Pessimism, from the Latin pessimus (worst), is a state of mind which negatively colors the perception of life, especially with regard to future events.

Understanding pessimism is not that simple  . Some people argue  optimism   represents a strong mind while  a pessimism  is the domain of the weak . But it is not necessarily true.  Both pessimist and optimist are unreal , and playing the dangerous game of predicting the future. So realism is the answer .

In this era of information highways , commercial exploitation of science ,  our thought process is grossly determined by our perception of events.We hardly have an intention or time to analyse our thought process.

• An optimist  ( Rather , unregulated optimist ! ) is a person who welcomes  any growth good or bad.*
• A pessimist  is  a  person who welcomes only good growth.*

So how to identify good growth ? That is the million dollar question!

• Many of the  optimists may not  bother about the final outcome of a treatment *
• A pessimist bothers only about that .
• An optimist  rarely asks questions, blindly accepts every thing !
• A pessimist never believes any thing !

Actually the fundamental principle of scientific medicine lies in proving the null hypothesis null and void.Any treatment is useless until proved other wise .  So pessimist can be argued to follow true science , while  many of  the hardcore  optimists are blind believers .

*It may be  a harsh   way of  interpreting an optimist  but  uncontrolled optimism  has played havoc in our  patients like many of the failed treatments (Some of them released prematurely into patient domain   has  killed many lives  . Power of positive thinking should be within the  realms of scientific feasibility !

So in  our  journey   to  conquer human health ,   we   may  proceed with  an optimistic mind and  a pessimistic eyes !

This understanding is all the more important in this era of contaminated science .It is a well known fact now last 50 years of  planet earth has inflicted the maximum damage  to ourself than our ancestors did in 5000 years. That’s why we are compelled to meet at Copenhagen .(We never learn from our mistakes, that’s a different story !) .

There is definite and urgent  need for world summit  on  cleansing the medical science from  the clutches commerce  and ignorance . A medical green house effect  with dangerous holes in health care  is imposing on us (Another pessimistic thought . . . of course in the interest of human kind !)

World health organization ,  a sleeping giant has to be awakened on this issue

Picture courtesy :  http://www.flickr.com/photos/ersama/2617189643/

Final message:

Mankind has evolved over many millenniums ,  with a single   purpose of living that is reproduction and propagation of our genre without harming the environment and other species.

Unrestricted  and unregulated growth of any kind is dangerous we call it as malignancy in pathology .In science , we tend to call it a” great future ”

Our  sixth sense*  has  outgrown  miserably  out of  reality we decided to take on the nature and GOD .Now many developing country men do not believe in death .They are fighting a losing battle against the God. And they suffer with escalating health costs of keeping the elderly alive who are at  knocking at the doors of heaven or Hell. The same countries which deny funds for curable illnesses of the poor is a different story altogether !

The principle of modern medicine  would ideally  be

• Reduce human suffering irrespective of economic status
• Curing a illness if there is a cure
• Prolonging life if there is useful purpose
• Allow a good quality death if there is no cure.
• Most importantly  , prey to god give us strength and capacity to identify which is good and which is bad for our patients  .

Read and learn for a  complete guide on optimism and pessimism

* It  is  important to recognise , the same sixth sense  has   made it possible to share our views through a great tool of  Internet & wordpress . So we should not be against the growth of science but against the misuses and wrong interpretations of it .

Pessimism

Optimism

The traditional characters  of  a pessimist

I was excited to see an article, “A Look at the Low-Carbohydrate Diet,” in the December 3, 2009, New England Journal of Medicine.  I was quickly disappointed.

Expecting a scholarly review of low-carb eating in humans, I found an exposition of a diet study in mice.  And not just your garden-variety mice.  These were a lab strain deficient in apolipoprotein E, which makes them particularly susceptible to atherosclerosis when fed a “Western” high-fat, moderate-protein, moderate-carbohydrate diet instead of standard lab chow.

Click on the HeartWire reference below for a discussion of the original mouse research.  I wrote a short post about it in August, 2009.

The article author, Dr. Steven R. Smith, states the usual concern that high-fat (especially saturated fat), high-protein, low-carb diets may cause cardiovascular disease such as atherosclerosis (hardening of the arteries).  He doesn’t mention the scientific evidence showing little or no role of total and saturated fat in cardiovascular disease.

I give credit to him for mentioning that high-fat low-carb diets area associated with improvement in several cardiovascular risk factors such as HDL cholesterol and blood pressure.  He thought they also improve ( lower) LDL cholesterol levels—not something I’ve been impressed with.  He didn’t mention the lowering of triglycerides so often seen. 

Dr. Smith explains that, compared with controls, mice eating the Western high-fat low-carb diet demonstrated progression of atherosclerosis, perhaps mediated by elevated nonesterified fatty acids and low numbers of endothelial progenitor cells.  These are not yet considered classic cardiovascular risk factors in humans.

To quote Dr. Smith, his main point is that . . .

The work of Foo et al suggests that the [high-fat low-carb] diet might increase the risk of cardiovascular disease through mechanisms that have nothing to do with these “usual suspects” [e.g., LDL and HDL cholesterol, blood pressure, C-reactive protein] and so provides a note of caution against reliance on the traditional cardiovascular risk factors as a gauge of safety.

He rightfully calls for investigation of these issues in humans, but . . .

In the meantime, the ageless advice applies to the consumer of the [high-fat low-carb] diet and other fad diets: caveat emptor.

Take Home Points

I agree that human studies are needed.

