Cooperation vs Competition in Health Care

I've long admired the Cleveland Clinic, so I hope this paragraph from a New York Times article on how drug shortages force rationing decisions, turns out to be incorrect:

The Cleveland Clinic has an advanced compounding room where workers swaddled in disposable gowns, bouffant caps and blue gloves mix up remedies from raw ingredients. During a shortage of papaverine, a drug used for surgery on blood vessels, the clinic produced its own version. When other hospitals began asking about it, Dr. Snyder said he had to tell them, “It’s a franchised recipe we can’t give out.”

 If "franchised recipe" means the Clinic wants to keep its way of producing papaverine secret, it's hard to see how that policy could be ethically justifiable.When a clinician or institution has figured out how to help patients in a better way, the new approach should be shared with others. The overarching goal of the health system is improved health for the entire population. We encourage competition to stimulate local improvements, but once achieved, those improvements must be shared. Competition in health care is justified when it serves population health.

The Cleveland Clinic already has a reputation for clinical excellence. Sharing its "franchised recipe" will enhance the respect the Clinic receives. As such, sharing the recipe would be both good ethics and good strategy. Truly a win/win outcome.

Medical Scribes and the Patient-Doctor Relationship

I'd heard and read about the practice of bringing "scribes" into the exam room to allow the doctor to relate to the patient rather than to the keyboard. But I hadn't experienced the phenomenon until last week. 

Prior to my appointment I was told that the physician I was about to see (my primary care physician has been ill, and I was seeing a physician I'd never seen before) worked with a scribe. Would that be OK with me? It was. The medical issue involved my big toe and foot, and didn't feel enormously personal.

The photo (it isn't me) shows the scribe interacting with the laptop but clearly in the patient's line of vision. At my appointment, when I looked at the scribe he was looking at me - we made eye contact. He said nothing verbally or via facial expression, but was clearly a third person in the office. Since the focus of the examination was my foot - not a very personal exposure - and the questions weren't about intimate matters, I didn't mind having a non-clinical stranger in the room. But if either of those conditions were different, I would not have wanted the scribe to be present.

The impetus for using scribes is directly related to the electronic health record and the incentives from Medicare (and others) for using the EHR. If physicians are doing the entry, it's either during the appointment or after. Entering the notes during the appointment is more efficient, but leads to the common patient complaint that "the doctor is treating the computer instead of me." But entering the notes after the appointment requires additional time that is not reimbursed and makes the working day longer. 

During my years of psychiatric practice I regarded myself as a devoted clinician. I loved my patients. But from residency on I generally made my notes during the appointment. I found that if I waited until the end of the day I'd forgotten things, and after a busy day of appointments I felt burdened by the additional time requirement. I didn't resent staying later to see a patient with an urgent problem, but I did resent writing notes rather than heading home to be with my family.

I can't believe that voice recognition technology can't make it possible for doctors to dictate notes while seeing patients. It could be done in a way that helped the patient to understand our thinking. From residency on I always wrote my notes with the assumption that the patient would read them. The discipline this imposed was useful. As an example, it helped me in relating to people with paranoia. I didn't write "Mr. Jones is paranoid and delusional," but rather "Mr. Jones believes extra-terrestrials have implanted a chip in his brain. He understands that I do not share this view. We discussed why I believe taking anti-psychotic medication would help him in his life..." 

I found that people with paranoia appreciated that I recognized the possibility that (in this example) extra-terrestrials might be causing mischief, but that I found this extremely unlikely. We could frame using medication as a hypothesis - "whether or not there is a chip in your brain, I believe that you will sleep better and be less afraid after a few weeks..." rather than as the equivalent of "you're crazy and I'm sane so you should do what I say..."

Writing notes with the patient in the office allowed for discussion of what should be said. With someone I'll call Mr. Jones, it had taken quite a bit of time to elicit a clear picture of how much alcohol he used and how alcohol might be affecting his mood and his physical health. I explained why I thought it was important for his primary care physician to know about his alcohol use. We sat together in front of the terminal to compose my note. Mr. Jones baulked at the word "alcoholism," but accepted "alcohol problem." This wasn't just a piece of collaborative writing and editing - it was an integral part of the treatment process.

It seems to me that the burgeoning of medical scribes is a workaround pseudosolution for a broken health care system. Adding a third party to the appointment is better than burning out our physicians - an all-too-frequent occurrence. But the real fix would be a combination of more realistic expectations for documentation and improved electronic health record technology. 

Boredom as a Health Hazard/Uber as a Cure!

A recent New York Times article featured a photo of Carol Sue Johnson, 73, in her rear view mirror, setting out as a Uber driver. Apparently, an increasing number of older folks are doing gigs for Uber and Lyft.

The main reason is to supplement their income and savings. The average retirement savings for Americans in their 60s is under $200,000. Extra income isn't just for luxuries. And driving for Uber or Lyft is self-scheduled, with no financial penalty for doing a smaller number of hours, appealing features for drivers of all ages. 

But what impressed me most in the New York Times article, and another piece in Time, is how often the older drivers cited the human interest provided by meeting passengers. This makes sense. When I'm in a taxi I often ask drivers about their experience hearing about life's troubles from their passengers. I not infrequently end up telling them that I'm a psychiatrist and that, in a way, they are too. 

