely the research findings are to be true.
Corollary 5: The greater the financial and other interests and prejudices in a scientific field, the less likely the research findings are to be true.
Corollary 6: The hotter a scientific field (with more scientific teams involved), the less likely the research findings are to be true.
Most Research Findings Are False for Most Research Designs and for Most Fields
Claimed Research Findings May Often Be Simply Accurate Measures of the Prevailing Bias
How Can We Improve the Situation?
Is it unavoidable that most research findings are false, or can we improve the situation? A major problem is that it is impossible to know with 100% certainty what the truth is in any research question. In this regard, the pure “gold” standard is unattainable. However, there are several approaches to improve the post-study probability.
Better powered evidence, e.g., large studies or low-bias meta-analyses, may help, as it comes closer to the unknown “gold” standard. However, large studies may still have biases and these should be acknowledged and avoided. Moreover, large-scale evidence is impossible to obtain for all of the millions and trillions of research questions posed in current research. Large-scale evidence should be targeted for research questions where the pre-study probability is already considerably high, so that a significant research finding will lead to a post-test probability that would be considered quite definitive. Large-scale evidence is also particularly indicated when it can test major concepts rather than narrow, specific questions. A negative finding can then refute not only a specific proposed claim, but also a whole field or considerable portion thereof. Selecting the performance of large-scale studies based on narrow-minded criteria, such as the marketing promotion of a specific drug, is largely wasted research. Moreover, one should be cautious that extremely large studies might be more likely to find a formally statistical significant difference for a trivial effect that is not really meaningfully different from the null [32–34].
Second, most research questions are addressed by many teams, and it is misleading to emphasize the statistically significant findings of any single team. What matters is the totality of the evidence. Diminishing bias through enhanced research standards and curtailing of prejudices may also help. However, this may require a change in scientific mentality that might be difficult to achieve. In some research designs, efforts may also be more successful with upfront registration of studies, e.g., randomized trials . Registration would pose a challenge for hypothesis-generating research. Some kind of registration or networking of data collections or investigators within fields may be more feasible than registration of each and every hypothesis-generating experiment. Regardless, even if we do not see a great deal of progress with registration of studies in other fields, the principles of developing and adhering to a protocol could be more widely borrowed from randomized controlled trials.
Finally, instead of chasing statistical significance, we should improve our understanding of the range of R values—the pre-study odds—where research efforts operate . Before running an experiment, investigators should consider what they believe the chances are that they are testing a true rather than a non-true relationship. Speculated high R-values may sometimes then be ascertained. As described above, whenever ethically acceptable, large studies with minimal bias should be performed on research findings that are considered relatively established, to see how often they are indeed confirmed. I suspect several established “classics” would fail the test .
It is quite obvious that most of the medical practitioners especially those in private practice have absolutely no idea of what is wrong with evidence based medicine or how certain articles are being touted as the new remedy, especially if they are relying upon drug company salesman or conferences in snow resorts or Hawaii for their continuing medical education. But they can feel that they are “legally” safe, but practice of medicine was supposed to be ethically safe and not legally safe.
As an anthropologist, I look at the published medical literature, even in prestigious journals such as NEJM and see the bias, such as: talking about pregnancy outcomes in San Antonio without mentioning that majority of the people studied there are of Mexican origin and poor, studies from Atlanta talking about High Blood Pressure fail to mention that it is the city with highest proportion of Americans of African Origin, more than once in my travels they have asked me Why do Pima have such high prevalence of Diabetes and people think Pima are the only Indians with Diabetes, such labeling had made pariahs of citizens of Nauru and other Pacific Islands.
Today I was seeing a patient, 38 year old and the note was made that her random Blood sugar was over 400 mg/dl (divide it by 18 to get SI unites i.e. about 22). She was on Long Acting Insulin and also Metformin, Actos and Glipizide.
It would have been so easy to look at the paper and give her more medicine or more of the same medicine and admonish her or label her as a Non Compliant patient. Obviously she was not taking the medications, but the reasons were, all non medical:
Lack of self-esteem in inability to look after family
Food Stamps not allowing her a healthy nutrition.
Bad relationship with Boy friend, who is yet arrested for another DUI (Driving Under Influence).
Alcohol abuse to stave boredom
Depression and lack of interest in her health.
She herself said: if I had a job, most of these problems would disappear.
The approach to this patient is not: more Pioglitazone or more Insulin; it is not a nutrition lecture; it is not Prozac for depression, it is not admission to the in patient ward.
The correct approach is culturally sensitive counseling. How many of our providers can be counted on doing that. I am very lucky since the person I work with, an RN with CDE is extremely competent and takes care of many of the aspects and gives me ample time to do what I think should be done for a Social Disease: Culturally Sensitive Counseling.
