the hundred-day cough

By | January 3, 2012

If you started coughing today, January 3rd, and coughed for a hundred days, you’d finish up on April 12th.

I know an adult who broke a rib with this kind of cough (but had to keep coughing with the broken rib. Made it hard to work). I know someone who had a prolapsed – well, you don’t want to think about the details. Suffice it to say, plenty of folks have weeks of incontinence with this kind of cough.

Click here for Dr Leigh’s “Pertussis Facts” handout (all ages).
Click here for a visual guide on how to diagnose a cough (all ages).

Click here, here, and here, for guidance on how to recognize “vaccine-preventable diseases” in children. If you don’t give your kids shots, it’s your responsibility to know how to spot, for example, whooping cough, measles, pneumonia (from HiB and/or pneumococcus), etc.

Why do I say, “your responsibility”? Isn’t that what doctors are for?

The reason we even have vaccinations is because those particular illnesses are difficult or impossible to treat. Your doctor needs to know as early as possible in the course of the illness, what is going on. Your doctor is also required by law to help keep track of epidemics*, and they can’t do that, if you didn’t tell them your suspicion.

Your doctor almost certainly did not receive training in the signs, symptoms, diagnosis and treatment of vaccine-preventable diseases – your doctor will have to look up and review that information. (Note: your doctor knows more than really seems reasonable about the microbiology and micro-patho-physiology of these critters – but that’s not the same as knowing how a baby looks when they have pertussis, knowing about proper nursing care for a kid with rotavirus, or knowing specific danger signs, beyond any physician’s simple “Hmmm, could this be encephalitis?”)

Note: I am speaking about family doctors. Pediatricians, no doubt, have superpowers to detect vaccine-preventable diseases and their complications. Unfortunately, if you do not give shots to your kids, you may already have been kicked out of your pediatrician’s practice.

Headlines from the internets this morning:

The rise in pertussis, or whooping cough, has reached the level of breakout in at least one New Mexico county.

DEXTER, Maine – Officials here hope they have seen the last of a whooping cough outbreak that has infected 33 students in the district so far this school year.

APPLETON [WI] – School District officials warned parents this week… of pertussis at five schools

The number of whooping cough cases continues to grow in Eau Claire County [WI]. The health department says there have been 41 confirmed cases. That’s ten times as many as the past several years.

Officials said there were seven cases of whooping cough reported in [Dane] county in November and 12 new cases reported since the beginning of December. [WI]

Statewide [in IL], the reported pertussis cases so far are on track to double the 648 recorded in 2009, and already are well above last year’s 1,056 reported illnesses. Nearly 10 percent of the current state total came in during the week between Dec. 13 and Dec. 20 [2011].

“In Minnesota we are seeing over 1,100 cases each year.” [Infectious Disease Consultant, Mpls]

Four additional cases of whooping cough have been identified at an Alamance County elementary school. [NC]

The number of whooping cough cases has increased dramatically in Utah County… In 2011, 155 residents were diagnosed with the highly contagious respiratory disease compared to 38 the year before.

As of Oct. 27 there have been 129 confirmed cases of pertussis,” said Dr. Gary Goldbaum, health officer and director of the Snohomish Health District. This is a drastic difference from the 25 reported cases in 2010. [WA]

Just across the [Oregon] border in Washington, 6.2% elected not to vaccinate [in 2011] – one of the highest rates of non-medical exemption rates in the country after Alaska (9%), Colorado (7%) and Minnesota (6.5%). Oregon’s exemption rate rose to 5.6%, up from 5.2. (The percentages refer to kindergarten students.)

*FYI – Only a few of the things your doctor is required by law to report to Public health:
Immediately, day or night: Measles, Rubella, Diphtheria, Polio
Within 24 hrs: HiB (causes pneumonia and meningitis), Bacterial meningitis
Within one working day: Pertussis, Mumps, Hepatitis A, Tetanus
…Also, of course, Rabies, Plague, Syphilis, Tuberculosis, Mad Cow Disease, etc.

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immunometabolism: in the micro-world

By | January 1, 2012

As you may know, I’m working on a cookbook. (It’s more than a cookbook.)