As the evidence in favor of the safety and efficacy of high-fat low-carb diets increases, the reigning medical establishment is looking for new ways to discredit them.  This attempt is pathetic.

Unfortunately, the typical physician reading NEJM will skim this article and conclude, “Yeah, I was right—the Atkins diet causes heart disease.  Low-fat high-carb is still the best.” 

If you have beloved pet mice that are deficient in apolipoprotein E, don’t feed them a high-fat low-carb diet.

Steve Parker, M.D.

References:

Smith, Steven R.  A Look at the Low-Carbohydrate Diet.  New England Journal of Medicine, 361 (2009): 2,286-2,288.  [This may cost you $10 USD.]

Foo, S.Y., et al.  Vascular effects of a low-carbohydrate high-protein diet.  Proceedings of the National Academy of Sciences of the United States of America, 106 (2009): 15418-15423.   doi: 10.1073/pnas.0970995106  [This may cost you $10 USD.]

Busko, Marlene.  Atherosclerosis heightened in mice fed low-carb, high-protein diet.  HeartWire, August 26, 2009.  [Free]

What are the fundamental  difference between randomised  studies and observational studies ?

New discoveries come from shrewed  observations made in bedside or labside  while ,  randomised studies evaluate these discoveries for it’s effectiveness or futileness  .

Let us realise ,  RCTs   primarily  never  contribute to  generation of  original  concepts or discoveries  ! .It is a  statistical tool to assess an observation .

Click below to reach the excellent knowledge  source on above  the issue .

PLoS Medicine: Observational Research, Randomised Trials, and Two Views of Medical Science

The fact that  observational studies are done with open eyes &  mind ,  it is  obvious it  demands  intense conceptualization and thinking .
Blinded studies  are  mechanical studies . It is pure statistical research . It requires  no thinking  , medical  mind , in fact one can do it with eyes closed as it is a strict protocol driven  , even a  non medical men  can do a  medical research , while it needs a  alert mind to do a observational study .

Observational studies , especialy  when done retrospectively  has  zero bias  as the case selection and  the potential intervention are completed even before the research question  is raised. In fact many of the  greatest medical breakthrough comes from retrospective analysis. Of course this has to be proved prospectively  preferably in a randomised fashion.

So , we the medical professionals ,  shall  do great observational  research with open eyes and mind and let the  the statisiticins do the outcome analysis blind folded .

If the core medical professionals are bothered more about  randomised blinded  studies ,which is  meant only for evaluation purposes , the  future of intellectual  medical research is  going to be in jeopardy!

If you or your loved ones take any of the following drugs: Zetia, Vytorin or Inegy, you may need to see your doctor as soon as possible to have your medications evaluated.

A new study, just published in the New England Journal of Medicine, evaluated the addition of either Extended-Release Niacin (also known as vitamin B3 or nicotinic acid) or Ezetimibe (found in the above named drugs) to statin therapy for reduction of cardiovascular risk factors.  The study found that despite the fact that Ezetimibe was designed to further lower bad cholesterol levels, the end result was thickening of the arteries (a bad thing!) and increased rates of cardiovascular events.

Authors of the study state: “Thus, we believe that prudent clinical practice currently favors the avoidance of ezetimibe, with consideration of further restriction on its use in lieu of clinically validated regimens, until its net effect on clinical outcomes can be fully ascertained.”

It is important that you not change your medication without seeing your doctor first.  It is also important to know that if you can tolerate Extended-Release Niacin, this may be a better choice for reduction of cardiovascular risk factors, as we have previously recommended.

www.symtrimics.com

http://twitter.com/mtnmd

NEJM, Nov 15, 2009, Extended-Release Niacin or Ezetimibe and Carotid Intima-Media Thickness, Taylor et al

The NEJM’s breaks the  hidden truths about cardiopulmonary bypass in a beating  heart. The irony in medical science is   ,  trend setting  land mark articles usually arrive  very late . . .   to disappoint  all those  patients who  got the wrong treatment ! Off pump by pass is definitely one among them . . .

The major reason for off pump CABG’s s poor showing is

• The surgeon’s  conflict   in defining   what is successful CABG  .The success of CABG   is   in    relief of symptoms & providing good bypass graft  with long term patency   .It is not in  less  thoracic trauma or in  a quick hospital discharge  !
• The second major reason is denial of  the fact  that off pump CABG is indeed inferior  and hence no course correction was attempted  ! ( And  now that it   has become a hard  evidence   we expect some changes  . It  required almost 10 years for our cardiology community to  recognise this .)
• Lesion access and  difficulty in mobilizing LIMA .Many times the the point of anastomoses is preselected by the accessibility and technical issues rather than lesion guided approach .This often happens than we imagine , and this could be a very bad advertisement for off  pump CABG

Click on the link to NEJM abstract  ROOBY study

http://content.nejm.org/cgi/content/short/361/19/1827

My, how far CME has come in the age of technology! It seems like just yesterday that CME was in the infancy stage of being offered through websites and portals. But now with the advent of ReachMD and its unique XM Radio/iPhone/social media approach to CME, physicians truly have a wide range of mediums to increase their knowledge. And it doesn’t stop there. According to the Bernard Sklar’s CME List their are more than 300 CME sites/portals/apps/podcasting available through the internet today compared to 87 just 10 years ago. And when you look at the physician participants from that time frame the numbers have increased by more than 4 million (181,922 to 4,365,013).

So where are all of these physicians spending most of their time? The top 30 CME sites (according to #hours available) are below.

