Category Archives: Morbidity - Page 2

PTSD: Military and Civilians

Posted by on July 1, 2013 Comments Off on PTSD: Military and Civilians

As I was surfing my car’s radio dial for some music–not much luck at the time–I heard a DJ defending his decision to discuss PTSD in the military. I guess some other listeners had been unsuccessful in finding music but found a serious discussion of trauma and war on a music show unacceptable.

What used to be called “shell shock” or “battle fatigue,” has the medical diagnosis of Post Traumatic Stress Disorder (PTSD). It is the kind of thing that got General George Patton in trouble, when he slapped a soldier suffering from it.

In many areas of brain disorder (ADHD, bi-polar, OCD, and PTSD), we can now provide a medical diagnosis rather than a moral diagnosis. Suffering from one of these disorders is no more evidence of moral shortcomings than diabetes, heart disease, or cancer–just different organs involved.

PTSD results from a shock or trauma–perhaps war is the most common and severe emotional trauma. I regret to note that having a volunteer army has resulted in the unintended consequence of making troops expendable to the civilian population. Now, we think nothing of sending them into combat with minimal reason or provocation, as they are volunteers, while we are in no way inconvenienced by doing so–no rationing, no higher war taxes, zilch.

As a result, we have decade-long wars (2 at last count in recent years) that cannot help but create PTSD along with other casualties of confict. And, of course, we need to make sure those needs are met along with the amputations and prostheses that the civilian population associates with war. The Veterans Administration (VA) maintains a National PTSD Center, and I have no idea how good the programs are, but they can be found by consulting the VA PTSD Locator

A related point, however, is that civilians as well as military are subject to the traumas that trigger PTSD. As the National Institute for Mental Health notes:

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.

While our primary concern may be with the direct effects (psychological and emotional) of PTSD, just this week an Emory University study of identical twin Vietnam War veterans found that risk of heart attacks was more than doubled in those with a history of PTSD.

Mental illness or brain disorders of any type require considerable investment of resources, professional and financial, to address. As a society we have dragged behind on this–mental health parity laws at the state level commonly had loopholes for high financial impact. There is a federal law in place, but it is not clear how effective it is. Change is occurring, but slowly.

Just within the past week, we learned that the California Department of Managed Health Care had imposed the second largest fine ever on Kaiser Permanente for failure to provide long term mental health care.

This country was founded by emptying Europe’s jails, and has been populated by escapees from prisons and hospitals around the world, along with other immigrants. As a nation, we have our share of people with “issues.” Some of the benefit has come from their creativity and willingness to challenge frontiers; however, in the 21st Century we need to help those folks adjust to what passes for civilization. Our veterans deserve it, but so do a lot of civilians, too. Let’s work to see they receive the necessary services–having mentally stable neighbors and colleagues improves life for all of us.

Doing the porcelain dance

Posted by on June 17, 2013 Comments Off on Doing the porcelain dance

As a general rule, food-borne illness, commonly called “food poisoning,” has remained fairly constant over the years. Indeed, since 1996 only one pathogen has shown considerable increase.

Based on 19,531 cases from Foodborne Diseases Active Surveillance Network (FoodNet) the CDC found:

Food Illness Trends 1996_2012

If Vibrio were a stock instead of a pathogen, you would have wanted to buy in around 1996 as it has enjoyed a considerable rise. Perhaps, like me, you wondered what Vibrio was. Most of the others have been in the news media or are simply well-known.

The trend continued in the period 2006 to 2012:

Foodborne Illness 2012

Vibrio is a genus of bacteria–one species causes cholera. This species Vibrio parahaemolyticus, however, likes sea water so much that it hangs out with oysters. If you get this infection, antibiotics do not help, so you drink liquids and wait it out.

Vibrio

By contrast, another species Vibrio Vulnificus can respond to anti-biotics. Among healthy people, the experience is likely to be the same as for Vibrio parahaemolyticus, but for those with compromised immune systems, immediate medical attention is indicated. Fortunately, this seems to be the more rare form of non-cholera Vibrio, and the incidence is much less frequent, generally occurring in the Gulf States.