Because of it, I have been learning a lot about “metabolic syndrome” – what it truly is, how it works, what we can do about it. I’ve been talking to a lot of you about this stuff in the office. You may have heard me say, “Inflammation is the most basic function of our immune system, and whenever we have a system like inflammation, we have another system to tone it down, because you don’t want inflammation getting out of control.” Right? And I’m talking to you about it in the context of metabolism – how we break down and use the foods and other stuff we take into our bodies.

So in the course of reading about “immunometabolism,” I found this review article that intrigued me, not only because it uses fabulous words like “nonphlogistic recruitment” (remember phlogiston? the fire within?) and “efferocytosis” (Latin, “to take the dead cell to the grave”), but also because it describes the condition of inflammatory obesity in terms of (to me) high drama.

Imagine, if you will, the micro-world…

high drama

In the micro-world, a human being (or a chocolate labrador, or a lab rat, or any other complex creature) is not the master or director of conditions; they are, instead, the universe. Their activities (skipped breakfast, chased ducks at the lake, was injected with an experimental drug) are undectectable, except insofar as they provide the ambient temperature, the shifts in water acidity, the relative amounts of nutrients and pollutants, and are self-correcting to a greater or lesser extent, locally.

There are TONS of players in any ecosystem; I am only going to mention the ones that particularly interest me today, so please don’t scold me for neglecting to mention the key roles played by T-cells and nitric oxide and leptin, insulin and cortisol and ghrelin, etc.

The micro-world is full of players. The ones I’m thinking on today are certain cells.

fallopian tube: this way in

When you imagine “a cell,” you might imagine a bacterium or an ameoba – a blob with an eye, crawling around. That’s pretty close.

Cells are born as baby cells and are small and simple, and they develop skills and identities and finally have a characteristic look. A bone cell looks like one thing (spiky). A muscle cell looks like another thing (bamboo). A nerve cell looks like another thing (a tree). A skin cell looks like another thing (a brick). A fat cell looks like another thing (a water balloon).

A lot of cells congregate together and form rows and walls and layers, tissues – like muscle tissue, brain tissue, fatty tissue.

layers

Cells talk to each other the same way cats talk to each other – with a look, a smell, an attitude – sometimes a show of force, sometimes a strategic withdrawal, sometimes a sort of invisibility. Cats talk to each other through air and light. Cells talk to each other in the dark, under water.

Cells make chemicals that indicate things. I am trying to find a better vocabulary than we use in the hard sciences. For example, a ripe banana makes a chemical, due to being ripe. If a fruit-fly or a monkey or a bird notices this chemical, they might seek, find, and eat the banana. If they used a nose to detect the chemical, then we call the chemical a smell or a scent or a fragrance or an odor. What if they don’t have a nose? We might call it a chemoattractant – not a very poetic term. What if the smell is bad? If a nose is involved, it’s a stink. Without a nose, what is it? Something else.

l’eau de cytokine

Here’s another notion. In 1788, somebody imported rabbits to Australia, where they had no ‘natural enemies.’ The rabbits had a bazillion baby rabbits and basically ate up every green thing growing on the land, because nothing could stop them except running out of clover. They are making Australia a desert. But it’s not the rabbit’s intention to do so – they are just going on about their normal rabbit business. One could say that the rabbits are “sending a signal” that isn’t being received or responded to properly by the “environment.” Usually “the environment,” receiving the “signal,” would fix the situation (hawks and foxes and cats would eat the rabbits).

Similarly, something weird might happen to a cell, so that it just keeps growing, out of control. Weird cells have an effect on the environment. The “signals” they send may or may not be properly “received.” The immune system may or may not send its hawks and foxes and cats to wipe them out, or at least to keep them in check. The environment will either seek balance, or adjust to the new normal. As with the rabbits in Australia, we personally may or may not be pleased with the results.

like with kudzu

Unfortunately, in the science of the micro-world, we do not have a very good vocabulary to describe this. We say things like,
“Cells exchange signals to maintain their phenotypes and to optimize their functions. When a cell receives a signal, it sets off complex cascades that trigger and modulate the activities of numerous genes and proteins.”

Sheesh! I suppose it’s accurate, but it’s not evocative. It evokes nothing, except a stuffed shirt. These are living organisms, in functional ecosystems. Just because they’re teensy doesn’t mean their lives aren’t complex.

jelly jelly

I usually make cells sound like creatures, even though, like jellyfish, they have no central nervous systems. I imagine their “nervous system” – the patterns which enable them to get things done in a coordinated way – is more like a communications network (or a zeitgeist), than a specific individual goal-driven or teleological set of behaviors.

