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Published on Leave a comment on How Should Physicians Be Evaluated?

Dr. John Mandrola again has a great blog post over at his site and at Medscape. The post is about how employed doctors nowadays are evaluated by a "measure of productivity" - called the relative value unit or RVU. This means one gets a higher score of productivity from the number of procedures done on patients, rather than listening and counseling patients, or reading medical studies or doing medical research.

Which is the opposite of how medical care should be. Also look at the comments after the post. From Dr. John M:

A Corrosive Force in Medical Care

It comes in a large white envelope each month. It’s marked confidential. When I hold it up to the light, I can see through the envelope. I can’t see the details, but the colored graphs give it away. It’s my monthly productivity report. Most employed doctors get these graphs.

These “dashboards” of value include your own productivity as well as many graphs on how you stack up with other doctors across the country. It shows your employer if you are a hard worker. The measure of productivity we use is called the relative value unit or RVU.

Doing an ablation, cath, stent or valve replacement earns a bunch of RVUs. Listening to patients, examining patients, counseling patients, hugging patients earns very few RVUs. Doing important research, teaching colleagues, and reading the medical evidence earns zero RVUs.

Too often, in too many medical systems, RVUs have become the primary unit of success. No, you can’t be a mean and nasty doctor. And no, you can’t be a totally unskilled doctor who has too many complications. But short of those extremes, if you make few waves, have good templates on your electronic health record so documentation is complete, and do tons of procedures, you are valuable.

If, on the other hand, you like slow conservative medicine, or narrative notes rather than templates, or worse, if you are thoughtful and frank about silly policies, you become an outlier. If you do these things, your RVU tally usually does not reach the 75% of standard. Then trouble can come to you.

What’s really scary, though, is that this is the milieu in which a younger generation is learning the craft. I was shocked to learn that a major teaching center (will remain nameless) has its teaching faculty on 100% productivity compensation. Imagine that. Teachers of young people whose paychecks are determined by how many RVUs they generate. This, my friends, is happening in many of the places you go to get health care.... Productivity and the RVU has no place in medical care. There needs to be a different system of valuing the care of people with disease.

Published on Leave a comment on System of Lymph Vessels Discovered In the Brain

I can't resist posting excerpts from a recent article announcing that researchers just found an entirely new lymph system ("lymphatic vessels") in the brain that transports fluid in the brain, and is probably "crucial to metabolic and inflammatory processes".  The image in this post shows the system in the brain. Amazing that it is only now "discovered" - apparently it was noticed by an anatomist 2 centuries ago, but this was pooh-poohed by modern day physicians. Until now. Excerpts from the Atlantic:

Scientists Somehow Just Discovered a New System of Vessels in Our Brains

You are now among the first people to see the brain’s lymphatic system. The vessels in the photo above transport fluid that is likely crucial to metabolic and inflammatory processes. Until now, no one knew for sure that they existed. Doctors practicing today have been taught that there are no lymphatic vessels inside the skull. Those deep-purple vessels were seen for the first time in images published this week by researchers at the U.S. National Institute of Neurological Disorders and Stroke.

In the rest of the body, the lymphatic system collects and drains the fluid that bathes our cells, in the process exporting their waste. It also serves as a conduit for immune cells, which go out into the body looking for adversaries and learning how to distinguish self from other, and then travel back to lymph nodes and organs through lymphatic vessels.

Senior investigator Daniel Reich trained as both a neurologist and radiologist, and his expertise is in inflammatory brain disease. The connection between the immune system and the brain is at the core of what he says he spends most of his time thinking about: multiple sclerosis. The immune system appears to modulate or even underlie many neurologic diseases, and the cells of the central nervous system produce waste that needs to be washed away just like other metabolically active cells. This discovery should make it possible to study how the brain does that, how it circulates white blood cells, and how these processes may go awry in diseases or play a role in aging.

Around the same time, researchers discovered fluid in the brains of mice and humans that would become known as the “glymphatic system.” It was described by a team at the University of Rochester in 2015 as not just the brain’s “waste-clearance system,” but as potentially helping fuel thebrain by transporting glucose, lipids, amino acids, and neurotransmitters.

