BCAAs and Keto diets

(Note: This article is a departure from our tradition of end-to-end citations, and other practices necessary for establishing high confidence in medical assertions. This departure is merely in the interest of publishing more ideas in less time, as our intensely busy lives have led to a huge backlog of unfinished articles for which the verification and explicit justification process has proved to be at least 80% of the work. Because of its importance to us, though, when we return to more fundamental ketogenic science articles, we will return that style.)

Benefits of BCAAs

If you follow the bodybuilding community, you are probably aware of some of the benefits of branched chain amino acids (BCAAs). That's because they are known to have positive effects on muscle growth and recovery. (See for example Nutraceutical Effects of Branched-Chain Amino Acids on Skeletal Muscle, and Branched-Chain Amino Acids Activate Key Enzymes in Protein Synthesis after Physical Exercise.)

Less well known is that BCAAs have favourable effects on the brain, in particular the glial cells (brain cells that aren't neurons, are more numerous than neurons, and turn out to be essential for supporting neurons — it seems probable that most brain afflictions are caused by problems in the glial cells). The beneficial effects of BCAAs come from their important role in the manufacture of neurotransmitters, and vital metabolic cycles such as the leucine-glutamate cycle.

Here are a couple of examples of beneficial effects of BCAA supplementation on the brain: Dietary branched chain amino acids ameliorate injury-induced cognitive impairment, Branched-chain amino acids may improve recovery from a vegetative or minimally conscious state in patients with traumatic brain injury: a pilot study, Recovery of brain dopamine metabolism by branched-chain amino acids in rats with acute hepatic failure..

The problems being helped by BCAA supplementation are similar to some of the benefits that have been shown to be helped by ketogenic diets, and this is no coincidence.

One important effect of keto-adaptation is a dramatic increase in circulating BCAAs.

This fact is one the many proposed mechanisms of the anti-epileptic properties of ketogenic diets. (See also The ketogenic diet and brain metabolism of amino acids: relationship to the anticonvulsant effect.)

There also appears to be a bit of a feedback loop, in that supplementing a ketogenic diet with BCAAs can itself increase ketogenesis relative to the same amount of other proteins.

Nonetheless, the important point to take away from this post is that a ketogenic diet itself achieves what others are striving for by ingesting expensive (and, frankly, revolting-tasting) powders. Therefore it is quite plausible that in addition to the more-studied positive nervous system effects, a ketogenic diet will improve muscle growth and recovery relative to a glycolytic diet, something already anecdotally reported.

Plastic Surgeon-Patient Sex

I recently received these questions about doctor-patient sex with a plastic surgeon:

My married sister's plastic surgeon called to give his condolences after the passing of our father. The doctor continued to call and fostered a personal friendship with her. He started to confide in her about his marital problems. They arranged to meet for dinner and entered into a 18 month affair. When my brother in-law discovered the affair, the doctor quickly abandoned her and started to make her look like the person who wanted the affair. My brother in-law filed an ethics complaint which is under investigation for over a year. I am the only person my sister will discuss the affair with, but not the only person that can see how the affair has affected her mentally. She is extremely depressed, filled with guilt and shame and has talked to me about ending her life. She refuses therapy, so I do the best I can to help her. Lately because of our conversations, I truly feel he took advantage of a vulnerable patient who was depressed over the loss of her father. She told me she had become dependent on him. Can you explain this dependence? She says she now knows how people follow a cult leader. Her pain is real and the result of a consensual affair with her doctor. He is not a mental health doctor; will he be held to the same standard? (emphasis added)

 In my response I emphasized that how important it was to help the patient accept counseling. Here I want to discuss the question of whether the plastic surgeon would be held to the same ethical standard as a psychiatrist.

To my eye, although the code of ethics for the plastic surgery specialty prohibits "sexual misconduct," it defines the term in a way that leaves patients and the profession vulnerable:

Sexual or romantic relationships with current or former patients are unethical if the physician uses or exploits trust, knowledge, emotions, or influence derived from the current or previous professional relationship.

