New Hope in Type 1 Diabetes

This week’s Journal of the American Medical Association published a study that may be a turning point in treatment of type 1 diabetes.  The study received much media coverage, including this LA Times article.

Type 1 diabetes is a very different disease than the much more common type 2 diabetes.  (They should probably just have entirely different names.)  Type 2 diabetes is predominantly a disease of overweight adults and results from insulin resistance, meaning a decrease in insulin’s ability to function.  It is usually treated with oral medications.  Type 1 diabetes is an auto-immune disease that usually strikes in childhood or young adulthood.  In it, the immune system destroys the cells in the pancreas that produce insulin leading to an absence of insulin in the body.  The only treatment for type 1 is insulin.

This study is promising because it hints at a possible way to reverse or delay type 1 diabetes as soon as it is diagnosed.  In the study 15 patients with newly diagnosed type 1 diabetes underwent chemotherapy to severely suppress their immune system.  After that, their immune system was rescued by giving them their own stem cells, which were collected before the chemotherapy.  Most of the patients did not require insulin for their diabetes for months, some for years, after the treatment, and there were no major adverse outcomes.

This study is small and needs to be duplicated with more patients, and hopefully with more prolonged benefits, but it’s a potentially novel treatment for a serious chronic problem.

Tangential Miscellany:

Two weeks ago, I wrote about an interview in U.S. News and World Report of Dr. Jerome Groopman about mistakes that doctors make by not spending enough time listening to patients.  In the current issue they published my letter in response.  (It’s the second letter on the page.)

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Computer Aided Mammography Interpretation Not Ready for Prime Time

Most of my patients know that I’m a big fan of technology.  From electronic medical records to viewing diagnostic images over the web, I love finding tools that help me take better care of patients.  A study in this week’s New England Journal of Medicine is an important cautionary tale that reminds us that new technologies should always be tested rigorously.

The study examined the use of a technology called computer-aided detection to assist radiologists in interpreting screening mammograms.  Computer-aided detection involves computer software that analyzes mammogram images and identifies suspicious abnormalities.  It was approved by the FDA in 1998 and has gained popularity since then.  The study was also covered in yesterday’s Los Angeles Times.

The study found that the technology actually decreased accuracy when compared to a radiologist reading the mammograms without computer assistance.  Computer assistance lead to an increase in potential abnormalities being identified that overwhelmingly turned out to be benign.  The number of women recalled for additional imaging increased by 32% and the number of biopsies increased by 20%, but the number of actual cancers detected did not increase.  So computer assistance only led to unnecessary procedures and didn’t assist in diagnosis.

So for now, we should leave mammogram interpretation to trained humans, and let computers do what they’re best at — connecting you to educational articles from your doctor!

Tangential Miscellany:

Drum roll, please.  The following are the winners of the Pedometer Project for March.

The winner with most steps was Sari A.  In her honor I’ll be donating platelets at Cedars-Sinai on April 12.

The winner for most improved walker in March was Victoria W.  In her honor I will volunteer at the Simms/Mann Clinic on April 18.

The winner for weight loss was Douglas C.  In his honor I will volunteer at the Simms/Mann Clinic on May 2.

My congratulations to all the participants!  The Project will continue through the end of April.

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Brevity is Bad Medicine

Last weekend U.S. News & World Report had a fascinating article called “The 18-second Doctor”.  The article is an interview with Dr. Jerome Groopman, author of How Doctors Think, a book that examines how physicians analyze information and make (occasionally wrong) decisions.

The article gives some examples of how taking the time to listen to the patient can be critical for arriving at the correct diagnosis.  I encourage all of you to read it.  I just added the book to my Amazon list.

I’m grateful to my patient Andy Raymond for pointing me to the story.

Tangential Miscellany:

My wife and I wish a happy Easter and a happy Passover to all of you who are celebrating.

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Concierge Medicine Gets Some Local Attention

Yesterday’s L.A. Daily News business section featured an interesting story about concierge medicine.  I was delighted to be one of the physicians interviewed for the story.  I’m grateful to Barbara Correa for shining some light on a practice model that has received very little attention — a model that I’m convinced is better for patients, better for doctors, and better for the healthcare system.  I’m also grateful to my patient Deborah Bradley for taking the time to talk to her.

The story is called “Ca$h Care”, which is a cute headline, but highlights what a strange marketplace healthcare has become.  We expect customers to pay for their own food, housing and transportation, but we’re still not used to patients paying for their own routine healthcare.  We would never let our employer decide for us who can sell us a car, or where we can shop for clothes, but we’ve become used to the idea that our employers should determine our healthcare options.  The only solution that will work nationally is the solution that has worked in the distribution of every other good and service.  Routine care should be paid by patients who should be free to seek care from any physician they choose.  The price for that care should be set by the patients and physicians.  Health insurance should only cover unaffordable catastrophes, and like life insurance or car insurance, should be removed entirely from the responsibility of employers.