Wouldn’t neurosurgeons, at some point in their meticulous down-to-the-millimeter dissecting of brains, have stopped and said, “Hey ... what’s this thing?”The lymph vessels probably escaped detection because they’re inside a thick membrane, the dura mater, which is the consistency of leather. They run alongside blood vessels that are much larger, and on MRI the signal that creates the images is dominated by the blood vessels.  

But this pathway appears crucial to life and health. A 2013 study in Science found that glymphatic flow seems to increase by almost double during sleep (in mice). Sleep disturbances are a common feature in Alzheimer’s and other neurologic disorders, and it’s possible that inadequate clearing of the brain’s waste products is related to exacerbating or even causing the disease.... 

The flow of glymphatic fluid can change based on a person’s intake of omega-3 fatty acids, a study showed earlier this year. Preliminary findings like these together suggest a pathway through which nutrition and sleep can be related to neurologic disorders. Optimizing this glymphatic flow could become a central theme for the future of neurologic health. “If all of this is true, there probably is a connection between these two systems, glymphatic and lymphatic,” Reich said. “And that would be one of the major functions of cerebrospinal fluid.”

From The Atlantic. Credit: Daniel Reich/ National Institute of Neurological Disorders and Stroke

Published on Leave a comment on Blueberries and Children’s Mental Processes

For years studies have suggested that eating blueberries and other berries is good for our health (here, here, and here). Now another study suggests that eating wild blueberries benefits children's thinking, specifically attention and "executive function" (mental processes which lets people plan, organize, and complete tasks). What was nice in this study was that it was "double-blind"- which meant that biases couldn't influence the results. 

Flavonoids are a diverse group of phytonutrients (plant chemicals) found in almost all fruits and vegetables. They are powerful antioxidants with anti-inflammatory and immune system benefits. And yes, other studies have also found various benefits to mental processes with an increase of flavonoids in the diet - in both children and adults.

What foods contain flavonoids? There are 6 main classes of flavonoids, and each is found in different foods: - Anthocyanidins – found in red, purple,and blue berries, red wine, and red and purple grapes. - Flavonols - found in onions, leeks, broccoli, Brussels sprouts, kale, tea, berries, beans, and apples. - Flavones - found in parsley, celery, and hot peppers. - Isoflavones - found in soybeans, soy products, and legumes. - Flavanones - found in citrus fruit and tomatoes. - Flavanols - found in tea, red wine, grapes, apples, fava beans, and cocoa. From Medical Xpress:

Blueberries may improve attention in children following double-blind trial

Primary school children could show better attention by consuming flavonoid-rich blueberries, following a study conducted by the University of Reading. In a paper published in Food & Function, a group of 7-10 year olds who consumed a drink containing wild blueberries or a matched placebo and were tested on their speed and accuracy in completing an executive task function on a computer.The double blind trial found that the children who consumed the flavonoid-rich blueberry drink had 9% quicker reaction times on the test without any sacrifice of accuracy. In particular, the effect was more noticeable as the tests got harder.

Previous [Univ. of] Reading research has shown that consuming wild blueberries can improve mood in children and young people, simple memory recall in primary school children, and that other flavonoid rich drinks such as orange juice, can also improve memory and concentration.

Wild blueberries are grown and harvested in North America, and are smaller than regular blueberries, and are higher in flavonoids compared to regular varieties. The double-blind trial used a flavonoid-rich wild blueberry drink, with a matched placebo contained 8.9 g of fructose, 7.99 g of glucose and 4 mg of vitamin C matching the levels of nutrients found in the blueberry drink. [Original study.] 

Published on Leave a comment on Our Genes, Lifestyle, and Longevity

The following study looked at genes and longevity. Researchers from the University of Edinburgh analysed genetic information from more than 600,000 people along with records of their parents' lifespan.