Musing on this topic got me thinking about the phrase "bored to death." A search of medical literature led me to a 2010 publication - "Bored to Death" - that reported on the famous Whitehall study of British civil servants. Those who reported higher levels of boredom had poorer health and increased risk of death in subsequent years. The authors speculated that boredom "is almost certainly a proxy for other risk factors." These could include social isolation, poor eating habits, and increased use of alcohol. 

In short, the familiar cliche - "bored to death" - has literal as well as metaphoric truth!

Carol Sue Johnson and the cohort of older Uber/Lyft drivers may well be improving their health by the dual mechanisms of improving their finances and diminishing the risk of boredom.

The Importance of Sleep and Rest

Sleep and rest are very important in our lives and should not be ignored or taken for granted. There are a lot of people who don’t sleep, because they are distracted by movies or any other technology. For others they work round the clock, trying to make a living for themselves. No matter your situation, it is important to find time and rest for the following reasons:

1 Sleeping slows down the ageing process

So many Health experts have confirmed the essence of sleep in relation to slowing down aging.  Renewal of the skin and elimination of waste takes place during sleep.

2 Brain health

When you sleep your mind and body are renewed from the stress encountered from your activities of daily living. Sleep and rest has been found to increase brain activity. If you feel tired during the day and lack concentration on some activities because of brain fatigue, adequate sleep and rest can reverse the situation.

3 Helps in preventing anxiety, depression and other diseases

Adequate sleep and rest helps in reducing Cortisol levels. The stress that we go through during the day raises our cortisol levels. An increased cortisol level causes us to be more prone to anxiety and depression, which makes us susceptible to other diseases.

4 Helps in growth and hormone regulation

When we sleep, our body releases growth hormones which helps in growth.

5 Sex drive

Those who do not have adequate sleep may experience a low sex drive. The solution to a low sex drive at times is adequate sleep and rest. 

Chronic Pain Following Mental Disorders

This is the fourth in a series of posts looking at some of the data from a study of chronic medical conditions following onset of a mental disorder (see citation below).

In this post I wanted to highlight the association of mental disorders with chronic pain conditions.

Onset of several anxiety disorders (OCD, panic disorder, generalized anxiety disorder, social phobia and PTSD) showed increased rates of later chronic pain by 80-110%.

Bulimia nervosa and mood disorders also showed later higher rates of chronic pain disorder.

Anxiety and mood disorders are commonly accompanied by significant physical symptoms including headaches and abdominal discomfort. Whether these features explain the association is unclear.

A take home message from this study is the need to carefully assess for mental disorder comorbidity in clinical populations with pain disorder. Additionally, use of narcotic analgesics is pain with comorbid mental disorders needs careful assessment and monitoring.

Follow the author on Twitter @WRY999

Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, de Girolamo G, Hu C, de Jonge P, Kawakami N, Medina-Mora ME, Moskalewicz J, Navarro-Mateu F, O'Neill S, Piazza M, Posada-Villa J, Torres Y, & Kessler RC (2015). Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries. JAMA psychiatry, 1-9 PMID: 26719969

5 HEALTH BENEFITS OF DIETARY FIBER

You've probably heard a lot about dietary fiber and how it is very effective for constipation. However, dietary fiber is not only good for constipation, but it has other health benefits. Dietary fiber can be found in foods such as whole grains, legumes, fruits and vegetables. Below you will find some of the health benefits that fiber has to offer.

1 Constipation

Fiber helps in relieving constipation because it increases, bulk and softens our stool if it is hard.  It therefore facilitates the movement of food and waste materials through our digestive tract.

2 Lowers bad cholesterol levels in blood

According to Mayo Clinic, when soluble fiber dissolves in water, it forms a gel-like material that can help in lowering cholesterol. It does this by lowering the levels of low-density lipoprotein (bad cholesterol).

3 Regulation of blood sugar levels

This is very beneficial for diabetics and healthy people as well. For diabetics, soluble fiber helps in slowing down the rate of absorption of sugar. It also helps healthy people in that it can reduce our risk of developing type 2 diabetes.

4 Weight loss

Foods that contain dietary fiber contain few calories and is therefore helpful for those who want to lose weight. It also makes us to feel fuller and we will therefore consume less.

5 Healthy heart

According to Dr Mercola, those who eat enough fibers have been found to have a 40% reduced risk of having heart disease.

Mindfulness, Clinical Outcomes, and Patient Safety

Two months ago, when I wrote a post about using the walking we clinicians do in the course of the working day as opportunities for  meditation, I wondered if it was a harebrained idea or a piece of personal eccentricity. But when I came upon "Use Hand Cleaning to Promote Mindfulness in Clinic" published in BMJ earlier this month, I decided there's something to it.

The author is Heather Gilmartin, a nurse fellow in the Colorado VA system. She makes the excellent suggestion that hand washing, a recurrent act of patient care and self care, can be used as a moment of meditation. Here's the practical summary Ms. Gilmartin presents:

A moment of mindfulness

Focus your attention on your thoughts and emotions. Stay present and accept whatever arises, just as it is, without reacting.

Set an intention—be it listening with intent, choosing your words mindfully, or acting with compassion in your next encounter.

Smile to acknowledge this act of kindness to yourself and to your patient.

Alcohol based hand rub

Pause, take a breath, and notice the sound and feel of hand rub being delivered to your palm.
Be present in the moment and experience the sensation of rubbing the foam/gel into your wrists, hands, and fingers until the product evaporates and leaves you clean.