The Top 30 CME Sites (according to the number of hours offered)

1.    Contemporary Forums-Online CE Library
2.   Audio Digest
3.   Challenger Online Lecture Hall
4.   CMEWeb
5.   Medscape CME Center
6.   Virtual Lecture Hall
7.   Clinical Directors Network (CDN)
8.   Pri-Med Online
9.   NetCE Continuing Education on the Internet
10.  American Society for Clinical Pathology
11.   RSNA (Radiological Soc North America)
12.   TheAnswerPage
13.   Practical Reviews Online
14.   CardioVillage
15.   Sullivan Group (The)
16.   theheart.org
17.   CME Institute
18.   CMELectures.org
19.   Oncologist (The)
20.  Harvard Online CME
21.   Drexel MCP Hahnemann Virt Grand Rounds
22.   MedRisk Online
23.   Johns Hopkins Advanced Studies Courses
24.   American Acad Ped PREP Self-Ass Online
25.   Neurology (J American Acad Neurology)
26.   Washington University (St Louis)
27.   Children’s of Minnesota Grand Rounds
28.   FreeCME
29.   NEJM Weekly CME Program
30.   American Acad of Orthopaedic Surgery OKO

La publicación New England Journal of  Medicine ofrece cada semana una imagen acompañada del caso clínico. Además te ofrecen la oportunidad de descargar la imagen y el caso en formato pdf o en una diapositiva power point para utilizarla con fines educativos o de investigación.

Ejemplo:

By Jacob Molyneux, blog editor/senior editor

How can we know if a drug really works? Gary Schwitzer, publisher of HealthNewsReview.org (an incisive Website that grades the quality of health news reporting) addresses this question on his blog this week by drawing attention to a recent perspective piece published in the New England Journal of Medicine (NEJM). It’s called “Lost in Transmission — FDA Drug Information That Never Reaches Clinicians” and it states the problem clearly:

The 2009 federal stimulus package included $1.1 billion to support comparative-effectiveness research about medical treatments. No money has been allocated — and relatively little would be needed — to disseminate existing but practically inaccessible information about the benefits and harms of prescription drugs. Much critical information that the Food and Drug Administration (FDA) has at the time of approval may fail to make its way into the drug label and relevant journal articles.

The most direct way that the FDA communicates the prescribing information that clinicians need is through the drug label. Labels, the package inserts that come with medications, are reprinted in the Physicians’ Desk Reference and excerpted in electronic references. To ensure that labels do not exaggerate benefits or play down harms, Congress might have required that the FDA or another disinterested party write them. But it did not. Drug labels are written by drug companies, then negotiated and approved by the FDA.

One example given in the NEJM article is the sleeping pill Lunesta:

Clinicians who are interested in (Lunesta’s) efficacy cannot find efficacy information in the label: it states only that Lunesta is superior to placebo. The FDA’s medical review provides efficacy data, albeit not until page 306 of the 403-page document. In the longest, largest phase 3 trial, patients in the Lunesta group reported falling asleep an average of 15 minutes faster and sleeping an average of 37 minutes longer than those in the placebo group. However, on average, Lunesta patients still met criteria for insomnia and reported no clinically meaningful improvement in next-day alertness or functioning.

What is the real benefit of a particular drug? You may not find it in the label.

FDA approval does not mean that a drug works well; it means only that the agency deemed its benefits to outweigh its harms. This judgment can be difficult to make: benefits may be small, important harms may not have been ruled out, and the quality of the trials may be questionable. Since the nature — or even existence — of reviewer uncertainty is not addressed in the label, clinicians cannot distinguish drugs that reviewers endorsed enthusiastically from those they viewed with great skepticism.

How can we make sure existing evidence reaches consumers and clinicians in a direct and useful fashion? The authors recommend that drug labels include an easily found box listing the evidence regarding harms and benefits of the drug. Or should we just go on buying drugs like Lunesta because their television advertisements suggest they have magical transformative properties?

A ‘Post Mortem” in the midst of health reform hysteria courtesy of the New England Journal of Medicine (Note: this is NOT for those craving sound bytes for emotive grand standing at ‘town halls’; will require active cerebral engagement):

President Barack Obama has placed U.S. health care reform at the top of his domestic agenda, and months of legislative work on the issue have resulted in five bills — three in the House of Representatives and two in the Senate — that proponents believe will move the country in the direction of universal coverage, a fairer insurance system, and slower escalation of health care costs. On September 25, in a symposium cosponsored by the Journal and the Harvard School of Public Health, four health policy experts — Henry Aaron, Katherine Baicker, Jacob Hacker, and Mark Pauly — explored the promise and limitations of the bills and the outlook for reform. The discussion was moderated by Arnold Epstein of the Journal and the Department of Health Policy and Management at HSPH.

What follows is a portion of the transcript of the program featuring:  Arnold M. Epstein, M.D., Henry J. Aaron, Ph.D., Katherine Baicker, Ph.D., Jacob S. Hacker, Ph.D., and Mark V. Pauly, Ph.D.

For the complete transcript click here. Page one only is pasted below:

Perspective Roundtable: Health Care Reform in Perspective.