The relationship between plastic surgeon and patient is intensely personal as well as technically demanding. Especially for surgery with aesthetic aims, patients entrust the surgeon with potential for making them look more the way they dream of appearing. For female patients, interventions may involve face, breasts, genitals, and their overall sense of "desirability." In terms of the question the patient's sister posed to me - the doctor-patient relationship in plastic surgery would seem to have all of the key characteristics that occur in mental health practice: exposure of deeply personal concerns, potential idealization of the clinician as a "saviour," and "transference" of feelings from the past. And, unlike psychiatry, ordinary practice involves disrobing and touching.

It's hard to see how a "sexual or romantic relationship" between plastic surgeon and patient would not draw in "trust, knowledge, emotions, or influence" derived from the professional relationship, whether or not the physician is consciously "using" or "exploiting" those factors. Even if passions are not involved, it would be very difficult to ascertain whether the factors the code of ethics prohibits were present. Sexual attraction and feelings of love are not known for inducing heightened intellectual and analytic lucidity!

I was unable to find any data on the frequency of complaints about sexual/romantic relationships between patients and their plastic surgeons. Unfortunately, a review of five years of complaints made to the ethics committee of the professional association did not report on the specific content of the complaints. But in light of the nature of the patient-doctor relationship in plastic surgery, I believe that the position of the American Psychiatric Association - that sexual relationships with current or former patients are unethical - would apply with equal relevance to plastic surgery.

In answer to the question posed by the patient's sister, I could not respond that the physician would be held to the same standard as a psychiatrist, but did say that I thought that should be the case.

National Leaders in Pancreas Surgery

Pancreas surgery is technically difficult and specialists at Penn Medicine perform among the highest volume of pancreatic operations in the Unites States, including the Whipple procedure, with complication rates and long-term survival statistics that set the standard nationally. As part of Penn’s Abramson Cancer Center, patients also have facilitated access to the full range of treatment options for pancreatic cancer including radiation, chemotherapy and the latest clinical trials—all under one roof.

At high-volume centers with integrated, multidisciplinary care teams, long-term survival for patients who undergo surgery for pancreatic cancer continues to improve. Recently, in one of the largest studies of its kind published to date, short-term recovery and long-term survival rates at Penn were shown to be among the best in the nation, demonstrating that Penn Medicine is at the forefront of providing the best care available for patients with pancreatic cancer.

Nationally and internationally recognized for their depth of experience and innovative research on the latest surgical treatment options, meet Penn’s pancreatic surgeons:

Jeffrey A. Drebin, MD, PhD
Chairman, Department of Surgery

A graduate of Harvard Medical School, Dr. Drebin continued his surgical training at the Johns Hopkins University School of Medicine before joining the faculty at the Washington University School of Medicine in St. Louis. In 2004 he was recruited to Penn Medicine as chief of the division of Gastrointestinal Surgery and vice-chairman for research for the department of Surgery. Following his tenure as chief, Dr. Drebin was appointed chairman of the department of Surgery at Penn Medicine and the 14th John Rhea Barton Professor of Surgery at the Perelman School of Medicine.

In addition to pancreas surgery, Dr. Drebin specializes in acute and chronic pancreatitis, the use of new technologies to manage liver tumors, disorders of the bile ducts and the management of gallbladder disease.

Learn more about Jeffrey A. Drebin, MD, PhD.



Charles M. Vollmer, MD
Director, Pancreas Surgery Program

Dr. Vollmer received his medical degree from Jefferson Medical College and completed his internship and residency in general surgery at Barnes-Jewish Hospital at Washington University Medical Center in St. Louis. Dr. Vollmer’s training includes a clinical fellowship in hepatobiliary and GI transplantation surgery at Toronto General Hospital, as well as research fellowships in surgical oncology at UCLA School of Medicine and hepatobiliary oncology at the Samuel Lunenfeld Research Institute at the University of Toronto. He comes to Penn Medicine from Boston where he practiced at the Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School.