Soap and water

Pause, take a breath, notice that you are turning on the faucet, and regard the feeling of water flowing from your wrists to your fingers.
Be present in the moment and experience the sensation of rubbing soap into your wrists, hands, and fingers, and then washing it all down the drain.

The VA system disseminates innovations well. I anticipate the potential for an epidemic of meditative moments arising from Ms. Gilmartin's modest but well articulated proposal!

Via her article I read an empirical study of the simple idea of using recurrent components of our days as opportunities for "mini-meditative-moments." College students were instructed to wash dishes in their usual manner or to do the ordinarily mindless chore in a mindful manner. The group that meditated as they scrubbed showed increased positive emotion and decreased "nervousness." (The article is at:
"Washing Dishes to Wash the Dishes: Brief Instruction in an Informal Mindfulness Practice.")

Reading the two articles emboldens me to out myself for another practice I've built into my day. I'm vigilant about brushing my teeth twice a day. If tooth brushing takes one minute, in a year it adds up to 12 hours. If it takes two minutes, it's a full day. That's a lot of time to devote to an uninspiring chore. I've taken to applying what Ms. Gilmartin recommends for hand washing to those moments of tooth brushing. It's an N of 1 experiment, but I believe it makes a contribution to overall well being.

I believe that most participants in the US health "system" would agree that the "system" is a mess. There's a massive outpouring of proposals for fixing the broken "system." We need to seek mega-solutions. But micro-improvements, such as what Ms. Gilmartin proposes in her BMJ article, are steps all of us in health care can and should take as part of the larger movement of creating an ever-more ethical environment of care.

What is dietary fiber?

It is very common to hear health experts recommending us to eat more foods that contain fiber. Some people do not really know what fiber is so here is a breakdown of it.

Fiber is also known as roughage. It is a component of plant foods but unlike other nutrients found in plant food which are broken down in the digestive tract and absorbed, fiber is not digested by the body.

There are two types of fiber, insoluble and soluble fiber. It is not really easy to distinguish which foods contain insoluble fiber and those that do not. Most of the time, one food possesses both soluble and insoluble fibers.

Insoluble fiber

Insoluble fiber does not dissolve in water. It mostly helps to facilitate the movement of food through our digestive tract and therefore it is very helpful for those suffering from constipation. Beans and potatoes contain insoluble fiber.

Soluble fiber

As the name implies, it is soluble and can therefore dissolve in water. According to Mayo Clinic, when soluble fiber dissolves in water, it forms a gel-like material that can help in lowering cholesterol and glucose levels in blood.

Examples of foods that contain soluble fiber include

• Fruits such as oranges, bananas, apples
• Foods that are roots such as potatoes and carrots
• Oats
• Beans
• Barley

7 HEALTH BENEFITS OF PEAR (AVOCADO

Avocados are fruits that are creamy and buttery in nature. It is found in Cameroon, Nigeria, Ghana, other African countries, America and in almost all parts of the world. It is commonly called pear in African countries.  It is a good source of healthy fats (unsaturated fats) and contains many vitamins and minerals.

1 Healthy heart

Studies have showed that Avocado contains a compound called beta-sitosterol. Beta-sterol is able to reduce bad cholesterol levels in our system and thus prevents bad cholesterol from destroying our heart.

2 Regulates Blood Pressure

Pear is significantly high in potassium. Potassium helps to regulate the effects of sodium. This is because an increase in the intake of sodium is responsible for an increase in blood pressure.

3 Vision

Avocado contains chemicals that promote good vision and enhance the overall health of the eye. These chemicals (zeaxanthin and lutein) help in reducing our risk of developing macular degeneration due to ageing.

4 Beautiful skin

Pear contains Vitamin C and E which helps in the growth of the cells of our skin. Pear has also been used in facial products to treat skin conditions such as acne. 

5 Digestion and constipation

Pear contains a significant amount of dietary fiber that encourages regular bowel movements. These are very essential for digestion and prevention of constipation.

6 Cancer

Some studies have established a link between consumption of pears and a decreased incidence of certain types of cancers such as breast, mouth, cervical, stomach and prostate cancer. Researchers have attributed this to the presence of dietary folates which helps in DNA and RNA production.

7 Prevention of birth defects in infants

In order to prevent neural tube defects in babies when they are born, it is recommended that pregnant women consume Folate. Studies also show that folate can prevent miscarriages.

Resources:

MNT: Avocados, Health Benefits, Nutritional Information

The World’s Healthiest Foods: Avocados

How much water should we drink daily?

A lot of people always ask questions relating to how much water one can consume a day. Some health experts will say 6 glasses, others will say 8 while others will say drink till you are full. 

Remember that even if you are told to drink 8 glasses of water a day, it must not necessarily be in liquid form. The fruits we eat, drinks we drink also supply  a percentage of total amount of water we need a day. According to Dr Don Colbert, the author of The Seven Pillars of Health, we should calculate the required amount of water to drink daily as follows:

Take your weight in pounds and divide it by two. The result is how many ounces of water you should drink daily.

Therefore, if you weigh 120 pounds, you will need to drink 60 ounces of water daily.

This calculation takes into consideration that people have different ages, weights and can either be male or female.