One mystery in the data: incidence of Vibrio is higher among adults over 65 years old. While it can be contracted by an open wound in the wrong sea water, most Vibrio results from consumption of raw oysters or other uncooked seafood. I have not been aware of any trend to gulping raw oysters among seniors, but as the boomers enter old age, maybe they are going for anything that might keep the Sexy Sixties going. It would be of interest to see the geographic distribution of these cases–are there a lot of them in South Florida, for example?

Be careful out there.

Obesity confusion

Posted by on June 10, 2013 Comments Off on Obesity confusion

We are agreed that obesity is a problem, for individuals and for society.

We are agreed that dieting alone will not help. The latest popular diet approach is part of the background noise not part of the solution. Here is some noise from my Facebook feed as I was writing this posting.

Obesity diet noise

Exercise and dieting combined would work, but is probably beyond the ability of many if not most people facing obesity. Indeed, starting any exercise program may be a challenge to both will and health of someone morbidly obese.

We know that bariatric surgery can work; however, it is invasive, expensive, and there are debates among specialists about what works sufficiently.

Indeed, after Governor Chris Christie of New Jersey announced that he had had a gastric band implanted, there was considerable debate about whether that was sufficient compared to gastric bypass surgery, particularly given the failure rate of the laparascopic gastric band or “lap band.”

There is open debate about whether obesity prevention measures are cost-effective.

As if the problem were not challenging enough, a study has shown that physicians fail to demonstrate to obese patients the empathy necessary to effect change.

Al Lewis argues that many of our workplace wellness programs are ill-conceived and ineffective.

The seriousness of the problem is underscored by a Metlife study showing that obesity contributes $1,723 per person per year to the Medicare budget, or 8.5 percent of the total.

We are not left with a solid place to make a stand against obesity. My plan is to walk a bit more and eat a bit less as I contemplate next steps. What are your thoughts?

Are we making progress or falling behind?

Posted by on May 27, 2013 Comments Off on Are we making progress or falling behind?

In health care we don’t need to look far for bad news. In the past week, I have read:

  1. The prevalence of diabetes has increases 75 percent from the early nineties to the late naughts. A more extensive discussion (may require free Medscape subscription registration) is at New Statistics Shed Light on ‘Worrisome’ Diabetes Epidemic
  2. Leapfrog Hospital Safety Scores ‘Depressing’
  3. Study finds jump in ER-related admissions

And certainly we could include partisan bickering in Washington among politicians more focused on the next election than any meaningful policy debate or measures.

However, the simple fact is that none of this matters. We have no choice. If we do not adequately address our health care needs, then we will no survive as individuals or as a society.

If that premise, the premise of this blog, is correct, then we must assure access to healthcare for everyone. We must get the public health epidemics of obesity, diabetes, and gun violence, among others, under control.

On this Memorial Day, as we reflect on how many Americans have given up their lives at a young age to protect the American experiment, let us consider our debt to them: we owe it to them to insure that our society does not fail and that individuals not on battlefields do not give up their lives at a young age because they ate too much or someone bought a gun out of fear.

We are Americans: we do not accept failure in ourselves. The rest is trivial distraction.

How researchers confuse the public

Posted by on May 20, 2013 Comments Off on How researchers confuse the public

A nursing professor once told me how a graduate student came to her all excited. There was a population cohort dying from an epidemic of cardiac disease that had been ignored in the literature: women above age 85.

Now, while we can chuckle together about the naivete of the observation, consider it for a moment from the graduate student’s perspective:

1. Clearly the phenomenon was real as a high percentage of women over age 85 may well be dying of cardiac disease.
2. The red flag of gender bias stood out–it was women who were being victimized by this scourge.
3. A literature search turned up no one acknowledging the problem.

What was missing was the larger context: the twin facts that no one lives forever, and everyone eventually dies of something.

Sometimes more experienced researchers fail to provide the needed context. The following study came to my attention this week. Truth be known, I have not read the entire study, just the abstract and the accounts of those who have, so I will admit up front that this discussion may be unfair to the researchers.

The Canadian study is The long arm of parental addictions: The association with adult children’s depression in a population-based study.