In addition to pancreas surgery, Dr. Vollmer specializes in treating all malignant and benign conditions of the pancreas and biliary system with a strong emphasis in care of pancreatitis. He also focuses on the management of pancreatic cysts and co-directs the Penn Pancreatic Cyst Program, a multidisciplinary team that evaluates and treats all types of pancreatic cysts.

Learn more about Charles M. Vollmer, MD.


Location:
Perelman Center for Advanced Medicine
West Pavilion, 4th Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104


For more information or to schedule an appointment, please call 800.789.PENN (7366) or request an appointment online.

Sex isn't the only lust that physicians succumb to

Money and power can also lead to ethical collapse.

A sad story today's New York Times tells how Dr. Sidney Gilman, a respected teacher and researcher on drugs for Alzheimer's disease, has been nailed for warning a hedge fund manager he'd been dealing with to dump a pharmaceutical stock before news of a failed drug trial became public. Gilman had access to the information from his role on an FDA panel.

From responses to a number of the posts I've written about doctor-patient sex, it's clear that physicians who violate basic ethical standards can be superb caretakers for their other patients. Dr. Gilman, now 80, apparently had an exemplary career in teaching and research. A neurology lecture series at University of Michigan Medical School is named for him. And a colleague reported that he frequently turned to Dr. Gilman for advice about ethical issues:

He always gave me rock-solid advice and counseled me to maintain transparency so as to avoid even the appearance of a conflict of interest.

Re Dr. Gilman's teaching about transparency, the Times reports that to avoid arousing suspicion about his consultation to the hedge fund about the Alzheimer's drug, Gilman asked his co-conspirator to label the consultations as about other, unrelated topics.

Dr. Gilman could do a service to medicine and medical ethics by sharing the inside story about how a physician who apparently conducted himself in an admirable manner for most of his career descended into obvious unethicality (and criminality) as he did. What steps led from honorable conduct to dishonor? Did he delude himself as to what he was doing, or did he make a Faustian bargain to proceed? Better understanding of the "mechanisms" that facilitate serious ethical lapses can help educators work more effectively towards prevention.

(For an interesting post from a hedge fund insider, see here.)

Accountable Care Sprints Ahead

A recent report from the Oliver Wyman consulting firm - "The ACO Surprise" - argues that ACOs are on the verge of triggering a major transformation of the US health system. I hope their prediction comes true!

For all the complexity of federal ACO regulations, I see ACOs as making four core basic commitments:

1. Take responsibility for helping a population be as healthy as possible
2. Connect specialties, disciplines, and sites (hospitals, rehabilitation, nursing homes) in a coordinated manner
3. Engage patients as active partners - ideally leaders - in promoting their own health and guiding their treatment
4. Accept payment for producing valuable results for the population, not for the individual units of service rendered

Here's the Oliver Wyman view of the near term ACO landscape:

• 2.4 million current Medicare ACO patients
• 15 million non-Medicare patients of the Medicare ACOs. The report predicts that the Medicare ACOs will move towards caring for all of their patients in the "ACO manner"
• 8 - 14 million patients to be cared for in non-Medicare ACOs

If Oliver Wyman is correct, it won't be many years before 10 percent of the US population receives its care in accord with the ACO philosophy. Insofar as ACOs are successful in creating more value for patients per dollar of investment, they'll come to dominate the marketplace.

In my physician hat I see the ACO vision as embodying the fundamental values that motivate most clinicians. The reason I joined the not-for-profit Harvard Community Health Plan practice in 1975 was because it was organized around those values.

In my patient hat, I've chosen to have my own medical care from one of the "Pioneer ACOs". I want my doctors, nurses and hospitalists (if I come under their wing in the future) to collaborate in what they do with, for and to me.

Some years ago a patient of mine was in a severe state of psychiatric crisis. The long term problem was a major psychiatric ailment, but the immediate challenge was getting control of acute alcohol abuse. I made what felt like a zillion telephone calls (this was before all parties used a shared electronic medical record) to alert all those likely to be involved with my patient to the clinical situation and what I was recommending. A week or so later my patient reported - with appreciation - "I spoke with nine different people last week and they all said the same thing..." The crisis subsided.