Some people are not familiar with pounds and ounces.They are  familiar with kilograms and liters.  Here is how you will go about it if you are used to kilograms and liters.

• take your weight in kilograms and multiply it by 2.2 to convert it to pounds. For example if i weigh 80 kg, my weight in in pounds will be 176 lbs
• Divide the converted value in pounds by 2 to get the ounces of water you need to drink in a day. that is 176 divided by 2 which gives  88 ounces of water to drink daily
• finally, you will have to convert 88 ounces to liters by multiplying 88 by 0.0295735 which gives  approximately 2.6 liters. (Remember that this 2.6 liters is a total of all the fluids that you take in; from pure water to soft drinks, fruits, vegetables and food)

7 Health benefits of tomatoes

Tomato is a reddish and fleshy fruit that is found in almost all parts of the world. I has many nutritional benefits especially when eaten raw or half cooked. here are some of the health benefits of tomato:

1 Reduces the risk of developing cardiovascular diseases

Tomato contains lycopene, which had been found to help in reducing the incidence of cardiovascular diseases and heart diseases such as hypertension and stroke. It also contains potassium which is an important element that helps in reducing our blood pressure.

2 Tomatoes are good for the skin

Tomato contains nutrients and compounds that enhance the beauty of our skin such as Vitamin C. The best way to take care of your skin is to eat fruits that promote the health of our skin and tomato is one of these fruits.

Raw tomato can also be used as a face scrub to peel off dead cells and smoothen our face.

3 Good for bone health

The antioxidants found in tomato such as lycopene has been linked to healthy bones. Tomato also contains calcium and vitamin K, which help in strengthening our bones.

4 prevention against cancers

Some studies have showed that tomato is able to reduce the risk of developing prostate cancer, lung cancer and breast cancers. The antioxidants found in tomato are responsible for this anti-cancer benefits. Lycopene in particular has been associated with a reduced risk of developing prostate cancer.

5 reducing the risk of developing obesity

The risk of developing obesity was found to be lower in people who included tomato in their diet. This has been attributed to the nutrients that are found in tomato.

6 Blood pressure

In order to lower our blood pressure, it is recommended that we avoid sodium.  Eating foods that have potassium can bring down our blood pressure and tomato contains potassium.

7 Good for pregnant women

Tomato is good for pregnant women because it contains folic acid. Folic acid helps to prevent neural tube defect in infants.

A heart age predictor to determine if you are at risk of developing heart attack and stroke

Recent studies on cardiovascular diseases has showed that we may have a heart age that is older than our actual age. The difference in age was accounted for by our unhealthy habits and lifestyle.

The Center for Disease control and prevention stated that 3 out of every 4 Americans have a heart age that is older than their actual age. This puts them at risk of developing heart attack and stroke.

Calculating the heart age involves the use of an online calculator which uses our age, BMI, sex, systolic blood pressure and other risk factors for heart disease such as the presence of diabetes or smoking.

Decreasing our heart's age to our normal age involves working on the risk factors that put us at risk for developing a heart attack or stroke such as watching our weight , reducing our blood pressure and making healthy choices.

In order to calculate your age using the online calculator, click here . More research is still being conducted on the use of this calculator to predict the risk of developing heart attack and stroke. 

The best way to avoid heart diseases is to eat Foods that prevent heart disease, do exercise regularly and avoid junk/processed foods. 

Resources:

Framingham Heart study: Heart Age predictor using BMI
CBS News: Is your heart older than you are?

Diabetes Risk Following Mental Disorders

This is the third in a series of posts looking at a recent research study of mental disorders and risk for later medical illnesses.

In this graph I has summarized data from the manuscript below on mental disorders associated with later risk of diabetes mellitus.

Two eating disorders, bulimia nervosa and binge eating disorder were both associated with a tripling of the rate for a later diagnosis of diabetes mellitus. Both of these eating disorders are linked to overweight and obesity possibly explaining the later association with diabetes.

Mood disorders and anxiety disorders panic disorder and agoraphobia also were associated with a later diagnosis of diabetes mellitus. One concern with this finding is the potential for drugs used for mood and anxiety disorders to increase weight.

I will finish out this series in the next post on mental disorders linked to later chronic paid disorder.

Follow the author on Twitter WRY999

Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, de Girolamo G, Hu C, de Jonge P, Kawakami N, Medina-Mora ME, Moskalewicz J, Navarro-Mateu F, O'Neill S, Piazza M, Posada-Villa J, Torres Y, & Kessler RC (2015). Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries. JAMA psychiatry, 1-9 PMID: 26719969

6 FOODS THAT PREVENT HEART DISEASE

As we grow older, we would not like to be victims of hypertension, heart attack, stroke, or congestive heart failure. Our diet and our lifestyle play a major role in the development of diseases of the heart. A healthy diet is one of the single and most powerful weapon to prevent heart diseases and avoid medications. Here are some foods for a healthy heart

1 Oranges

Oranges are able to lower bad cholesterol, reduce hypertension and prevent heart failure. In order for this to be very effective, you don’t have to wait till you develop hypertension before you start looking for a healthy diet. It is important to eat orange as a preventive measure to ensure that you don’t develop heart diseases.

Oranges contain fiber which is known as pectin. Research has showed that pectin helps in removing bad cholesterol from our system. Oranges also contains potassium which acts against sodium, one of the causes of increased blood pressure. This helps in regulating blood pressure. To get the best health benefit from orange, eat the whole fruit instead of extracting the juice.