So imagine, if you will, this micro-world. Here is a fat cell – an “adipose” cell.

belly belly

Adipocytes look like water balloons. That’s not the prettiest picture. Here’s a nicer one:

As babies, they lived in the walls of the blood vessels that run through the fat tissue. When high amounts of nutrients ran through the blood vessels, the baby fat cells started growing up, and moved out into the adipose tissue – a forest of fat cells, all crowded together – next door.

As babies, they looked like regular cells, with one eye (a nucleus) and the usual internal organs, but as they started their normal job of absorbing and storing droplets of oil, they expanded bigger and bigger, so the eye and the internal organs got squished off to one side. This is why, as grownup cells, they look like water balloons.

You might wonder how we can take pictures of these cells, and why they are these various colors. Normally, they are so small that to our eyes, they are basically see-through. What we do is grab some (via blood test, biopsy, scraping, etc.), stain them with colors, and put them in the kind of environment they started out in. (If you looked at them in dry air, they’d be like collapsed balloons.)

a biggish blood vessel.

Why do adipose cells have this job?

Droplets of oil are fatty acids and triglycerides. They can be used as emergency fuel when there’s not a lot of blood sugar around, but they also can be toxic and harmful to most cells in general. All cells absorb fats, but adipose cells soak up more.

You don’t want a buildup of fatty acids, inside your blood vessels (atherosclerosis), your liver cells (steatohepatitis), your pancreas that is supposed to be making insulin (pancreatic steatosis).

That acid doesn’t belong there, and those cells have to work hard to detoxify it and get rid of it, taking energy away from what they normally should be doing. Sometimes they aren’t able to detoxify it, and the heart muscle, liver, and pancreas cells get sick and weak.

bluck

Luckily, there are adipose cells – starting as babies in the blood vessel walls, sensing excessive amounts of nutrients in the blood – that will soak up and store these acids, and keep them away from other cells.

Adipose cells, like all cells, need a supply of oxygen to stay alive. They are just single cells; they do not have a heart or blood vessels of their own. Oxygen, riding on red blood cells through the bloodstream, simply falls off the red blood cells and leaks through the blood vessel walls, into the adipose cells. However, as the adipose cells collect more and more oil, and get bigger and bigger, eventually it’s just too far for oxygen to travel, and a lot of cells that are far away from blood vessels become starved for oxygen, and start to die.

It’s like blood in the water: the sharks come out. When cells are dying, other cells start coming around to eat up the debris.

Sharks? Macrophages. From the Greek, “macro,” big, + “phagos,” glutton. They literally eat stuff – odds and ends of sugars and proteins, dead cells, etc. Here’s one, in a 30-second movie. It’s chasing a bacterium around, in and out amongst some red blood cells. (A neutrophil is like a macrophage for bacteria.)

Like sharks, macrophages travel from far away to gather in bunches – once again, not talking to one another through light or air, but communicating underwater and in the dark, through a smell, a change in temperature, a flavor, however you want to imagine the “chemical signals” they possess. Remember, like the ripe banana being eaten by the fruitfly, they don’t necessarily choose or intend to set in motion a chain of events – it’s just a natural outcome of their normal behaviors and life cycles.

mac.

How do they get to where the action is? They float around in the bloodstream until something attracts their attention, and then they wiggle out into the tissues – like diving off the freeway into the jungle. Another way of looking at it is, they float along until something grabs them, like someone in a flood getting yanked out by the leg.

If you ask me, this is tricky. You don’t want to be punching a hole in the side of the blood vessel, you don’t want the blood vessel seams to be loose and flimsy – they’re under blood pressure, and could spring a leak. But macrophages – like T-cells and other kinds of white blood cells – do squiggle out into the tissue, following whatever trail they are following. Here’s a 40-second reenactment.

Macrophages will behave in certain ways – and even look certain ways – depending on the environment around them. They have superpowers of being able to function in low-oxygen conditions. When they are attacking stuff, in an inflammatory way, spraying poisons around and eating up debris, we call them by the unromantic name “M-1.” Like attack elephants, they can be indiscriminate, and cause a lot of extra damage.