Introduction

DR. ARNOLD EPSTEIN: Past, present, and future. That’s the sequence, that’s how it unfolds. Let’s look back. When President Obama was candidate Obama, just a year ago, when we did our last forum here, he was very clear about his domestic priorities. The economy was number one, and after that was health care and energy. And he has not wavered one bit. And if you look at how health policy has unfurled from the White House, I wouldn’t be the first one to comment that it looks like a redux of reverse Clintonism. For if you go back to 1993, President Clinton wrote the first textbook. He came out in January, and at the end of the month, created a task force of federal bureaucrats, advisors, and counselors to ultimately produce a 1300-page document called the Health Security Act. Enormous in its scope and complexity, and what was remarkable about it is it came totally out of the executive branch. Not a whit out of Congress. It took until September before it was even introduced to the populace, leave alone going through the committees. And the President, to demonstrate his commitment to it, said, with a typical Clintonian gesture, it will be universal coverage and not one bit less. And he appointed his wife to head the task force putting the bill forth as an additional sign of his resolve, not to mention her own formidable ability. And despite that ability, and his resolve, it did not work, and we did not get health reform last time. No legislation.

So this time, we see President Obama really following a totally different script. No executive task force, just the opposite. This is Congress’s job, to propose the laws and make them. And it was the executive’s job, at least until 2 weeks ago, to merely espouse eight very broad principles and to partake in a very modest public relations campaign — getting information, regional forums, things like that. And Mr. Obama made it clear that he wanted something simple, not with labyrinthine complexity. Let’s stick to what we’re familiar with. He made it clear that he was ready to compromise — I have eight principles, but I’m ready to give in. And, oh, yes, please get on it, time is of the essence.

And so now we’ve come full circle towards the endgame. It’s September, and 2 weeks ago today, President Obama took eight principles and started to hone in on some of the things that he thinks are most important. And in Congress, we’ve seen the Congress do its job, still doing its job. Five committees of jurisdiction, three of them in the House, Ways and Means, Labor, and Energy and Commerce, have produced HR 3200, slightly different variants out of each committee, but basically the same bill. The HELP Committee — Health, Education, Labor, and Pensions in the Senate — has produced a bill on the delivery system, but they can’t touch finance. And the Finance Committee is marking up as we speak.   Cont’d

Perspective Roundtable: Health Care Reform in Perspective.

Introduction

DR. ARNOLD EPSTEIN: Past, present, and future. That’s the sequence, that’s how it unfolds. Let’s look back.

When President Obama was candidate Obama, just a year ago, when we did our last forum here, he was very clear

about his domestic priorities. The economy was number one, and after that was health care and energy. And he has

not wavered one bit. And if you look at how health policy has unfurled from the White House, I wouldn’t be the first

one to comment that it looks like a redux of reverse Clintonism. For if you go back to 1993, President Clinton wrote

the first textbook. He came out in January, and at the end of the month, created a task force of federal bureaucrats,

advisors, and counselors to ultimately produce a 1300-page document called the Health Security Act. Enormous in

its scope and complexity, and what was remarkable about it is it came totally out of the executive branch. Not a whit

out of Congress. It took until September before it was even introduced to the populace, leave alone going through

the committees. And the President, to demonstrate his commitment to it, said, with a typical Clintonian gesture, it

will be universal coverage and not one bit less. And he appointed his wife to head the task force putting the bill forth

as an additional sign of his resolve, not to mention her own formidable ability. And despite that ability, and his

resolve, it did not work, and we did not get health reform last time. No legislation.

So this time, we see President Obama really following a totally different script. No executive task force, just the

opposite. This is Congress’s job, to propose the laws and make them. And it was the executive’s job, at least until

2 weeks ago, to merely espouse eight very broad principles and to partake in a very modest public relations

campaign — getting information, regional forums, things like that. And Mr. Obama made it clear that he wanted

something simple, not with labyrinthine complexity. Let’s stick to what we’re familiar with. He made it clear that he

was ready to compromise — I have eight principles, but I’m ready to give in. And, oh, yes, please get on it, time is

of the essence.

And so now we’ve come full circle towards the endgame. It’s September, and 2 weeks ago today, President Obama

took eight principles and started to hone in on some of the things that he thinks are most important. And in

Congress, we’ve seen the Congress do its job, still doing its job. Five committees of jurisdiction, three of them in the

House, Ways and Means, Labor, and Energy and Commerce, have produced HR 3200, slightly different variants out

of each committee, but basically the same bill. The HELP Committee — Health, Education, Labor, and Pensions in

the Senate — has produced a bill on the delivery system, but they can’t touch finance. And the Finance Committee

is marking up as we speakPerspective Roundtable: Health Care Reform in Perspective.

Introduction

DR. ARNOLD EPSTEIN: Past, present, and future. That’s the sequence, that’s how it unfolds. Let’s look back.

When President Obama was candidate Obama, just a year ago, when we did our last forum here, he was very clear

about his domestic priorities. The economy was number one, and after that was health care and energy. And he has

not wavered one bit. And if you look at how health policy has unfurled from the White House, I wouldn’t be the first

one to comment that it looks like a redux of reverse Clintonism. For if you go back to 1993, President Clinton wrote

the first textbook. He came out in January, and at the end of the month, created a task force of federal bureaucrats,

advisors, and counselors to ultimately produce a 1300-page document called the Health Security Act. Enormous in

its scope and complexity, and what was remarkable about it is it came totally out of the executive branch. Not a whit

out of Congress. It took until September before it was even introduced to the populace, leave alone going through

the committees. And the President, to demonstrate his commitment to it, said, with a typical Clintonian gesture, it

will be universal coverage and not one bit less. And he appointed his wife to head the task force putting the bill forth

as an additional sign of his resolve, not to mention her own formidable ability. And despite that ability, and his

resolve, it did not work, and we did not get health reform last time. No legislation.