2 Garlic

Garlic has so many health benefits. It promotes a healthy heart by eliminating plaque in our blood vessels and reduces high blood pressure. It is more beneficial to eat the real garlic in its natural form instead of taking garlic supplements.

3 sardines

Sardines contain omega-3 fatty acids which helps in lowering triglycerides and increases high density Lipoprotein (HDL). In other words, it helps in reducing bad cholesterol and helps in increasing the good cholesterol.

4 Pomegranates

Pomegranates help in reducing the occurrence of atherosclerosis (hardening and narrowing of our arteries due to the buildup of plaque or fatty deposits) by bringing down LDL (bad cholesterol). LDL (low density lipoprotein) is responsible for the buildup of plaques or fatty deposits around our arteries.

5 kale

Kale is a dark leafy green vegetable that promotes a healthy heart because it is able to prevent atherosclerosis due to the nutrients and compounds found in it. 

6 Tomato

Tomato contains lycopene, which had been found to help in reducing the incidence of cardiovascular diseases and heart diseases.

References:

Mayo Clinic: Heart-healthy diet: 8 steps to prevent heart disease

Helpguide.org: Heart healthy diet tips

5 HEALTH TIPS TO PREVENT HEART DISEASE

Having a healthy heart in the future requires some small sacrifices today. Our future will depend on the choices we make today.

When it comes to preventing diseases of the heart, the most important choice you will have to make is to control what goes into your stomach.  Heart disease is the number one killer of men and women and it kills more than cancer or HIV.

Changing your diet to a healthier one is one of the best ways to prevent heart disease or to reverse heart disease if you have been diagnosed with one.  Here are some tips to prevent diseases of the cardiovascular system or heart disease.

1 stay away from salt  
    

     

Salt contains sodium. Sodium is responsible for raising our blood pressure. High blood pressure is a risk factor heart diseases. In order to improve the taste of your food, use natural spices like garlic, ginger or celery to improve the taste of your food instead of using salt. The American Heart Association has recommended that an adult should not consume more than a teaspoon of salt in one day.

2 Reduce your consumption of canned and processed foods

Canned and processed foods are very high in sodium. It is preferable to buy fresh foods and use them for cooking instead of canned foods.

3 Eat more healthy fats and reduce unhealthy fats

When protecting yourself from diseases of the heart, beware of trans fats. Trans fats are otherwise known as unhealthy fats. Trans fats raise your level of Low density lipoprotein (LDL) which is commonly known as bad cholesterol.  LDL is responsible for increasing your risk of a heart attack or stroke.

Trans fats are found in the following:

• Fried foods such as fried chicken, donuts
• Baked things such as biscuits, cakes, cookies
• Fats which are solid at room temperature like hydrogenated margarine

Th next thing to do is to avoid eating too much saturated fat. It is not as dangerous as trans-fat but eating large quantities of it has been linked to an increase risk of diseases of the heart. Saturated fats can be found in tropical oils, dairy products such as cheese or animal products such as red meat and chicken.

Healthy fats will include all unsaturated fats (mono-unsaturated and polyunsaturated). Unsaturated fats help to prevent diseases of the heart and improve the level of good cholesterol in our blood. Healthy fats are found in foods that contain omega-3 fatty acids like trout fish, salmon, sardine, spinach, flaxseed or kale. Pear (avocado) is also a good source of unsaturated fats.

4 Cut down on your sugar

Sugars have been found to increase our blood pressure which in turn damages the health of our heart. The American Heart Association has recommended that women should not eat more than 6 teaspoons of sugar a day and men should not consume more than 9 teaspoons of sugar a day. It is important to know that even though we may not consume sugar physically in teaspoons, sugar is also found in sweet drinks, and foods such as cakes, ice cream or cookies.

5 Eat foods that contain fiber such as fruits and vegetables 

Fiber can prevent heart disease because it is able to lower blood pressure and reduce the level of bad cholesterol.  Fruits and vegetables are high in fiber and nutrients that help in the prevention of many diseases. Fibers are also low in calories. Foods that contain fiber include orange, banana, peanut, pear, apple, cooked grains, beans, whole wheat bread, carrots, broccoli, spinach, cereals etc.

References:

Mayo Clinic: Heart-healthy diet: 8 steps to prevent heart disease

Helpguide.org: Heart healthy diet tips

Heart.org: Added sugars add to your risk of dying from heart disease

A Surgeon Explains and Defends Simultaneous Surgery

In the continuing discussion sparked by the Boston Globe Spotlight Team's reporting on simultaneous surgery, Dr. Alexander Langerman, a head and neck cancer surgeon from Vanderbilt, wrote an informative piece explaining and defending how he conducts the practice. I, as a non surgeon, found his description of the clinical aspects of the practice very informative, and I encourage you to read his article here.

I was especially happy with Dr. Langerman's discussion of informed consent:

If you’re a patient, in your first visit with a surgeon, ask about the plan for your case, the surgeon’s strategies for trainees, and the way the surgeon handles his or her surgical schedule. I encourage you to get to know any residents who may be involved in your operation; they are a highly valuable second set of eyes who have already completed college, medical school, and often years of training so their ideas, questions, and participation elevate care. I would argue you do not need to require the absence of trainees or the continuous presence of the surgeon but rather a well-thought-out plan that has your best interests in mind.