They found that the following factors were correlated with longevity: not smoking or giving up smoking, a higher educational attainment, openness to new experiences, and good cholesterol levels. On the other hand, the following factors were correlated with reduced longevity ("were negatively correlated"): genetic susceptibility to coronary artery disease (CAD), smoking, lung cancer, diabetes, and higher body fat. For example, 1 year of education adds 11 months to expected lifespan, and gaining weight reduces life-span (lose 2 months for every 2.2 lbs extra weight), while losing extra weight increases it. From Science Daily:

Learning and staying in shape key to longer lifespan, study finds

People who are overweight cut their life expectancy by two months for every extra kilogramme [2.2 lbs.] of weight they carry, research suggests. A major study of the genes that underpin longevity has also found that education leads to a longer life, with almost a year added for each year spent studying beyond school. Other key findings are that people who give up smoking, study for longer and are open to new experiences might expect to live longer.

Scientists at the University of Edinburgh analysed genetic information from more than 600,000 people alongside records of their parents' lifespan. Because people share half of their genetic information with each of their parents, the team were able to calculate the impact of various genes on life expectancy. Lifestyle choices are influenced to a certain extent by our DNA -- genes, for example, have been linked to increased alcohol consumption and addiction. The researchers were therefore able to work out which have the greatest influence on lifespan.

They found that cigarette smoking and traits associated with lung cancer had the greatest impact on shortening lifespan. For example, smoking a packet of cigarettes per day over a lifetime knocks an average of seven years off life expectancy, they calculated. But smokers who give up can eventually expect to live as long as somebody who has never smoked. Body fat and other factors linked to diabetes also have a negative influence on life expectancy.

The study also identified two new DNA differences that affect lifespan. The first -- in a gene that affects blood cholesterol levels -- reduces lifespan by around eight months. The second -- in a gene linked to the immune system -- adds around half a year to life expectancy. Data was drawn from 25 separate population studies from Europe, Australia and North America, including the UK Biobank -- a major study into the role of genetics and lifestyle in health and disease.  [Original study.]

Published on Leave a comment on What Role Do Gut Microbes Play In Longevity?

A number of recent studies have suggested that as people age, the community of gut microbes (gut microbiota or gut microbiome) becomes less diverse than in younger people. And note that greater gut microbial diversity is generally viewed as healthy and good. However, now a study done in China finds a different result. The study examined the gut microbes of more than 1000 very healthy people, from ages 3 to over 100, and found that the gut microbial communities were very similar among very healthy people in their mid 30s to over 100 years in age.

Whether this is cause or effect is unknown. But the researchers speculate that the similarities in the gut microbiota among people from their 30s to 100+ is a consequence of an active healthy lifestyle and diet. And it suggests that somehow changing an elderly person's gut microbial community (if it's not "normal") to that of a 30-year-old might help promote health. From Science Daily:

'Ridiculously healthy' elderly have the same gut microbiome as healthy 30-year-olds

In one of the largest microbiota studies conducted in humans, researchers at Western University, Lawson Health Research Institute and Tianyi Health Science Institute in Zhenjiang, Jiangsu, China have shown a potential link between healthy aging and a healthy gut.

With the establishment of the China-Canada Institute, the researchers studied the gut bacteria in a cohort of more than 1,000 Chinese individuals in a variety of age-ranges from 3 to over 100 years-old who were self-selected to be extremely healthy with no known health issues and no family history of disease. The results showed a direct correlation between health and the microbes in the intestine. ....The study, published this month in the journal mSphere, showed that the overall microbiota composition of the healthy elderly group was similar to that of people decades younger, and that the gut microbiota differed little between individuals from the ages of 30 to over 100.

"The main conclusion is that if you are ridiculously healthy and 90 years old, your gut microbiota is not that different from a healthy 30 year old in the same population," said Greg Gloor, the principal investigator on the study and also a professor at Western's Schulich School of Medicine & Dentistry and Scientist at Lawson Health Research Institute. Whether this is cause or effect is unknown, but the study authors point out that it is the diversity of the gut microbiota that remained the same through their study group.