So this time, we see President Obama really following a totally different script. No executive task force, just the

opposite. This is Congress’s job, to propose the laws and make them. And it was the executive’s job, at least until

2 weeks ago, to merely espouse eight very broad principles and to partake in a very modest public relations

campaign — getting information, regional forums, things like that. And Mr. Obama made it clear that he wanted

something simple, not with labyrinthine complexity. Let’s stick to what we’re familiar with. He made it clear that he

was ready to compromise — I have eight principles, but I’m ready to give in. And, oh, yes, please get on it, time is

of the essence.

And so now we’ve come full circle towards the endgame. It’s September, and 2 weeks ago today, President Obama

took eight principles and started to hone in on some of the things that he thinks are most important. And in

Congress, we’ve seen the Congress do its job, still doing its job. Five committees of jurisdiction, three of them in the

House, Ways and Means, Labor, and Energy and Commerce, have produced HR 3200, slightly different variants out

of each committee, but basically the same bill. The HELP Committee — Health, Education, Labor, and Pensions in

the Senate — has produced a bill on the delivery system, but they can’t touch finance. And the Finance Committee

is marking up as we speak.

The New England Journal of Medicine　NEJM
下記2論文同日掲載 Published at www.nejm.org October 8, 2009

(10.1056/NEJMoa0906695)
Hospitalized Patients with 2009 H1N1 Influenza in the United States, April–June 2009
Seema Jain, M.D., et al.
　http://content.nejm.org/cgi/content/full/NEJMoa0906695
北半球(US)
流行早期　From May 1, 2009, to June 19, 2009

Of the 272 patients we evaluated, 67 (25%) were admitted to an ICU; 19 died.

　入院患者の死亡率 7% (19/272 = 0.07)

(10.1056/NEJMoa0908481)
Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand
The ANZIC Influenza Investigators
　http://content.nejm.org/cgi/content/full/NEJMoa0908481
南半球(Australia and New Zealand)
冬季 From June 1 through August 31, 2009

a total of 722 patients with confirmed infection with the 2009 H1N1 virus (**) were admitted to an ICU in Australia or New Zealand.
a total of 103 of the 722 patients (**) had died,

　集中治療室(ICU)入院患者の死亡率 14.3% (103/722 = 0.143)

El Mundo-Maria Sainz

El programa se actualiza con datos de organismos oficiales y medios de comunicación .Los usuarios pueden enviar reportes desde el iPhone para informar de nuevos brotes

 Aunque en los últimos meses así pueda parecerlo, la gripe A no es ni la única enfermedad ni la más importante. ‘Health map’, un mapa ‘on line’ de la salud en el mundo, ofrece de un vistazo una valoración de los distintos brotes presentes en el planeta, como el cólera, el dengue o el sida. Ahora, el éxito de esta iniciativa ha llevado a sus creadores a lanzar una aplicación para iPhone que identifica las epidemias que rodean al usuario. 70.000 personas se la descargaron en dos semanas.

El citado atlas digital se nutre de forma automática de distintas fuentes de información: organismos oficiales (como los Centros de Control de Enfermedades de EEUU o la Organización Mundial de la Salud) y medios de comunicación. De esta manera, el sistema se actualiza según se van haciendo públicos los nuevos datos y ofrece una visión general de los principales brotes.

Según explican sus creadores, John S. Brownstein y Clark C. Freifeld, del Hospital Infantil de Boston (EEUU), el hecho de que los datos no sólo provengan de organismos oficiales agiliza bastante el sistema. “Por ejemplo, en España, detectamos un brote de legionella gracias a la información publicada en la prensa, antes de que la dieran a conocer las organizaciones”, explica a elmundo.es Brownstein.

En este sentido, los responsables de la herramienta aseguran que los propios organismos también visitan su página web para conocer las novedades en enfermedades emergentes. “No está sólo dirigido a la población en general”, apunta Freifeld, quien, gracias a su labor en el MIT (Instituto Tecnológico de Massachusetts, EEUU), se ha encargado de desarrollar gran parte del software.

Las buenas propiedades de Internet

“El valor de la información ‘on line’ para la detección temprana de enfermedades, el análisis de la salud pública y la comunicación de riesgos es evidente hoy en día, sobre todo a raíz de la emergencia creada en torno al actual virus de la gripe A/H1N1″, explican estos expertos en un documento aparecido en ‘The New England Journal of Medicine’ el pasado mes de mayo.

En aquel trabajo, los científicos, con la ayuda de Lawrence C. Madoff (del departamento de Salud Pública de Massachusetts), expusieron las bondades de su ‘mapa de epidemias’ y se centraron en su utilidad como herramienta para seguir la nueva gripe.

“Aunque los canales clásicos y oficiales siguen en marcha, los mapas basados en la Red, el seguimiento con búsqueda de términos, los ‘microblogs’ y las redes sociales han emergido como alternativas para la diseminación rápida de la información [...] Está claro que estas herramientas deben utilizarse con cautela y con una evaluación apropiada“, concluye el artículo aparecido en ‘NEJM’.

Una nueva herramienta para el iPhone

Visto el éxito de esta iniciativa, desarrollada hace tres años, los expertos del Hospital Infantil de Boston decidieron dar un paso más y ahora han desarrollado una aplicación para iPhone con una función similar. Bautizado como ‘Outbreaks near me’ (o ‘Brotes cercanos a mí’), el programa se descarga de iTunes y ofrece la posibilidad de detectar las enfermedades cercanas a un punto geográfico determinado.