If you are a surgeon or part of a surgical team, discuss your plan with your patients. You should let them know whether a trainee will be participating in or handling a portion of the procedure, and you should let them know if you are going to be out of the room.

If Dr. Langerman's surgical colleagues had all followed his wise guidance, the practice of simultaneous surgery would not have had the shocking impact it had when the story broke.

New Massachusetts Regulations on Simultaneous Surgeries

Two weeks ago I posted about the practice of simultaneous surgeries. It had been the focus of a Boston Globe Spotlight series. Two days ago, the Massachusetts Board of Registration in Medicine - the body that regulates medicine on behalf of the state - ruled that surgeons must record when they leave and reenter the operating room. Nurses currently do this. At many hospitals, surgeons don't.

Simultaneous surgery raises two central questions: What is its impact on patient safety and surgical outcomes? And, what is the impact on patient and public trust of physicians and hospitals?

Dr. James Rickert, president of the Society for Patient Centered Orthopedics, correctly identified informed consent as the central ethical issue:

“I know that surgeons don’t think this is an important issue, so they assume that it’s not important to patients. However, this thinking is wrong. Patients want to know that their surgeon is the individual who actually operated on them, and I think they have a right to this information. We are talking about situations where patients are completely vulnerable and, by definition, there is a risk of death or severe bodily injury.”

I learned from an op ed piece in today's Boston Globe that the American College of Surgery has created a committee to develop policy about simultaneous surgery. The committee includes proponents and opponents of the practice.

There's an important lesson about health system ethics in all of this. Just as it takes a village to raise a child, it takes multiple components of civil society to promote an ethical health system. With regard to the practice of simultaneous surgery, the Boston Globe Spotlight Team brought the issue to a wider public. Individuals, like the author of the op ed I cited (Nancy Brinker, founder of the Susan Komen breast cancer charity) pitched in thoughtfully. A professional association - the American College of Surgery - is working on evidence-based guidelines for how the practice should be handled. Another professional organization - the Society for Patient Centered Orthopedics - nailed the fact that meaningful informed consent must be part of the process.

We tend to think about ethics in terms of individual conscience and behavior. But just as we have come to see quality of care as a system responsibility and errors as not simply the result of individual "bad apples," we must understand health system ethics as the responsibility of organizations as well as individuals. To improve the ethics of the health system we depend on ethical health organizations as well as vigilant individuals.

Heart Disease Risk Following Mental Disorders

This is the second in a series looking at the recent study of physical illness in those with a diagnosis of a mental disorder.

Today, I am published a chart of the mental disorders associated with increased risk for report of heart disease at a later time.

Alcohol and drug dependence diagnoses are associated with the highest risk of later heart disease. The odds ratio estimates this increase at better two and three times higher than those without an alcohol or drug dependence diagnosis.

Two specific anxiety disorder conditions also show association with later heart disease, panic disorder and PTSD.

Additionally, bulimia nervosa and bipolar disorder also show greater rates of heart disease although these associations are at around 60% to 80% higher rates.

These associations do not prove causality. For example heart disease may share susceptibility genes with some mental disorders.

Nevertheless, these associations should prompt rigorous medical heart disease surveillance in those with substance abuse and anxiety disorders. 

Follow the author on Twitter WRY999

Chart is an original figure created using data from the manuscript cited below.

Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, de Girolamo G, Hu C, de Jonge P, Kawakami N, Medina-Mora ME, Moskalewicz J, Navarro-Mateu F, O'Neill S, Piazza M, Posada-Villa J, Torres Y, & Kessler RC (2015). Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries. JAMA psychiatry, 1-9 PMID: 26719969

When it comes to drinking alcohol, what quantity is considered normal? What is considered as drinking alcohol in excess? How many bottles or glasses of alcohol should we drink per day?

Everybody is aware that drinking alcohol in excess will harm our health.  There are a lot of question that people ponder on silently when thinking about the safe limits of drinking alcohol.

The effects of alcohol cannot be seen immediately. It usually takes so years to be seen. You may be drinking above normal now without seeing any effects, but it will surely come to pass after some years.

In order to know how much alcohol you drink, u should be able to calculate the units of alcohol in your drink. The units of alcohol will help you to know the quantity of pure alcohol that is found in your drink, no matter the size of it and volume of the drink.

The NHS has recommended that

• Women should not drink more than 2-3 units of alcohol every day or for most of the days in a week
• Men should not drink more than 3-4 units of alcohol every day or for most of the days in a week 

In General, men should not drink more than 21 units of alcohol per week and women should not drink more than 15 units of alcohol per week. Both men and women should have 2 days free from drinking alcohol every week.

How to determine the units of alcohol that are found in your glass or bottle of drink

In order to calculate the units of alcohol, you will need two values:

1 Total volume of drink in ml: the total volume of drink is usually written on the bottle of the alcohol. for example 350 ml, 750 ml. 1000 ml. If the drink is in a glass, you will need to estimate its volume in the glass e.g. 100 ml. 

2 The alcohol by volume: it is abbreviated as ABV, abv or alc/vol. it is a measure of how much ethanol (alcohol) is found in a given volume (bottle, can) of an alcoholic beverage. It is expressed as a volume percent.