However, they relieve the pressure. The oxygen content starts to improve. If all goes well, the ecosystem starts to re-balance. The macs start to change in character and become “M-2.”

“Macrophages downregulate their proinflammatory activity and shift their function towards local resolution of inflammation and tissue repair.”

This really does mean making new tissue, new cells to replace the ruined ones, new blood vessels. Now the previously-rampaging elephants pitch in to rebuild walls, clear roads, and generally make things better than they were before.

Some will change up even further, and become “M-res” macs – “resolution” macrophages. These carry away the dead. When cells die, you don’t want them to just suddenly explode – for example, if they’re fat cells, they would spray fatty acids everywhere; if they are immune cells (like neutrophils), they’re full of bleach and peroxide and other other nasty bacteria-killing stuff. The “resolution macrophages” engulf these dead cells whole, and carry them away out of the area.

At any given time, tissues have a certain number of macs that hang around. Under healthy conditions, most of them are the friendly, helpful M-2s. But if things go haywire, you get a higher population of strong, savage, attacking M-1s. What if this happens without an obvious suspect, like a staph germ in your lung, a tapeworm in your belly, or a tumor in your gut? Then the attack just generally creates mayhem wherever it happens to occur. You get chronic inflammation, to a greater or lesser degree.

When we are looking at the micro-world to find out how inflammatory obesity occurs, we are looking at immunometabolism. Let’s review:

baby fat cells, with tiny droplets

Baby fat cells, in the walls of tiny blood vessels, are bathed in floods and floods of nutrients, because we eat too much (too much starch and sugar and fat and protein), for most of our lives. They gather together, they encourage one another, they coordinate activities to form fatty tissue, to store away the strong stuff – the overload, day-in-day-out, of acidic oil, one of the main results of your egg-and-pancake breakfast, your deluxe burrito lunch, the snickers snacks, the mac and cheese, etc.

They gather in bigger and bigger crowds – far from the blood vessels carrying oxygen. They fill up fuller and fuller with oil – they crush their own internal organs under the weight, trying to sequester all that oil.

Some die. Some spring leaks. Free fatty acids float around in the tissue. And it’s strong stuff.

“The response of the adipose vasculature and stroma to adipose expansion is often insufficient, leading to hypoxia and overcrowding… This perturbs adipocyte integrity and function and may lead to apoptosis and necrosis… resulting in the spill-over of free fatty acids into the circulation. Excess circulating free saturated fatty acids are harmful to the vasculature and also [build up] in numerous organs, including liver and muscle. Insulin resistance and lipotoxicity ensue.”

What do the macrophages see? Dying cells, toxic crud, low oxygen levels… could be a staph infection. Could be a tapeworm. Could be a tumor. They see red. And if they’re in stressed, wounded, sick adipose tissue, they see it everywhere they go.

clear lipid, red macs

“In lean, healthy mammals, macrophages account for approximately 10% of adipose tissue cellularity and are interspersed between adipocytes” – mostly M-2, build-and-repair macs.

“Obesity is accompanied by a robust influx [of] M1 macrophages… reaching 40% of adipose tissue cellularity. These staggering statistics exemplify the concept of an inflamed adipose tissue.”

Did you see those numbers? When the little village was small and efficient, one in ten citizens was a beat cop, helping folks out, jumping dead batteries for people.

When it became a crowded, polluted, crime-infested urban area, four in ten citizens was not just a cop, but an armed thug, jumping people for batteries.

Is that too much of a stretch? Try this instead:

When my belly fat was just a regular layer of warm insulation over the muscles, a few of the cells in there were build-and-repair macrophages, cleaning up any debris from micro-injuries and wear and tear.

However, when my belly fat became as big and heavy as three grocery bags full of food, almost half the cells were inflammatory macrophages… doing, ominously, what they do.

“The inflamed adipose tissue of obesity resembles an organ chronically infected by an intracellular organism, despite the absence of any pathogen.”

Your body – in the micro-world – is a universe of individual cells, coordinating their activities as appears appropriate given environmental conditions, and/or wreaking havoc for one reason or another.

Even if you could somehow command the actions of one of the individual players, it wouldn’t make any difference… you must instead seek to be influential over the whole situation.

How can you – your brain, your soul, your pure intention, and what you do – influence this ecology?