“Se introducen unas coordenadas en el GPS, esa petición pasa por el ‘Mapa de Salud’ y de manera inmediata se ofrece la respuesta”, explica Clarke C. Freifeld. El sistema permite, además, que los usuarios envíen sus propios informes. “Por ejemplo, están de visita en un país y se enteran de un brote y nos pueden enviar los datos. La información siempre pasará antes unos filtros de validación”, añade el experto del MIT.

En dos semanas, 70.000 personas se descargaron esta aplicación de iTunes. A tenor de la buena acogida, los especialistas están trabajando en un programa similar para el ‘hermano’ del iPhone, el Android de Google.

Early detection of prostate cancer is a two edged sword. To be sure, as with all cancers, your odds of not dying from prostate cancer are improved with early detection.  Still, questions remain about the amount of screening, diagnostic testing and treatments that need to be carried out to realize substantive gains in survival.  Yet, survival remains an individual issue with each patient.  So early detection (a preferred term over screening, which implies shopping mall testing) along with treatment remain a personal decision between patient and doctor.

One thing which does jump out in this study is the fact that many men have cancer but have small prostate volumes meaning they likely have few if any symptoms.  The study also focused on men with what would be termed normal PSA levels (< 3.0) and yet found that a large number of these men not only develop cancer but develop clinically significant, high grade cancers.

An additional alarming note was that even in men with negative biopsies initially, they were at a higher risk of having a second or third biopsy be positive, and with a higher grade (worse) cancer.

In the end, we are still lacking that “magic bullet” of a test, one which will with a high degree of certainty, identify which men who have prostate cancer, are actually likely to progress and die from prostate cancer.  Until that test becomes available, early detection and treatment remain the key elements in any strategy to deal with prostate cancer . . . ben kazie md

Men with small prostate volumes and high initial prostate-specific antigen (PSA) levels have a greater risk for cancer detection and aggressive disease than other men.  Prostate biopsy is the standard method for the early detection of prostate cancer, but prostate volume may affect the detection rate on traditional sextant biopsy and current screening protocols may consequently result in missed cases.

The study (see reference below) enrolled 182,000 men between the ages of 50 and 74 years through registries in seven European countries. They were randomly assigned to a group that was offered PSA screening once every 4 years or to a control group that did not receive such screening.  During a median follow-up of 9 years, the cumulative incidence of prostate cancer was 8.2% in the screening group and 4.8% in the control group. The rate ratio for death from prostate cancer in the screening group, as compared with the control group, was 0.80 (95% confidence interval [CI], 0.65 to 0.98; adjusted P=0.04). The absolute risk difference was 0.71 death per 1000 men. This means that 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent one death from prostate cancer. The researchers concluded that PSA-based screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis.

Also of great note in this study was the finding that men with a smaller prostate volume, who had, at the initial screening round, an indication for biopsy and a negative biopsy result, were at greater risk of being diagnosed with prostate cancer, and of aggressive prostate cancer, during the 8 years of follow-up

Prostate cancer detection and aggressiveness raised in smaller prostates – http://www.medwire-news.md/46/84390/Oncology/Prostate_cancer_detection_and_aggressiveness_raised_in_smaller_prostates.html

Screening and Prostate-Cancer Mortality in a Randomized European Study  (NEJM, Vol 360:1320-1328 March 26, 2009 #13) – http://content.nejm.org/cgi/content/full/NEJMoa0810084

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I drink a lot of soda.

I mean, a lot of soda.  In fact, the only beverages I seem to drink any more are Coke products, coffee and tea.  I drink at least one glass of water every day, but most of what I drink is some form of manufactured beverage.

According to a report in the New England Journal of Medicine, I should have to pay a great deal more for what I drink.  Last night, I bought two 2-liter bottles of Coke products.  They cost me about $3.  If we were to adopt the 1-cent-per-ounce tax on sugary beverages recommendation of the NEJM, I would have to pay another $1.38 for those 2-liters.  The argument they make is that, like cigarette taxes, the tax on sugary beverages would reduce consumption and improve America’s overall health.

From the Wall Street Journal:

The paper, by seven experts in nutrition, public health and economics, called for an excise tax of a penny per ounce on caloric soft drinks and other beverages that contain added sweeteners such as sucrose, high-fructose corn syrup or fruit-juice concentrates. Such a tax could reduce calorie consumption from sweetened beverages by at least 10% and generate revenue that governments could use to fund health programs, the authors said.

“The science base linking the consumption of sugar-sweetened beverages to the risk of chronic diseases is clear,” the authors wrote. “Escalating health-care costs, and the rising burden of diseases related to poor diet, create an urgent need for solutions, thus justifying government’s right to recoup costs.”

There’s just one problem:  Caloric intake is not the sole measure of “poor diet,” nor is poor diet the sole reason for poor health.  Lack of physical activity, other habits like smoking, drinking, drug abuse, chronic dehydration, lack of minimal sun exposure (for Vitamin D) and others also have a cumulative lifetime effect on people’s health.  Simply cutting people’s intake of sugary beverages will not, on its own, solve the obesity problem in the United States.

Further, if caloric intake is such a serious problem, why not go after the source?  Why not tax refined sugar, high-fructose corn syrup and other high-calorie additives?

The answer is obvious:  The agricultural industry would throw a fit!  Most of those additives are actually refined agricultural products.  Taxing them directly would earn the ire of that industry, which can be political suicide.  Attacking the beverage industry, however, is politically feasible, just as attacking “Big Tobacco” by cigarrette taxes was easier than taxing tobacco farming directly.