I do 5 minutes Continuing Medical Education vignettes for my colleagues. They dismiss the ranting of professors from New Orleans who push vigorously the new generations of drugs (Byetta,ONglyza etc) but are very happy to hear when I give them the summary of article that appeared in Archives of Internal Medicine, Sept 27, 2010
Long Term Effects of a Lifestyle Intervention on Weight and Cardiovascular Risk factors in individuals with Type 2 Diabetes
I quote their conclusions
Intensive lifestyle intervention an produce sustained weight loss and improvements in fitness, glycemic control and CDG risk factors in individuals with Type 2 Diabetes.
The study lasted 4 years.
As a good hearted friend of mine from the West Coast said to me: we already know what is good for Diabetes, but so little money goes into the research and implementation of that but millions of dollars are spent by Pharma so that Bald Head professors (Bob Marley would have said that) can go around the world touting that 140 usd per month medications have dubious value over 20 usd per month medications but they certainly reduce something or other from 9.7 to 8.1 and stress the fact that the reduction is 20 per cent! Most of the erudite listeners have no idea that the way it is being presented is an exaggeration and what does 20 per cent mean to most people?
I am currently reading
Diabetes Sugar Coated Crisis
Who gets it, who profits and How to stop it
If you are among those who is not manipulated by the drug companies in your prescribing habits and one of the few who hang on to the youthful hopefulness that you had when you were a medical student, I recommend you read this book…
Within the first few pages, you would read
Social Diseases need Social Approaches….
Hope my doctor friends in the Far East read this blog!
you can read about Dr Ioannides and his great efforts at
to recognize how popular his astringent work has become appealing to the world wide audience that he gets over 1000 invitations internationally to speak! per year..
Saturday, 16 October 2010
14 October 2010
Background noise affects taste of foods, research shows
By Jason Palmer Science and technology reporter, BBC News
Empty table overlooking vineyard This might be the best place for the tastiest meal
The level of background noise affects both the intensity of flavour and the perceived crunchiness of foods, researchers have found.
Blindfolded diners assessed the sweetness, saltiness, and crunchiness, as well as overall flavour, of foods as they were played white noise.
While louder noise reduced the reported sweetness or saltiness, it increased the measure of crunch.
The research is reported in the journal Food Quality and Preference.
It may go some way to explaining why airline food is notoriously bland - a phenomenon that drives airline catering companies to heavily season their foods.
"There's a general opinion that aeroplane foods aren't fantastic," said Andy Woods, a researcher from Unilever's laboratories and the University of Manchester.
"I'm sure airlines do their best - and given that, we wondered if there are other reasons why the food would not be so good. One thought was perhaps the background noise has some impact," he told BBC News.
"Nasa gives their space explorers very strong-tasting foods, because for some reason thay can't taste food that strongly - again, perhaps it's the background noise.
"There was no previous research on this, so we went about seeing if the hunch was correct."
In a comparatively small study, 48 participants were fed sweet foods such as biscuits or salty ones such as crisps, while listening to silence or noise through headphones.
Meanwhile they rated the intensity of the flavours and of their liking.
In noisier settings, foods were rated less salty or sweet than they were in the absence of background noise, but were rated to be more crunchy.
"The evidence points to this effect being down to where your attention lies - if the background noise is loud it might draw your attention to that, away from the food," Dr Woods said.
Also in the group's findings there is the suggestion that the overall satisfaction with the food aligned with the degree to which diners liked what they were hearing - a finding the researchers are pursuing in further experiments.
Tuesday, 12 October 2010
Lipid and lipoprotein profiles among middle aged male smokers: a study from southern India
Tobacco Induced Diseases 2010, 8:11doi:10.1186/1617-9625-8-11
|Published:||5 October 2010|
Objectives: The objectives were to investigate into the relationship between lipid profile including Apolipoprotein-A1 (Apo-A1) and Apolipoprotein-B (Apo-B) and smokers and to relate them with smoking pack years. Materials and Methods: A total of 274 active male smokers without any other illnesses and age matched male healthy control subjects (78) with similar socio-cultural background were assessed for clinical details, dietary habits, physical activities, smoking and alcohol consumption. Standard methods were adopted to check the lipid levels. The data were analyzed statistically.