"This demonstrates that maintaining diversity of your gut as you age is a biomarker of healthy aging, just like low-cholesterol is a biomarker of a healthy circulatory system," Gloor said. The researchers suggest that resetting an elderly microbiota to that of a 30-year-old might help promote health. "By studying healthy people, we hope to know what we are striving for when people get sick," said Reid. [Original study.]

Centenarian in Bama County, China. Credit: National Geographic.

Published on Leave a comment on Magnesium and Dementia Link?

Interesting study finding - that both high and low levels of magnesium is associated with a higher risk of dementia. Magnesium is an essential mineral needed for more than 300 biochemical reactions in the body. According to a large study done in the Netherlands of people who were followed for about 8 years - there was a U-shaped incidence of dementia based on their levels of magnesium. The lowest incidence was in those with "in the middle" normal levels of magnesium in the blood. All the study participants were mentally healthy when the study started.

The researchers stated that magnesium levels are considered "relatively stable over time", but a limitation of the study is that they only looked at magnesium levels once - at the beginning of the study, so they could have changed over time. Of course further studies are needed. [Other posts on magnesium and health - here, here, and here.]

Magnesium is widely available in foods. Foods that are good sources of magnesium include: spinach and other dark green leafy vegetables, almonds, cashews, peanuts, bananas, soybeans, kidney and black beans (legumes), whole grains, lentils, seeds, yogurt, brown rice, potatoes, and avocados. It is recommended that magnesium is obtained from the diet, and not from supplements (due to health risks from high doses). From Science Daily:

Both high, low levels of magnesium in blood linked to risk of dementia

People with both high and low levels of magnesium in their blood may have a greater risk of developing dementia, according to a study published in the September 20, 2017, online issue of Neurology®, the medical journal of the American Academy of Neurology.

The study involved 9,569 people with an average age of 65 who did not have dementia whose blood was tested for magnesium levels. The participants were followed for an average of eight years. During that time, 823 people were diagnosed with dementia. Of those, 662 people had Alzheimer's disease. The participants were divided into five groups based on their magnesium levels. Both those with the highest and the lowest levels of magnesium had an increased risk of dementia, compared to those in the middle group.

Both the low and high groups were about 30 percent more likely to develop dementia than those in the middle group. Of the 1,771 people in the low magnesium group, 160 people developed dementia, which is a rate of 10.2 per 1,000 person-years. For the high magnesium group, 179 of the 1,748 people developed dementia, for a rate of 11.4 per 1,000 person-years. For the middle group, 102 of the 1,387 people developed dementia, for a rate of 7.8. Kieboom noted that almost all of the participants had magnesium levels in the normal range, with only 108 people with levels below normal and two people with levels above normal. [Original study.]

Published on Leave a comment on Pesticide Use During Pregnancy and Childhood Brain Tumors

Once again a study finds that pesticide exposure is linked to an adverse health effect - that pesticide exposure in the home during pregnancy and early childhood is linked to an elevated risk of brain tumor in the child. Other studies have also found that pesticides used in the home are associated with a higher risk of childhood cancers.

This is because pesticides do cross the placental barrier, as the study researchers point out: "There is evidence that pesticides cross the fetal-placental barrier since residues of some insecticides have been found in umbilical cord blood, neonatal hair, and meconium following maternal exposure during pregnancy." Also, the International Agency for Research on Cancer (IARC) has classified "more than twenty pesticide chemical compounds as potential human carcinogens".

The following are examples (but there are more) of other studies finding pesticide and childhood cancer links: A meta-analysis published in 2015 in Pediatrics by researchers at Harvard University found that children exposed to indoor insecticides (also herbicides) have a higher risk of certain childhood cancers, specifically leukemia, lymphomas, and brain tumors. A 2013 study published in Cancer Causes and Control found that professional pest control applications in the home within a year of conception and during pregnancy was associated with a higher risk of childhood brain tumors. A review of studies published in 2010 found that pesticide exposure during pregnancy and childhood increased the risk of childhood leukemia.