Adding this tax would seriously affect the soft-drink industry, which produces not just soft drinks but sports drinks, coffee drinks, fruit drinks and bottled water.  With higher prices will come reduces sales, which will cause thousands of people in that industry to lose their jobs.

Again from the Journal:

Beverage-industry executives vehemently oppose the idea, which experts say would result in significant price increases. Coca-Cola Co. Chairman and Chief Executive Muhtar Kent called the proposed tax “outrageous” in a speech Monday in Atlanta, saying it reminded him of his days as a Coke executive in the former Soviet Union, when he watched the government dictate consumers’ choices by stocking only one type of fruit in a store at a time. “I have never seen it work where a government tells people what to eat and what to drink,” he said. “If it worked, the Soviet Union would still be around.”

Well, that’s a bit of an exaggeration, but the basic concept is sound:  Central planning of anything by those who are not directly affected by the results never works.  This results in unhappy consumers and shortages of desired goods.  The article continued:

“A penny per ounce would have a seriously negative impact on the industry, as it could potentially raise prices on key packages by 40% to 50%,” said John Sicher, editor and publisher of Beverage Digest, an industry publication.

PepsiCo Inc. and Coke referred questions on Wednesday’s report to the American Beverage Association, a trade organization. Spokesman Kevin Keane said a federally funded study, also published earlier this year in the NEJM, supports the notion that all calories count, and the key to a healthy lifestyle is balancing consumption with exercise.

“It makes no sense to single out one particular food product as a contributor to obesity when science shows that’s not supportable,” Mr. Keane said.

Taxing soft drinks only makes sense if it is a prelude to attacking all “unhealthy” foods.  Simply reducing soft-drink intake is not going to cure the nation’s obesity ills.

No matter how many people exchange soft drinks for other beverages, the costs will be massive: Lost jobs, lost productivity, reduction in economic output and greater dependence on government to make our choices for us.

So just ignore the idea of personal responisibility.  Just ignore the idea that people should be allowed to make their own choices and live with the consequences.  Just ignore the fact that lifestyle (such as exercise and other habits) has more to do with health than soda consumption.  None of that matters.  We have an obesity crisis, and the only way to cure it is to stop people drinking soda!

Oh, all that soda that I mentioned earlier that I drink?  The vast majority of it is artificially sweetened.  This tax would not affect me.

Cross-posted at TMR.

Image: Pete Chapman under Creative Commons Attribution ShareAlike 3.0 License

There is almost a sad inevitability about the discussion in the media around the issue of giving heroin to heroin users. When it come to heroin-assisted treatment (HAT) it is inevitable that any reasonable discussion will be drowned out by the clamouring commentariat.

The UK has been using heroin as part of the treatment of users in one form or another since 1926. More recently, there have been studies of HAT in Switzerland, Germany, the Netherlands and Canada which have shown benefits in health, psycho-social adjustment and illicit drug use to socially excluded heroin dependent patients resistant to other treatments.

However, it’s inevitable that ill-informed parallels will be drawn with alcohol, smoking and the funding of almost anything else in the NHS deemed more worthy. It’s even possible to drag in ‘our boys’ fighting the drugs (spot of mission creep here) war in Afghanistan if one wants to work up a proper lather. The RIOTT study (I am assuming the obligatory acronym is an ironic nod to the impact this study will have on Daily Mail readers) isn’t even published yet and already the hysteria begins…

Is it even worth discussing the science amongst this hubbub? It might be better to crawl back under the duvet, let the dust settle and have a more rational discussion when we actually have the results of the UK study.

But there is some science to look at and consider. It is only last month that the New England Journal of Medicine published the results of NAOMI, the North American Opiate Medication Initiative (another tortured acronym) which looked at exactly this issue and it’s probable that RIOTT will have similar results. NAOMI compared oral methadone versus injectable diamorphine. It was open-label and there was no attempt to blind users to their treatment. They had better retention in the diamorphine arm at 88% versus the methadone arm at 54%. The reduction in rates of illicit drugs were 67% in the heroin group and 48% in the methadone group. Overall, the diamorphine arm tended to do better.

There were clear benefits but it wasn’t without issues and there were serious adverse events. There were 18 events in the methadone group (n=111) but none of them were felt to be related to the treatment. In the diamorphine arm (n=115) there were a total of 51 serious adverse events. However, it was reckoned that 27 of these were directly related to the diamorphine and included overdoses and seizures. This has to be put in context: a total of 89,924 doses of diamorphine were self-administered during the course of the study so that’s 0.03% of injections causing an event.

There are some issues around the methodology. Users know what kind of trial they are entering and many will drop-out when they get randomised to methadone rather than injectable. Indeed, this was the case in this study and it raises some issues around bias. The methodology of RIOTT was published in the Harm Reduction Journal in 2006 and is available for free.

The final conclusion of the NEJM paper is a reasonable one:

In this trial, both diacetylmorphine treatment and optimized methadone maintenance treatment resulted in high retention and response rates. Methadone, provided according to best-practice guidelines, should remain the treatment of choice for the majority of patients. However, there will continue to be a subgroup of patients who will not benefit even from optimized methadone maintenance. Prescribed, supervised use of diacetylmor-phine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system.