Their ages ranged from 40 to 59 years, systolic BP from 110 to 130 mmHg, and diastolic BP from 76 to 88 mmHg. All of them had similar pattern of diet (vegetarianism with occasional meat). None was on any medication influences lipid level. Their physical activity was moderate. Number of pack years varied from 10 to 14 (mild), 15 to 19 (moderate) and 20 and above (heavy) among 69, 90 and 115 cases, whose mean ages were 43, 44 and 49 respectively. The mean (+SD) values in mg/dl of total cholesterol (TC), Triglyceride (TGL), Apo-B, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol and Apo-A1 in mg/dl among mild/ moderate/ heavy smokers and control subjects were 198 (30.6)/ 224 (27.2)/ 240 (24.3) and 160 (20.4); 164(42.6)/ 199 (39.5)/ 223(41.7) and 124 (31.6); 119 (24.9)/ 121 (27)/ 127 (28.3) and 116 (21.4); 94 (19.7)/ 104 (21.8)/ 120 (20.5) and 82 (17.6); 42 (5.9)/ 39 (3.1)/ 35(4.4) and 48 (5.3); and 120 (17)/ 119 (21)/ 115 (25) and 126 (19), respectively. In smokers, there was a rise in TC, TGL, LDL, Apo-B and fall in HDL and Apo-A; these changes were significant (P<0.05).
Number of pack years was directly proportional to abnormal lipid profile. It is also concluded that changes in Apo-A1 and Apo-B were more significant when compared to HDL and LDL cholesterol among smokers. In the view of double risk for smokers (smoking and altered lipid profile) efforts may be made to introduce smoking cessation program.
Monday, 11 October 2010
FRANCE of course..
A mother is a little anxious that her Little One, 11 months and 17 days old, who has not been sick the entire year has a runny nose and a weeping eye. Coughs but no Fever. The discharge from the nose and the eyes are clear. Being unaccustomed to the Little one, now coughing, she requests an emergency appointment with the local Paediatrician. She called the doctor at 9 30 am and was granted an appointment for the child at 3 45 pm.
The Little One arrives at the consulting rooms of the paediatrician which is on the first floor of a residential building. There are no secretaries or hum of a railway station with people milling around, like I saw in a Gastroenterologists office in Miami, all wearing white coats assigned various jobs, mainly collecting money. There was no one waiting in the waiting room, soon the doctor appears, Bon Jour and come in...It is now 3 40 pm. There are no multiple appointments or overbooking in France, in general and you are seen closer to when you are told you would be seen. The MD checks the child,oral exam, nasal exam, looks into the ears, listens to the heart and the lungs. A few questions and a clinical diagnosis of simple Rhinitis is made. Are you willing to take Homeopathic medications? asks the MD, and prescribes homeopathic eye drops, and four kinds of homepathic pills to be taken at frequent intervals, they are not pills in the regular sense but small pellets which runs out of tubes of medications. A nasal spray is also prescribed in case there is any difficulty in breathing in the coming days, should the child get worse.
The normal fees for consultation with a paediatrician is 28 euros and this time 3 euros was added on because it was an emergency consultation! 31 euros total. You pay the MD and she gives you a preprepared form in which she writes down the name of the patient, the amount paid and her signature. When you send it in to the Social Security, a similar amount is added to your bank account. In fact, today's consultation does not cost the mother any money.
She walks to the nearest pharmacy, In fact there are six pharmacies within walking distance and in Paris, the flashing green signs of pharmacies are a common sight. The prescription and the social security card (Vitale) is given to the assistant, who enters that in the computer and then takes off tubes of homeopathic medications off the shelf. The nasal spray the only concession to western medicine is to be given only if the condition is getting worse. Eye drops were single use containers packed in sums of twenty. The cost of the above prescriptions, should you have no social security as in the case of a visitor from a non EU country..Eye drops 5.15 Euros Nasal Drops 4.19 euros the homeopathic medications were 1.80 euros each, altogehter it would have set a non french person back 17 euros! But since the child is French and the mother is employed, her absolute cost for all the medications were a mere 5.15 euros! In fact the entire urgent expedition to the Paediatrician cost the parent 5 euros! including a consultation and the medications..
Imagine this child with parents who have medical insurance was to get sick in Miami? You can bet that the aggressive medical system there would have included a throat swab, perhaps an Xray and definitely a blood test of some sort and of course the consultation with the paediatrician who could be about one hour late! in the mean time you would be interviewed by the Insurance clerks and also a nurse would have seen and taken all the measurements of the child.
Even if you had insurance, it could set you back 200 dollars for the consultation and the medications. God Forbid, you decided to walk into the Emergency Room of the Baptist hospital, the same consultation which cost the parents 5 euros ie 6.50 us dollars,in France, would end up with multitudes of bills amounting to about 2000 us dollars.
So before you knock the Frenchies, just remember, they have the best health care system in teh world, it is just in that, no one is discriminated because of lack of insurance or income. Like their educational system, which is slightly more elititst, they can take pride of their medical system.
For those doctors practicing in India or Malaysia or Singapore or Thailand or Cambodia or Vietnam, and who wish to follow the American System (results from USA are no better in any field except perhaps in Oncology!), please think of your patients and follow the french system whereby you make clinical diagnosis, do as few tests as possible, and prescribe medications that dont kill the patients ... and dont empty their bank accounts by using a system which is only marginally shown to be better than systems that are so much more humanistic and caring and gentle and less aggressive..