From the perspective of clinicians and patients, care delivered in accord with the first three ACO commitments listed above feels right. The three commitments meet patient wishes and reflect the underlying ideals of the health professions. The fourth commitment is what matters to us from the economic perspective. I share CMS's belief that doing the right thing in health care will end up saving money. But that will be a happy result of ACOs, not the reason for going down that path.

Tomatina Ratatouille & Review

I recently had the opportunity of reviewing a new product called Tomatina.  If you have ever tried V8 juice this juice is about 100 times better!!  The first thing I noticed when I received this product sample was how dark red it was.  This told me that it was loaded with lycopene at the highest level. My first taste was so flavorful and delicious. Tomatina was created by John Goldfuss. He is at the point with his new company that he needs some help getting his first production of juice going. Up to now, all of the money invested has been his own. Getting some momentum going is key to Tomatina’s launch and survival.  Please check out the links below to where you can help donate money so he can purchase bottles for his first run of product. Any amount will help him reach the goal of $10,000 by January 7.  It truly is a product beyond others I have tasted and deserves to be on the grocery shelves. 
Tomatina owes its name to a tomato festival in Spain.  In this celebration, the entire town of Buñol is filled with truckloads of tomatoes, and a huge tomato fight ensues. Afterward everyone washes up so the feasting, dancing, and partying festivities can begin. ¡Olé!

Tomatina's unique recipe went through 70+ variations to get to its current delicious state. The recipe includes tomatoes, beets, ginger, carrots, celery, cucumber and red bell pepper. 
The tomatoes support a happy heart by softening sticky cholesterol. It's generous antioxidants also reduce harmful oxidative bone stress. They are the most abundant source of lycopene. Studies that look at large groups of people (observational studies) in many countries have shown that the risk for some types of cancer is lower in people who have higher levels of lycopene in their blood. Studies suggest that diets rich in tomatoes may account for this reduction in risk. Evidence is strongest for lycopene's protective effect against cancer of the lung, stomach, and prostate. It may also help to protect against cancer of the cervix, breast, mouth, pancreas, esophagus, and colon and rectum. Beets anti-inflammatory compounds soothe and repair strained organs.  Ginger, with a magical, almost spiritual repute, is a medicinal root known for its stomach-soothing and anti-inflammatory effects. A carrot a day keeps the dermatologist away. Celery  is associated with reduced blood pressure. The anti-oxidants in cucumbers devour menacing free-radicals. Red bell peppers are dutiful stewards of good health with an abundant mix of nutrients and anti-oxidants.

Please help get this fabulous product to market.

The recipe I created using this delicious tomato juice was a YUMMY Ratatouille. Ratatouille originated in the area around present day Nice. It was originally a meal made by poor farmer's (in essence it started out life as a peasant dish), and was prepared in the summer with fresh summer vegetables. The original and simplest form of Ratatouille used only zucchini, tomatoes, green and red peppers (bell peppers), onions, and garlic. Today, eggplant  is usually added to the list of vegetables. You can choose to add eggplant or not, since the recipe is delicious with or without it. I spiced it up with some oregano & thyme. You can serve it over potatoes, rice or noodles.  Enjoy good health and check out Tomatina's website and facebook pages below. 

PRINTABLE RECIPE

Tomatina Ratatouille
Serves 4
                                                                                   

1 small onion, diced 
1 garlic clove, minced  
1 tsp. olive oil 
1 medium zucchini, diced
1/2 red bell pepper, diced
5 Shitake mushrooms, sliced
1/2 cup diced eggplant (OPTIONAL)  
1/4 teaspoon oregano leaves
1/4 teaspoon thyme leaves
sea salt & pepper to taste
1 cup Tomatina or your favorite tomato juice
(Potato, Rice or Noodles)

1.  Saute onion and garlic in olive oil until soft. 

2.)  Add diced vegetables and seasonings. Continue to saute until vegetables are soft.  Salt & pepper to taste. 

3.)  Add 1 cup of Tomatina. Simmer for 5 minutes.