Further reading:

Lipotoxicity: http://diabetes.diabetesjournals.org/content/50/suppl_1/S118.full.pdf

Adipose hypoxia: http://diabetes.diabetesjournals.org/content/58/1/95.full.pdf

Inflamed fat: http://www.jci.org/articles/view/27280

Macrophage transformations: http://www.frontiersin.org/inflammation/10.3389/fimmu.2011.00049/full

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nuns vs. heartless corporations

By | December 30, 2011

Backstory: When I moved to town, I signed up with the biggest, fanciest lab, went there and toured the facility, listened to a presentation in a conference room with a complementary bottle of water, and found out the details of how they do their work, which was cool.

Then I was gently told that no, they can’t allow any discounts for patients who pay out-of-pocket, except for HIV tests (provided to them for free by the state), and that if I needed an interface between the lab and my electronic medical record, that would be $300 please.

So naturally I took my business to the other lab in town, which provides same-day service for my homebound patients, sends results to my secure email, and provides a hefty discount for all out-of-pocket labs – and what else? They’re really nice. They remember who I am, despite my small practice providing almost no business to them. My lab rep and I commiserate about adjusting to western Oregon, since we both moved here the same year, from very different climates. When I have weird questions about arcane lab tests (as a recovering biochemist), we conduct chatty email conversations about them.

(This is also why I send Paps and biopsies to a particular pathology lab; they have a ridiculously extravagant commitment to both cutting-edge science and full accessibility, including rock-bottom prices for out-of-pocket payers. Oh, and that independent radiologist in town, with the advanced training in women’s imaging? I send him all the business I can, too.)

However, sometimes a patient (with insurance) prefers to go to the giant corporation instead, where they always went before. And that’s okay. Shouldn’t be any problem.

So three weeks ago, a patient dutifully got blood drawn at the “old branch” of the giant corporation, downtown near her work. It was just a routine cholesterol screening. She was getting frustrated because I never sent her any results.

However, I never received notification of the test, or any results, by fax or by snail, even though I have received (from them, for other patients) prior records, specialist reports, warnings not to prescribe certain drugs, and plenty of advertisements for their glossy new facilities and their amazing new specialists – both by fax and by snail.

So I called the “old branch” downtown. The operator transferred me to medical records and put me on hold. Ten minutes later, I was told they had no records of the patient since 2009. (I explained that her insurance company had already paid for it and sent her a receipt, however.) I was told to call the “new hospital” medical records department “which is the main one.”

Here I was given the option of pressing 1 to ask for a release of records, 2 to get their fax number, or 3 to hear their hours. (Why is there never “Press 666 if you are a doctor in a hurry”?) Then I had the option of leaving a voicemail.

Eventually heard back. Was told by the medical records-keeper, who was looking at his computer screen, “I can see the patient, but I can’t see the lab test, because it’s an outside physician.” He asked, “Who are you with again?” I replied, “Nobody – I’m a family doctor in private practice,” and he said under his breath, “Ohhh, you’re not with anyone…” Finally he decided to connect me directly with the lab itself, who could straighten it out directly.

Here I spoke to a somewhat embarrassed lab tech who said, “I’m so sorry, this is just a draw station, I don’t know why they sent you here!” She told me I needed to call Client Services, because “only they have that kind of information.”

Called Client Services, where they promised to fax the results immediately. I asked if the original results had been sent to some other doctor, but no, it was my name and contact information on the original lab order. So what happened? (You need to understand, dear reader, that lab orders always-always emanate from a doctor and then results go to a doctor. They never-never just float around homeless in limbo – theoretically.)

The Client Service person explained that even though she could see that my fax number has been active in the files since 2009, it was, nevertheless, chronically in the inactive stack, and the backup system of telephoning-the-doctor-with-results was simply never activated.

I went, “Huh?” …and I may be reporting this conversation incorrectly, because it was such a complex set of stacks and piles and lines and actives and inactives that I’d never heard of before.

This person was clicking many buttons and saying, “Huh. But why – That’s weird… Huh. I don’t know… Hmmm.” Her final solution was, “I’m gonna print up the lab slip, hand-write a note on it that this fax number is the correct number, and send it back in, so somebody can re-enter your information into the right part of the system.”