So please help me spread the word.  Otherwise, when patient-sponsored medicine makes quality affordable healthcare widely available, the L.A. Daily News will get all the credit.

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Thank You for Scheduling Your Heart Attack on Wednesday

This week’s New England Journal of Medicine has an interesting study about how differently emergencies are handled outside of normal working hours.  The study looked at every patient in New Jersey hospitalized with his or her first heart attack between the years of 1987 and 2002.  The authors separated the patients into two groups: those who were admitted on a Saturday or Sunday, and those admitted on a weekday.  For each of the two groups the study looked at the fraction of these patients who received angioplasty or bypass surgery and the fraction of them who died within the year following their admission.

The patients admitted on the weekend were less likely to receive bypass surgery or angioplasty, and received these interventions longer after admission than the patients admitted on a weekday.  The patients admitted on the weekend also had a 1% higher rate of mortality than those admitted during the week.  This means that for every 100 patients admitted on the weekend there was 1 excess death over the number of deaths in 100 patients admitted during the week.  Interestingly, the difference persisted even when the authors only considered hospitals that were supposedly equipped and staffed for emergency angioplasty around the clock.

Obviously these results have nothing to do with what patients should do.  Don’t wait until Monday to get hospitalized if you get crushing chest pain on Saturday!  But for hospital administrators this provides much to think about.  For a disease as lethal as heart attacks, even a tiny improvement in the quality or timing of care might make a huge difference in the numbers of lives saved.

Tangential Miscellany:

I was contacted recently by the owner of a website called The Walker Tracker.  He had noticed my Pedometer Project and wanted my readers to know about his site.  His website allows you to keep track of your steps, chart your progress, and connect with other walkers for encouragement and support.  It’s free.  Check it out.

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Women on Atkins Diet Lost More Weight than on Other Diets

Losing weight is the second hardest thing I ask my patients to do.  (Quitting smoking is the hardest.)  Typically, physicians have generally recommended a low-fat diet which is still the diet recommended by national guidelines.  Despite this, several different kinds of diets have become popular recently with varying amounts of carbohydrates, most notably the Atkins diet which is very low in carbohydrates and very high in fat.

This week’s Journal of the American Medical Association contains the first study comparing several such diets.  The study enrolled overweight women who had not yet gone through menopause and randomized them to four diets.  In order of carbohydrate intake the diets were the Atkins diet (very low in carbohydrates), the Zone diet (low in carbohydrates), a diet based on national guidelines (low in fat and high in carbohydrates), and the Ornish diet (very high in carbohydrates).  The women’s weights were followed for 12 months.

Women on the Atkins diet lost the most weight, 10.4 lbs on average.  The other three groups had approximately the same weight loss (the differences were not statistically significant) of on average 4.7 lbs.  Interestingly the number of calories consumed by the four groups was not statistically different.  The Atkins diet, because of its high fat intake is occasionally criticized for increasing cholesterol, but in this study cholesterol decreased by the same amount in all groups.

So the Atkins diet is a sensible choice for overweight women.  What I find most sobering is that even in the best diet after a whole year the average weight loss was only about 10 lbs.

Tangential Miscellany:

The results from the first month of the Pedometer Project are in!  In February participants tallied over 2.4 million steps.

The winner with most steps was Marcia W.  In her honor I’ll be donating platelets at Cedars-Sinai on March 20.

The winner for most improved walker in February was Richard T.  In his honor I volunteered at the Simms/Mann Clinic yesterday afternoon.

My congratulations to all the participants.

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Garlic Doesn’t Lower Cholesterol

Garlic is frequently touted as a natural treatment for high cholesterol, and many garlic extracts are sold with the suggestion that they improve cholesterol levels.  The current issue of the Archives of Internal Medicine has an article reporting the most definitive study yet looking at the effects of garlic on cholesterol.  Volunteers were randomized into four groups:  raw garlic, powdered garlic supplement, aged garlic extract supplement, or placebo.  None of the groups had a significant change in their cholesterol, though the raw garlic group reported much more bad breath and body odor.

The results are also reported in this Los Angeles Times article.  This statement from the study’s principal author summarized it well.

“It just doesn’t work,” said Christopher Gardner, a Stanford professor of medicine who led the study. “If garlic was going to work, in one form or another, then it would have worked in our study. The lack of effect was compelling and clear.”

Nevertheless, I still think it’s yummy.