4.)  Serve over sliced potato, rice or noodles.  

Check out the links below and follow TOMATINA.

TOMATINA  

• Follow Tomatina

 

Introducing Tomatina: Video

Shoulder or Elbow Pain? Penn Orthopaedics Can Help You Live Pain-Free

Whether it’s the result of an injury or just from typical wear and tear, you don’t have to live with shoulder pain.



The Penn Shoulder and Elbow Service provides comprehensive care for shoulder and elbow injuries or problems. Penn’s nationally and internationally recognized orthopaedic specialists create and use the latest advances in shoulder and elbow diagnosis, treatment, surgery and rehabilitation to treat complex issues.

Shoulder and elbow problems can affect your ability to enjoy your favorite activities. Some commonly treated issues include:

• Dislocation/separation
• Tendinitis
• Bursitis
• Torn rotator cuff
• Fracture
• Biceps
• Tendon rapture
• Arthritis
• Golfer's elbow
• Tennis elbow

For more information about the Penn Shoulder and Elbow Service or the shoulder and elbow specialists, visit PennMedicine.org or call 800-789-PENN (7366).

Penn Presbyterian Medical Center named “50 Top Cardiovascular Hospital”

Penn Presbyterian Medical Center (PPMC) has been named as one of the nation’s “50 Top Cardiovascular Hospitals” by Truven Health Analytics, formerly the Healthcare Business of Thomson Reuters.

The 50 Top Cardiovascular Hospitals annual report identifies the nation's top hospitals performing cardiovascular services, selected from more than 1,000 hospitals across the country.

The honor recognizes PPMC’s consistent leadership and quality in cardiology and cardiac surgery.  Penn Presbyterian is recognized for expertise in:

• Complex arrhythmia management
• Interventional cardiology
• Noninvasive cardiology and cardiac imaging
• Preventive cardiology
• Vascular medicine and endovascular therapy 
• Women's heart health

For more than a century, Penn Heart and Vascular at PPMC has provided outstanding health care services.   Penn Presbyterian's cardiac care teams work together to diagnose, treat and prevent a wide range of cardiac conditions.  In addition to heart operations, PPMC’s cardiovascular surgeons also perform coronary artery bypass in high-risk patients, complex aortic surgery, heart valve repair and minimally invasive robotic-assisted cardiac surgery.

According to Harvey Waxman, MD, chief of cardiology at PPMC, the staff adheres to a process of continuous improvement to reduce surgical complications.  Even though the wound infection rate has been below 1 percent for the past several years, the staff wants to do better.  “Our goal is zero,” Waxman says.

For information about Penn Heart and Vascular at Penn Presbyterian Medical Center, or to request an appointment, visit PennMedicine.org or call 800-789-PENN (7366).

Politics vs Rational Medicare Reform

I'm a staunch New England liberal/yellow dog Democrat. And I support Howard Dean's organization - Democracy for America. But I shuddered when I received this message in a fund-raising email:

Republicans lost big in the election, but John Boehner is trying to force his right-wing agenda on the American people anyway. Republicans in Congress are taking advantage of the fiscal showdown and trying to jam through massive cuts to Medicare that would be devastating to America's seniors. (emphasis in the original)

Republicans, occasionally joined by renegade Democrats, have plenty of bad ideas about Medicare, like raising the age of eligibility (see here) and turning Medicare into a voucher program (see here).

But experts agree that at least 30% of what we spend on health care is waste. I've talked with lots of practicing physicians about this. No one has ever estimated waste at less than 25%, and many have estimated it at 50%.

The threat to Medicare is dumb ideas like vouchers and raising the age of eligibility, not the idea of reducing the trend line of cost increases. Doing that is an economic necessity for a thriving economy and a moral necessity on behalf of future generations and other social needs.

Dumb cuts "would be devastating to America's seniors." Clinically guided waste reduction would be a positive service, not a devastation. I hope that behind closed doors and away from sloganeering, our leaders - Democrats & Republicans - will move beyond demagoguery to consider how the federal government can promote prudent waste reduction in the Medicare program.