It came to my attention in Trouble Coping with Parental Addiction

I am going to quote the abstract in full:

Parental addictions have been associated with adult children’s depression in several clinical and population-based studies. However, these studies have not examined if gender differences exist nor have they controlled for a range of potential explanatory factors. Using a regionally representative sample of 6268 adults from the 2005 Canadian Community Health Survey (response rate=83%), we investigated the association between parental addictions and adulthood depression controlling for four clusters of variables: adverse childhood experiences, adult health behaviors, adult socioeconomic status and other stressors. After controlling for all factors, adults exposed to parental addiction had 69% higher odds of depression compared to their peers with non-addicted parents (OR=1.69; 95% CI, 1.25–2.28). The relationship between parental addictions and depression did not vary by gender. These findings underscore the intergenerational consequences of drug and alcohol addiction and reinforce the need to develop interventions that support healthy childhood development.

The authors suggest that previous studies have not directly looked at gender differences of children of addicted parents. If so, then that is a clear contribution to the literature. But, the abstract and the descriptive article that I cited above go further: there is the clear implication that beyond a correlation or “relationship,” depression is the consequence of parental addiction.

Let’s consider two scenarios:

First, parents engage in substance abuse. The substance abuse causes them to act out, to neglect their children’s physical and emotional needs. The children grow up insecure and prone to depression. That is the clear implication of the abstract.

Second, a small but measurable percentage of the population inherit a tendency to mental illnesses (bi-polar, uni-polar depression, anxiety disorder, etc.) They self-medicate with both legal and illegal substances. They have children, whom they raise while self-medicating. A high percentage of their children inherit the tendency to mental illness, including uni-polar depression, and depressive cycles of bi-polar, showing a higher tendency toward those illnesses in the general population.

I find the second scenario more compelling. Indeed, attributing the problems of children to their parents because children follow their parents temporally is to my mind a classic case of the post hoc, ergo propter hoc logical fallacy in which one concludes that events following another event were caused by the previous event due to their proximity.

Runny noses do not cause colds, nor does “catching a chill,” whatever that means. Scientific studies are confusing enough to the general public, particularly through the filter of news media that do not look past the headline. We need researchers to be more cautious and guarded in their conclusions.

When we read that President Harry Truman wanted some “one-handed economists,” we can be sure that the economists were doing their job in informing him. We need the same of healthcare researchers.

Are we doing ourselves in faster than we think?

Posted by on May 6, 2013 Comments Off on Are we doing ourselves in faster than we think?

We know that our health is adversely affected by obesity, a sedentary lifestyle and fat consumption, not to mention tobacco and lack of access to healthcare. These factors are holding down what should otherwise be continued gains in life expectancy. They also adversely affect those who survive: the strains of obesity on the skeletal structure, emphysema from tobacco consumption, chronic heart disease, cancer that takes over lives, etc.

Recent studies indicate that not only are we experiencing indirect and long-term impacts on our lives and health, but the rate of suicide is increasing, surpassing deaths by motor vehicles in 2009. What adverse lifestyles are not doing to us in the long-term, we are doing directly to ourselves in the now.

The recent CDC study Suicide Among Adults Aged 35–64 Years — United States, 1999–2010 showed that the largest increase in the suicide rate was among whites between ages 45 and 64, in contrast to the common concern about teen and geriatric suicide.

In general, the suicide rate is related to stressors and the availability of means. The following chart, with data from the National Vital Statistics system, is from that CDC study:

Suicide by Sex and Means 1999-2010

Noteworthy are the increased use of firearms, which account for about half of all suicides among men, and suffocation (euphemism for hanging). The study lists the rates of suicide by state as well as the rate of increase from 1999 to 2010. I wondered about the ownership of firearms in those states.

I found that the study, “Association of suicide rates, gun ownership, conservatism and individual suicide risk,” was published online in the journal Social Psychiatry & Psychiatric Epidemiology in February.

The title a bit provocative, but if the availability of firearms reflects the political views of a population, and if the availability of firearms is related to the suicide rate, then it is possible to find statistical correlations among the three, without implying that a particular political view is suicidal or causes suicide any more than suicide causes a political view.

The study by researchers at the University of California, Riverside presented the following map of suicide rates by state:

Suicide_2000_2006

The map seems to show higher rates in states where one might expect more gun ownership, but, being a data person, I did a little experiment of my own.

I ran a couple of regressions, down and dirty, not up to publishable, academic standards. I used MS Excel, probably acceptable for this purpose but not a tool I would use for a publishable regression analysis.