An alcoholic beverage that has “10% ABV”, “vol 10%” or says “10% alcohol by volume “  means that of the total volume of drink, 10% of it is pure alcohol.

The formula for calculating the number of units of alcohol found in your drink is as follows:

(Total volume of drink in ml × alcohol by volume in %) ÷ 1000

Example 1, to calculate the units of alcohol in a 330 ml bottle of beer that has an ABV of 5 %:

(330ml × 5%) ÷ 1000 = 1.65 units

Example 2, if you have a bottle of KING’S CASTLE blended Scotch whisky that has 43% VOL and 75CL (cl stands for centiliter and 1 centiliter equals 10 milliliter so the volume in ml is 750):

(750 ml× 43%) ÷1000 = 32.25 units. 

This means that if you have whisky you will need to drink it in “shots” or in very small quantities per day in order not to exceed the recommended 3 /4 units of alcohol per day.

Example 3, if you happen to share a glass of wine or you are at a party and you are offered a small glass of red wine that has 12% ABV and the volume of red wine in the glass is 125 ml:

(125 ml × 12%) ÷ 1000 = 1.5 units

Read about the health effects of drinking alchohol in excess here

Sources:

NHS Choices. Alcohol units. Available at: http://www.nhs.uk/Livewell/alcohol/Pages/alcohol-units.aspx

Patient. Recommended safe limits of alcohol. Available at: http://patient.info/health/recommended-safe-limits-of-alcohol

Stroke Risk Following Mental Disorders

An important recent manuscript published in JAMA Psychiatry looked at medical illnesses rates following diagnosis of a brain (mental) disorder.

This very large international study examined over 47,000 subjects followed between 2001 and 2011.

Baseline psychiatric assessment was completed using the Composite International Diagnostic Interview. Physical illness was assessed using a self-report of physician's diagnosis.

The manuscript is not free but I was able to obtain a professional courtesy copy of the manuscript from the lead author. 

The study found that a diagnosis of a mental disorder increased rates for a variety of later physical conditions.

I have put together a graph of the mental disorders associated with higher rates of later stroke (above).

Bulimia nervosa showed a three fold increase in later stroke. I am not aware of this association previously being noted. Alcohol and drug use disorders are known to increase stroke risk and this was found in the study lending face validity support.

Additional mental disorders associated with later stroke were bipolar disorder and panic/agoraphobia. 

Bipolar disorder has been linked to higher risk of hypertension and smoking.

The implications of these findings include need for enhanced medical illness screening and risk factor reduction in those with a mental disorder diagnosis. 

I will look at some the other individual medical conditions in future posts.

Follow the author on Twitter WRY999

Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, de Girolamo G, Hu C, de Jonge P, Kawakami N, Medina-Mora ME, Moskalewicz J, Navarro-Mateu F, O'Neill S, Piazza M, Posada-Villa J, Torres Y, & Kessler RC (2015). Association of Mental Disorders With Subsequent Chronic Physical Conditions: World Mental Health Surveys From 17 Countries. JAMA psychiatry, 1-9 PMID: 26719969

The battle with tap water

Water is needed for the body to survive. We all know the health benefits of drinking water, but the important question we sometimes fail to ask is the right kind of water to drink. Not all water that looks clean is safe for drinking.

Of recent, health experts have been raising some concerns with respect to the water that is being supplied to us as tap water.

Here are some of the reasons why health scientist are raising concerns with respect to the safety of tap water being supplied to our homes.

1 Our tap water contains chlorine

The reason why some health experts are raising concerns that tap water is not very safe for drinking is because it contains chlorine. Chlorine is popularly known in the health world as an anti-vitamin. This means that chlorine destroys vitamins.

Chlorine is added to water as a means of purifying it, to make it safe for home use. However, some studies have showed that chlorine may be responsible for causing some cancers.

2 tap water contains fluorides

Adding fluorides to water is a common public health measure to treat water in developed countries. This fluoride is in the form of Sodium silicofluoride which is toxic to man when ingested. Fluoride has been shown to have a link between cancer, arthritis and osteosarcoma.

3 Tap water contains Aluminum

Aluminium is used to treat water.  This is because aluminium makes organic materials in water to coagulate and sediment. However after treatment, it is impossible to remove all traces of Aluminium in water. Aluminium when ingested is more dangerous that chlorine and fluoride. Aluminium has been found to cause cancers and Alzheimer’s disease

5 Pollution of water from the environment

Our environment contributes to water pollution. The sprays, pesticides, fertilizers, drugs, shampoos easily find their way into water that is being recycled for use. Rain also washes these chemicals into water supplies. 

Get Fit While at Work

These days, it seems as though more and more people are working longer hours and using the old "no-time-to-exercise" excuse.

Unfortunately, this lack of physical activity can be harmful to your health, as it increases the risk of obesity, back pain, poor posture, leg cramps and tense muscles, among other things.

Wouldn't it be great if you could find a way to fit in some type of workout during those 8+ work hours?

Well, the good news is…you can. It just requires a slight change in how you work or get to work, to make a meaningful improvement.

Cardio

Schedule walk-and-talk meetings. Who says a meeting needs to be held around a table? Take a brainstorming stroll with a colleague. If you need to take notes, schedule the meeting at a park where you can sit on a bench.