The good news is that there are alternatives to exposing fetuses and children to toxic pesticides at home - by using alternative ways of dealing with pests, such as least toxic Integrated Pest Management (IPM) or organic methods. That means doing other things (such as sealing or caulking holes, putting out traps and baits, vacuuming), a focus on least toxic methods and on prevention (here and here), rather than routinely applying toxic pesticides. If needed, least toxic pesticides include boric acid and vinegar. Other sources of pesticide exposure for pregnant women and children are foods and exposure in settings outside the home - perhaps even a friend's yard. By the way, pesticide exposure for everyone is linked to a higher risk of health problems, not just pregnant women and children.

From Science Daily: Pesticide use during pregnancy linked to increased risk of childhood brain tumors

Previous epidemiological studies have suggested that exposure to pesticides during pregnancy may have a possible role in the development of childhood brain tumors. In a new International Journal of Cancer analysis, researchers found a link between maternal residential pesticide use -- particularly insecticides -- and the risk of childhood brain tumors. The analysis included 437 malignant childhood brain tumor cases and 3102 controls from two French studies. Pesticide use was associated with a 1.4-times increased risk of childhood brain tumors.

The investigators noted that many pesticide compounds are classified as probable carcinogens, and there is evidence that some insecticides can pass through the feto-placental barrier. "Although such retrospective studies cannot identify specific chemicals used or quantify the exposure, our findings add another reason to advise mothers to limit their exposure to pesticides around the time of pregnancy," said Nicolas Vidart d'Egurbide Bagazgoïtia, lead author of the study. [Original study.]

Published on Leave a comment on Reduce the Number of Urinary Tract Infections By Drinking More Water?

The following study was presented at the recent annual meeting of the Infectious Diseases Society of America. A study of women prone to recurrent urinary tract infections (UTIs) found that increasing daily fluid intake by 1.5 liters of water a day (about three 16-ounce glasses) in addition to their usual daily fluid intake - had a reduced incidence of UTIs that year by 48%, as compared to women who drank their usual daily fluid amount (1.2 liters).

So the women who drank about 2.8 liters (water and other beverages) a day had 1.6 UTIs that year on average, and the women who drank their usual fluid amount had 3.1 UTIs on average. Which also resulted in fewer courses of antibiotics in the increased water group. A great result.

Bottom line: Drinking a lot more fluids daily (to flush the bacteria in the bladder and urinary tract) may benefit those with recurrent UTIs. [See more posts on UTI research, and the one treatment that many swear by as truly effective (D-mannose)]. From Futurity:

Women who get frequent UTIs may reduce risk by drinking plenty of water

Drinking an additional three pints of water a day may keep the urinary tract infection (UTI) away - at least for women who are prone - suggests a study being presented at IDWeek [Infectious Diseases Society of America Week] 2017. The study found women at risk of UTIs who increased their water intake by about that much water every day were nearly half as likely to get UTIs as women who did not.

Women are more likely to get UTIs than men in part because the urethra is shorter, meaning it is easier for bacteria to travel from the rectum and vagina to the bladder. Drinking more fluids increases the rate of flushing of bacteria from the bladder and also likely reduces the concentration of bacteria that enter the bladder from the vagina. This reduces the opportunities for bacteria to attach to cells that line the urinary tract, which is necessary to cause an infection, Dr. Hooton said.

The study included 140 healthy premenopausal women who had at least three UTIs in the last year and reported low daily fluid intake. Half of the women (70) who served as the control group continued their usual daily fluid intake, while the remainder were told to drink 1.5 liters of water a day (about three 16-ounce glasses) in addition to their usual daily fluid intake. After one year, women in the control group had 3.1 UTIs on average, whereas those in the water group had 1.6 UTIs on average, a 48 percent reduction. As a result, the water group averaged fewer regimens of antibiotics (1.8) than the limited-water group (3.5), a reduction of 47 percent.

Researchers followed the women throughout the year using visits and telephone calls. They documented that over the course of the study, on average women in the water group increased their daily water intake by 1.15 liters (about 2-1/2 pints) for a total daily fluid intake (including water and other beverages) of 2.8 liters, whereas women in the control group did not increase the amount of water they drank and had a total daily fluid intake of 1.2 liters.