My data sets were gun ownership from the Behavioral Risk Factor Surveillance System for 2001 and Median Income from the US Census Bureau for 2006. First, regressing gun ownership by state on income found that income was a significant factor, inversely related to gun ownership, and explaining 35 percent of the unexplained variation. This is not surprising as rural states are generally poorer and are more likely to have traditions of gun ownership for protection as well as for hunting.

It also meant that the cross correlation of income and firearms ownership might cloud the findings when I looked at the suicide rate from the latest CDC report and its separate relationships to the two factors. Those figures were for only 39 states, so that is how I handled it. My informal findings were that gun ownership rates were strongly correlated with the suicide rate, p=.00025 with R squared =.308, accounting for 30.8% of the unexplained variation. Income was inversely related to suicide and was much weaker, with p=.045 and R squared = .104.

Now, you might say, “Oh, suicide is related to economic factors. With recent economic challenges, of course suicide is rising.” You would be correct. Researchers from Rutgers have provided a graph of the relationship between suicide and unemployment.

Suicide and Unemployment
Source: Social Fact: The Great Depressions?

That is not, however, the public health issue, as there will always be stressors causing suicide. We need to find a way to block access to guns in the same way that we block access to bridges for suicidal people. Of course, there are a lot more guns than bridges. In the United States we ban automatic weapons from private ownership, so the issue is not whether the right to bear arms can be restricted: the entire debate is how extensive those restrictions should or should not be. The data on suicide suggests that greater restrictions on access would have a positive public health impact.

The latest in DME: an umbrella

Posted by on March 25, 2013 Comments Off on The latest in DME: an umbrella

When my wife moved to the States from Singapore, she was amazed to find that the umbrellas sold did not list their UV protection. Singapore is 137 km or 85 miles from the equator, and light skin is valued in Chinese culture. So protection from the aging and darkening effect of the sun’s rays has strong cultural underpinnings–unlike the US where there seems to be a tanning salon in every strip mall.

Normally we don’t think of an umbrella as DME (Durable Medical Equipment). However, if DME is home medical equipment you need for your health, then using an umbrella to prevent melanoma seems to qualify. As reported in JAMA Dermatology The researchers Josette R. McMichael, MD, Emir Veledar, PhD, and Suephy C. Chen, MD, MS of Emory University performed a simple, but well-designed experiment: they invited friends to join them in a parking lot, took 3 ultra-violet radiation (UVR) readings, and then opened umbrellas the friends had brought, taking two UVR readings, 1 cm from the individual, and 1 cm from the edge of the umbrella as shown:

Umbrella_uvr_measurement_20130304

There was wide variety in protection among the 22 umbrellas tested, ranging from a white totes® (77%) to a silver Coolibar® (99%). Fourteen were black in color.

Some of the numbers: Umbrella_findings_20130314

As is apparent in the account, the two readings (close and far) were highly correlated. The following scatterplot shows that as the values of each of the two readings are on the axes. The lowest reading shows the greatest protection, so umbrella 6 is the Coolibar®.

Umbrella_uvr_emory_20130304

As the earth warms, we can expect disturbances in the atmosphere that increase our exposure to UVR. Borrowing the style of the 19th century, carrying umbrellas, especially those designed to screen UVR, may be the best we can do.

What’s a woman to do? Or a man? Dairy and weight and bones and stuff.

Posted by on March 18, 2013 Comments Off on What’s a woman to do? Or a man? Dairy and weight and bones and stuff.

In many ways women’s health is more challenging than men’s.

Women over age 50 are much more likely to get breast cancer, or its precursors, such as fibrocystic breast disease.

Women get cervical and ovarian cancer–men don’t need pap smears or the equivalent.

Women are five times more prone to osteoporosis.

Many medical studies have disproportionately targeted men, although that is changing.