Avoid the elevator. The Centers for Disease Control and Prevention recommends adults get two hours and 30 minutes a week of moderate-intensity exercise to stay fit. Stair climbing for just 10 minutes, three times a day, for example, will total 30 minutes of heart-strengthening exercise, putting you well on your way to reaching that mark.

Take a stand. Set a timer to remind yourself to get out of your chair every 30 minutes. Use this time to walk to the water cooler or check in on a project.

Flexibility

Reach for the sky. Sitting at a desk all day can lead to neck pain between the shoulder blades. You can reduce the pain by reaching both arms up to the ceiling and arching your back. Then bring your arms down and stretch forward, opening the upper back. Do this every 20 minutes.

Stretch out your shoulders. Sit straight in your chair and reach one hand behind your back with your palm out. Then reach your other hand up and bend it down, trying to touch both hands. Hold for 10 seconds.

Point your fingers. Typing for eight straight hours can be harmful to your hands, wrist and forearms. Stretch one hand in front of you, pointing your fingers toward the ground. Use your other hand to gently push your fingers down and toward your body. Repeat on the other side. Then, stretch your hands upward doing the same.

Strength

Tone your arms wherever you can. A great way to sneak fitness into your day is to do a few push-ups here and there. Remember, all you need is a flat surface – and it doesn’t need to be horizontal. Simply lean against a wall, desk or other sturdy surface and get a few reps in.

Rise up out of your chair. Even if you are stuck in your chair all day, you can still get some core work in. Throughout the day, simply lift yourself off your chair with your arms.  If your chair is on wheels, it'll be even harder to hold your body still.

Get your legs up. While sitting in your chair, extend one leg out straight in front of you and hold for a few seconds. Then raise it up as high as you can and hold it again for a few seconds. Repeat with each leg multiple times.

These simple actions can significantly increase your physical health. Squeezing in a little exercise also improves concentration and could actually improve your productivity.

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10 health effects of drinking alcohol in excess

It is very common for Nurses, Doctors Health Scientist and so many other professionals to tell you not to drink alcohol. But what exactly does the famous saying “alcohol is not good for your health “mean? Here is a breakdown of how alcohol damages our health.

Majority of people who suffer from the health effects are not necessarily alcoholics or drunkards. They are ordinary people who have been drinking alcohol a little above normal for so many years.

1 Cancers

Drinking excess alcohol is a risk factor for cancers like Mouth cancer, Breast cancer, liver cancer, throat cancer or cancer of the esophagus.  

Health experts believe cancer results from our body’s conversion of alcohol into aldehyde, which is considered a possible carcinogen.

2 Pancreatitis

Alcohol pancreatitis can occur as a consequence of long term addiction to alcohol. This can make the pancreas not to function properly.  

The pancreas helps our excretory system to break down substances so that it can be easily excreted. The pancreas also secrets digestive enzymes. Apart from this, the pancreases also help to regulate the amount of glucose in our body. If the pancreas is destroyed as a result of alcohol, problems like hyperglycemia and hypoglycemia will result.

3 Damage to the liver

The liver is an organ that cannot escape the effects of excessive alcohol intake. Cirrhosis and alcohol hepatitis are some health effects of alcohol that can be seen with the liver.

The liver breaks down and processes substances in our body, preparing them for excretion. When we drink too much alcohol, it can cause chronic liver inflammation which can lead to scarring of the liver (cirrhosis).  If the liver is destroyed, our body will not be able to break down toxic and poisonous substances in our body.

4 Heart attack, stroke and cardiomyopathy

Drinking excess alcohol can cause problems like irregular heartbeat cardiomyopathy and stroke. Scientist have found out that drinking alcohol can make some of our blood cells (platelets) to stick together forming clots. This clots have a high chance of causing a heart attack or a stroke.

The muscles of our heart can also get weak and fail to work as a result of drinking alcohol in excess for a long period of time. This condition is called cardiomyopathy.

5 Depression

Depression has always been associated with drinking alcohol in excess.

6 Hypertension

Bingeing alcohol or drinking it heavily can cause our blood pressure to increase above normal. 

7 Erectile dysfunction and infertility

When men drink alcohol in excess for long, it can cause erectile dysfunction. Infertility can also be a consequence of abusing alcohol.

Women who abuse alcohol can suffer from irregular menstruation and infertility.

8 Birth defects in children

Drinking alcohol for a long period and during pregnancy can result in developmental abnormalities in children.  This developmental activities are generally known as fetal alcohol spectrum disorders (FASD). The baby can grow up to have learning disabilities, physical abnormalities and a low IQ.

Alcohol can also increase a woman’s chances of having still births or miscarriages.

9 Weak immune system

Alcohol weakens our immune system, making us susceptible to diseases caused by many microorganisms.

10 Drunkenness

Drinking alcohol in quantities that our body cannot process can lead to drunkenness, dizziness, hallucinations and slurred speech. It also alters our mood and judgment. If a person drives in any of these states, it can cause road traffic accidents.

 Sources:

National Institute on Alcohol Abuse and Alcoholism (NIAAA) available at http://www.niaaa.nih.gov/alcohol-health/alcohols-effects-body

WebMd, Health Risks of Alcohol. http://www.webmd.com/mental-health/addiction/features/12-health-risks-of-chronic-heavy-drinking

Healthline. The effects of alcohol on the body. Available at: http://www.healthline.com/health/alcohol/effects-on-body