Tangential Miscellany:

I wrote last summer about my involvement with the Society for Innovative Medical Practice Design (SIMPD), a national organization of physicians who work for their patients, not for insurance companies.  Because of my long-standing interest in medical ethics, I had the honor to serve with Dr. Robert Briskin and Dr. Garrison Bliss on the SIMPD ethics committee.  We were charged with the task of crafting a statement of ethical principles that would guide us and future physicians in our new practice models.  I’m very happy with the product of our work.  Our statement of ethical principles demonstrate that concierge physicians take ethics seriously, and that practices that align physician interest with patient interest can avoid many of the ethical pitfalls of traditional practices.  If you have an interest in medical or business ethics, I’d love to hear your feedback.

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We Could Always Go Back to Leeches

Last week’s TIME Magazine has an excellent article about a very important trend in healthcare:  evidence-based medicine.  It’s not long, and I urge you to read it.

The surprising truth is that the scientific practice of medicine is a very new development.  For centuries medicine was an apprenticeship in which traditional treatments were handed down from teacher to pupil without any objective investigation of either the mechanisms of disease or the effectiveness of treatment.  Even after the enlightenment and the spread of the scientific method, virtually no effective treatments had been developed for any illness.  Before the mid-nineteenth century, when Dr. Ignaz Semmelweis saved countless lives by insisting that doctors wash their hands before attending to women during childbirth, it is very unlikely that being treated by a physician for any condition did more good than harm.  (For those interested in history, a fascinating review of the history of medicine is in this Wikipedia article.)

The actual rigorous testing of treatments (whether they be medications, or surgeries, or psychotherapy) to see whether patients randomized to receive those treatments do better than patients randomized to receive placebo is embarrassingly recent.  Evidence-based medicine is simply educating doctors to look for such studies and to base their treatment of patients on the best scientific evidence available.  Evidence-based medicine began to be recommended in the 1990s!  As the TIME article details, it led to the realization that we were mistreating lots of diseases and lots of patients.  From treating irregular heartbeats in patients with heart attacks to estrogen replacement therapy after menopause, we were using medications that we thought should have been helping patients.  But we only found out we were hurting people after randomized trials were done.

The criticisms of evidence-based medicine in the article strike me as silly.  Practicing evidence-based medicine doesn’t mean I have to ignore my patients’ preferences or values.  It doesn’t mean I can’t be compassionate.  It doesn’t mean I have to prescribe the same thing for everybody.  Practicing evidence-based medicine just means that for some diseases, I know what works and what doesn’t.

(Thanks to my patient Mr. Milton Jupiter for pointing the TIME article to me.)

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First Nonprescription Diet Medicine Approved

This week the Food and Drug Administration approved orlistat for over-the-counter sales.  Orlistat is currently available as the prescription medicine Xenical, and will be marketed over-the-counter under the brand name alli.

The details of the announcement, and reactions by various weight loss experts are detailed in this interesting LA Times article.

Orlistat works by blocking the absorption of fat from the intestine into the blood stream, thereby causing fewer of the calories of each meal to stay in the body.  Unfortunately, this yields only a modest weight loss, and only when used in conjunction with diet and exercise.  This is why, as the article reports, Xenical has not sold very well.

The side effects are also annoying.  Since orlistat blocks fat absorption, it causes greasy stools and diarrhea.  (That’s almost worse than lavender oil!)

GlaxoSmithKline hopes that making alli available over the counter will increase the number of patients who use it.  I hope my patients just eat sensibly and exercise.

Tangential Miscellany:

The Pedometer Project started two weeks ago, and the participants have already walked a total of over a million steps!  If you’d like to join, or if you don’t want to participate in the contest but would just like a pedometer, let me know.

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Skin and Beauty Products Containing Lavender and Tea Tree Oils Should be Avoided

A popular misconception (at least in health-conscious Southern California) is that natural substances are in general safer than artificial ones.  Some people who would never take a prescription medication without educating themselves about the possible side effects use natural products without a second thought.

Last week’s New England Journal of Medicine published an article which is a startling example of natural products having potent and harmful health effects.  The article reports the case studies of three healthy prepubescent boys who developed breast tissue enlargement (gynecomastia).  Blood testing showed that their endogenous hormone levels were normal for prepubescent boys, meaning their bodies were not making excess estrogen which would cause the gynecomastia.

Detailed questioning revealed that all three boys were using topical products containing lavender oil or lavender and tea tree oil.  One boy’s mother was regularly applying a balm containing lavender oil on his skin.  The second boy was using a hair styling gel and a shampoo both of which contained lavender oil and tea tree oil.  The third boy was using lavender-scented soap and lavender-scented skin lotions.  All three boys’ gynecomastia resolved after discontinuation of these products.  Testing in the laboratory of lavender oil and tea tree oil on human breast tissue showed that these oils have estrogen-like effects.

Is there a larger lesson here other than that we should avoid lavender oil and tea tree oil?  Only that we should not assume anything about a substance’s safety from the fact that it’s natural.  Both humans and nature have produced biologically potent dangerous chemicals.  The only way to distinguish them from safe chemicals is to study their effects.

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