Published on Leave a comment on Some Benefits of Black tea

OK, this study was done in mice, but it's the kind of study results that everyone hopes (and thinks) is also true for humans. So drink a nice cuppa black tea and think about how you're increasing bacteria in the gut associated with weight loss.

Black tea (as well as green tea) has polyphenols that stimulate the growth of gut bacterium and the formation of short-chain fatty acids. By the way, the mice were given decaffeinated tea extracts, so theoretically both decaf and caffeinated tea should have benefits. The big question though is - will drinking black tea daily actually result in weight loss? From Medical Xpress:

Black tea may help with weight loss, too

UCLA researchers have demonstrated for the first time that black tea may promote weight loss and other health benefits by changing bacteria in the gut. In a study of mice, the scientists showed that black tea alters energy metabolism in the liver by changing gut metabolites. The research is published in the European Journal of Nutrition. The study found that both black and green tea changed the ratio of intestinal bacteria in the animals: The percentage of bacteria associated with obesity decreased, while bacteria associated with lean body mass increased.

Previous studies indicated that chemicals in green tea called polyphenols are absorbed and alter the energy metabolism in the liver. The new findings show that black tea polyphenols, which are too large to be absorbed in the small intestine, stimulate the growth of gut bacterium and the formation of short-chain fatty acids, a type of bacterial metabolites that has been shown to alter the energy metabolism in the liver.

The researchers also collected samples from the mice's large intestines (to measure bacteria content) and liver tissues (to measure fat deposits). In the mice that consumed either type of tea extract, there was less of the type of bacteria associated with obesity and more of the bacteria associated with lean body mass. However, only the mice that consumed black tea extract had an increase in a type of bacteria called Pseudobutyrivibrio, which could help explain the difference between how black tea and green tea change energy metabolism.

The new study also concluded that both green tea and black tea have different effects on liver metabolism. According to Henning, the molecules in green tea are smaller and can more readily be absorbed into the body and reach the liver directly, while black tea molecules are larger and stay in the intestine rather than being absorbed. When black tea molecules stay in the intestinal tract, they enhance the growth of beneficial bacteria and the formation of microbial metabolites involved in the regulation of energy metabolism. [Original study.]

Published on Leave a comment on Exercise and Lower Rates of Depression

A newly published study suggests that exercising an hour or more per week could lower the incidence of depression. The study followed 33,000 adults in Norway  for 11 years, and found that an hour or more of weekly exercise was associated with 12% fewer cases of developing depression. But note that it didn't prevent anxiety.

Interestingly, the researchers found that "regular leisure-time exercise of any intensity" had these positive effects - it doesn't have to be aerobic or incredibly strenuous exercise. Exercise is associated with a number of biological changes that could have an impact on mental health. From Science Daily:

One hour of exercise a week can prevent depression

A landmark study led by the Black Dog Institute has revealed that regular exercise of any intensity can prevent future depression -- and just one hour can help. Published in the American Journal of Psychiatry, the results show even small amounts of exercise can protect against depression, with mental health benefits seen regardless of age or gender.

In the largest and most extensive study of its kind, the analysis involved 33,908 Norwegian adults who had their levels of exercise and symptoms of depression and anxiety monitored over 11 years. The international research team found that 12 percent of cases of depression could have been prevented if participants undertook just one hour of physical activity each week.

A healthy cohort of participants was asked at baseline to report the frequency of exercise they participated in and at what intensity: without becoming breathless or sweating, becoming breathless and sweating, or exhausting themselves. At follow-up stage, they completed a self-report questionnaire (the Hospital Anxiety and Depression Scale) to indicate any emerging anxiety or depression.

Results showed that people who reported doing no exercise at all at baseline had a 44% increased chance of developing depression compared to those who were exercising one to two hours a week. However, these benefits did not carry through to protecting against anxiety, with no association identified between level and intensity of exercise and the chances of developing the disorder. [Original article.]