It will certainly need to be given in a specialised environment so it is likely to remain a very limited intervention. The headlines have tended to highlight that crime rates fall. How can this be surprising? UK studies have shown reductions in criminal activity across all treatment modalities for years. Part of the reason for this emphasis is presumably to make it as palatable to the public as possible. It’s not enough for it to be a useful option to improve health in a limited group of treatment resistant users. There has to be a fringe benefit to society as well.

There is an excellent paper by the authors of NAOMI commenting on some of the controversies around HAT. Again, it is freely available at the Harm Reduction Journal and will give you as good a background knowledge of the issues around HAT as anything. The authors commented on the media:

Treating heroin addiction with heroin tends to evoke a knee-jerk reaction. Lack of understanding, restrictions on time and resources, and the need for a catchy headline often lead to sensationalism by the media. As previously mentioned, opposition both within Canada and the US also contributed to misleading reports from local, national, and international media. The resulting focus has been on a seeming shift in Canadian drug policy in direct contradiction to the US war on drugs, rather than on the scientific or medical merits of the NAOMI study.

Much hand-wringing will be provoked by these studies for the simple reason that some will perceive that the logical development of this whole debate is that the next step will be de-criminalisation of drugs. It is entirely possible that we are waging a phoney ‘war on drugs’ but that’s really not what these studies are all about.

Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, & Schechter MT (2009). Diacetylmorphine versus methadone for the treatment of opioid addiction. The New England journal of medicine, 361 (8), 777-86 PMID: 19692689

In my second week of medical internship, I received a “friend request” on Facebook, the popular social-networking Web site. The name of the requester was familiar: Erica Baxter. Three years earlier, as a medical student, I had participated in the delivery of Ms. Baxter’s baby. Now, apparently, she wanted to be back in touch. – New England Journal of Medicine

by Manuel Villacorta

Recently The New England Journal of Medicine released a two-year study on the Comparison of Weight-Loss diets with Different Compositions of Fat, Protein, and Carbohydrates.

Popular media outlets took this 2 year study and drastically over-simplified the findings into something as simple as “Reducing Calories leads to weight loss regardless of what you eat.”  Look at these sample headlines from a quick search on the web.

“Weight loss bottom line: Fewer calories Carbohydrate, protein, or fat content doesn’t play a key role” – Harvard Science

“Diets That Reduce Calories Lead to Weight Loss, Regardless of Carbohydrate, Protein or Fat Content” – Science Blog

“Fewer Calories Equal Less Weight, Regardless of Carb, Fat, or Protein Content” – Medscape by WebMD

“Study of diets shows what truly counts: calories” – LA Times

The study results included great information that confirms what Nutrition for You experiences with our members  However, by over-simplifying this important study into simply cutting calories to lose weight, we’ve lost many very important details. This study is not giving the green light to eat whatever you want as long as it reduces calories.

Here is what you should know

1. This study was not only about counting calories

The subjects were divided into four groups and were given a macronutrient distribution (ratio of carbohydrates, protein, and fat) to follow throughout the study. The study showed that regardless of the macronutrient distribution; everyone lost weight.   All four diets had a 750 calorie deficit with different nutrient composition of calories.  None of the study groups were just counting calories.

2. Important facts were all but ignored by most reports on this study

One important fact ignored by most was that all diets were required to eat 20 grams of fiber per day, they used whole grains for the carbohydrates and saturated fats were at 8% or less.  All diets were considered “heart healthy” diets so it is natural that someone eating a heart healthy diet will experience those benefits.

3. Record Keeping and Counseling was part of the study

All participants were doing record keeping and participants either had group or individual counseling sessions.   The study demonstrated that those that participated in group or individual counseling sessions, lost more weight.

4. The study ignored the quality of the weight loss, and the long term sustainability

The study only reported weight loss and did not look at muscle retention and fat loss. The quality of the weight loss does matter in the long run.

You can’t simply reduce and count calories.  If you were to simply do that you could have a slice of pizza and four chocolate chip cookies and meet your calories for the day.  With this scenario you would be lacking vital nutrients, including protein, which will decrease your metabolism in the long run.

Participants only exercised 90 minutes per week and the type of exercise (cardio or weight training) was not reported.  As a result the study ignored the relationship of macronutrient distribution and how it contributes to muscle mass retention while losing weight.

5. The study makes a very important point for weight loss.  Losing weight is 80% nutrition and 20% exercise

The participants were only asked to perform 90 minutes of moderate exercise per week.  The fact that very little exercise was required to obtain weight loss benefits demonstrates that the majority of your weight loss occurs because of what you eat and not how much you exercise.

Our experience and our opinion

Nutrition for You’s experience validates the actual study, but not the way much of it was portrayed in the media. This study validates and reinforces what Nutrition for You does every day.  We have always known that weight loss occurs because of a deficit of calories.  However unlike the reports of this study we recognize and address all aspects of your nutritional well-being.

Our program starts and continually works with our members to determine the amount of energy (calories) your body needs each day.  Once we understand your caloric needs we find the right calorie deficit to help you lose weight.  We go beyond simple calorie reductions to make sure you are getting the right balance of nutrients carbohydrates, protein, and heart healthy fat so that your body has everything it needs for proper brain function, muscle retention, fat loss, and healthy nutrition.

As with the study participants we provide tools to our members such as  record keeping, and personalized support by our expert nutrition staff.  In addition we teach you lifestyle changes and self awareness in your eating habits.  These tools are incredibly important in the long run.  Losing weight is not enough. If you do not keep the weight off, then you will lose all of the benefits of your weight loss.

In conclusion, understand that you must eat a healthy balanced diet with a deficit in calories for weight loss that takes into account more than just your calorie count.