But let’s just consider osteoporosis for a moment. Some risk factors are:

  1. Unchangeable
    • Sex
    • Age
    • Race
    • Family History
    • Frame Size
  2. Hormone Levels
    • Sex Hormones
    • Thyroid
    • Other Glands
  3. Dietary
    • Low Calcium Intake
    • Eating Disorders
    • Weight Loss Surgery
  4. Steroid Prescriptions and Others
  5. Lifestyle
    • Sedentary Lifestyle
    • Excessive Alcohol Consumption
    • Tobacco Use
  6. Too little estrogen

This is but one ailment, but threading the needle is difficult. Consider that sedentary lifestyle and inadequate weight are opposites. If someone exercises and loses weight, the risk is increased. If someone does not exercise, the risk is increased. And the task is even more complicated. A recent study found that consumption of high-fat dairy is associated with increased mortality from breast cancer–so your doctor will probably tell you to stick to low-fat dairy to get additional calcium–be sure to ask.

Very often we hear that someone fell and broke their hip; less often we realize that someone’s hip broke, and they fell.

The International Osteoporosis Foundation estimates that 1 in 3 women and 1 in 5 men will experience a fracture from osteoporosis.

Osteoporosis affects more than 10 million Americans, accounting for 1.5 million fractures annually.

Bad News for Boomers: Our Parents Were Healthier

Posted by on March 14, 2013 Comments Off on Bad News for Boomers: Our Parents Were Healthier

As Americans we believe in progress, in a better tomorrow, sometimes with a bump in the road or a hiccough, but always a better tomorrow.

The data are in (March 4,2013 edition of JAMA Internal Medicine), and it ain’t happening for boomers. Blood pressure, cholesterol, diabetes, and obesity–all greater than the previous generation.

Boomer_Parent_Comparison_JAMAinternalmed_20130304
Source: The Status of Baby Boomers’ Health in the United States The Healthiest Generation?
Dana E. King, MD, MS; Eric Matheson, MD, MS; Svetlana Chirina, MPH; Anoop Shankar, MD, PhD, MPH; Jordan Broman-Fulks
JAMA Intern Med. 2013;173(5):385-386

Although longevity has risen during the twenty-year gap between the two groups, every other indicator of health, except smoking, has become less favorable. And the pattern is clear.

At the top of the following chart are general measures of health. Then, we can see that lifestyle factors have declined leading to the trends in the last section: declining indicators of cardiovascular health.

We can’t choose to be healthy or not: what we can do is make healthy choices by changing the lifestyle factors.

We are choosing illness at great expense to ourselves, both financially and in quality of life, while continuing to endure longer and sicker lives instead of enjoying healthier lives.

Boomer_Parent_Extract_Comparison

Salt: Connecting the Dots

Posted by on March 11, 2013 Comments Off on Salt: Connecting the Dots

Some number of millenia ago our evolutionary forebears crawled out of the sea, carrying its salt flowing through their veins to ours. In the right amount, salt is not only good for us but essential to life.

That is not the same, however, as dumping salt on our food before tasting it or eating processed dinners, from the supermarket or from the nearest fast food franchise.

Most of us have long known that salt increases hypertension among salt-sensitive individuals.

Two sets of studies have come out, one widely publicized, the other well below the radar, that add concerns about excess salt consumption.

Researchers publishing in a recent issue of Nature have linked salt consumption to auto-immune disorders such as multiple sclerosis, psoriasis, ankylosing spondylitis, and rheumatoid arthritis. Unless you have a $200 annual subscription to Nature, you may wish to google “salt autoimmune” to read descriptions of the studies. Or, you may wish to simply click on these links to Medical News Today or The Huffington Post.

So, what are the dots to be connected? That’s where the second study comes in, the one with little publicity.

A presentation at the 2013 American Academy of Dermatology annual meeting in March found that individuals with psoriasis were more likely to have metabolic syndrome. They found that 30 percent of the psoriasis children had metabolic syndrome symptoms compared to the non-psoriasis group. There were not significant differences in Body-Mass Index (BMI), c-reactive protein, or endothelial cells

A 2012 study in South India found a higher incidence of metabolic syndrome among those with psoriasis. In this case:

Patients were diagnosed with MetS for having three or more South Asian Modified National Cholesterol Education Program Adult Treatment Panel III criteria: abdominal obesity (waist circumference ≥90 cm for men, ≥80 cm for women); blood pressure, >130/85 mm Hg; fasting blood glucose, ≥100 mg/dL; hypertriglyceridemia, >150 mg/dL; or low HDL (<40 mg/dL for men, <50 mg/dL for women).