So maybe soon, after this hour-long process, I’ll be getting this lab result that I didn’t even know was drawn (three weeks ago), even though I am “an outside physician.” Yes, here I am, “outside,” pressing my nose against the glass, looking in at the big shiny information network reserved for the “inside” doctors, who are on the payroll…

By the way, earlier this year, the giant corporation (note to self: stop calling it “heartless”) did break down and start offering lower prices to people paying out of pocket. A few of these prices are lower than those offered by the lab I usually use. Most are not. If you are insured but obliged to pay out of pocket (for example, with a high deductible policy), the price is generally about 300% higher than it could/should be. This, of course, is not sustainable for most of the folks I know. (I can’t be more specific, because doctors are not allowed to discuss fees or prices specifically, by law; see here, and scroll to the bottom for last year’s Justice Department ruling.)

Do you also want to hear the story about how a long chain of command amongst the corporate doctors led to a friend paying full price for an MRI of her child’s wrist, with inconclusive results, leading them back to doing the simple office exam, for a common harmless condition, that they should have done in the first place? Do you want to hear how I spoiled the Christmas of a rural family by sadly telling them their child really will have to have a belly CT, which they had to pay cash for, to make sure it’s not a ruptured appendix? Why aren’t we occupying medical corporations?

You know, the main reason I originally gravitated to the corporate lab was that it had once been founded by nuns, and I like nuns. The founder, Sister Francis Clare (nee Margaret Anna Cusak) was an Irish proto-feminist who once said, “I do not believe in offering the gospel of talk to starving people.” This was at the end of the second Irish Famine, which killed a million people – about 1 in 8. She also said: “What kind of liberty of conscience is it which tolerates, or rather encourages, oppression in one place and cries with wild shrieks of rage against what is a simple matter of duty?” She ended up quitting, finally, as her order’s website describes, “sick and disillusioned with a patriarchal Church.”

I have to wonder what Mother Clare would be saying about the heartless corporation today. In an article this year about the disappearance of nuns from leadership roles in Catholic – often charity – hospitals, one 73-year-old nun-boss said, “We can’t be maudlin about this… I mean, yes, we are a dying breed. We are disappearing from the face of the earth and all of that. That being said… there is this thing called Presence,” explaining that she was trained to see Jesus in the face of every patient, “and I think that’s the piece that is lost.”

Her replacement states that he will be “trying to drive more efficiencies in the system.”

“It is almost six years since Katrina. Charity sits empty.”

So anyway… Waiting for those lab results, and wishing for the thousandth time that socialized medicine would reduce the temptations of filthy lucre to people of conscience.

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$40, the Payroll Tax Cut, that wicked cough, and you

By | December 21, 2011

You might recall I wrote earlier about “The 99%.” “The 99%” are not actually the working class and unemployed folks standing in the park holding cardboard signs, if you ask me. “The 99%” includes CEOs, professional athletes, Senators, neurosurgeons, etc., who have little in common with the cardboard-sign-holders, in terms of lifestyle, life chances, or vested interests.

So now the White House (my Facebook friend), is soliciting comments about “what $40 means to you.” Because, they explain, if the Payroll Tax Cut is not extended – and the Republican majority has zero interest in extending it – that’s the amount by which a ‘typical’ paycheck would be short.

Typical?

Forty bucks is the amount that someone would lose on a biweekly (twice a month) paycheck if they earned $50,000 per year.

People who earn $50K per year are part of “the 75%,” but most of the cardboard-sign-holders are not $50K/year folks.

Even if they did get lucky and find a full-time job, it would have to be as an accountant, or a psychologist, or a biologist, for a few examples – to be part of “The 75%.” And the folks who are commenting on the Facebook page – and most of the comments are simply hateful – but the few folks who do answer the question, they’re almost never $50K/yr people. Just like the cardboard-sign holders.

“$40 would mean I wouldn’t have enough for groceries for the next two weeks or transportation to work & school.”
“I could give up my internet access or having a phone.”
“Losing $40.00 would mean not being able to buy school lunch for my child, for three weeks.”
“$40 is my whole food budget for a week. Or fuel for my car to get to work for 2 weeks.”
“Medical bills… I have made a contract with these clinics for $50.00 a month.”
“$40 = week of gas.”

The White House has a little calculator that can tell you what you’d stand to lose, or what you’d stand to gain, if the Payroll Tax Cut were rescinded, versus if it were expanded by another 1.1% as it says in the proposed American Jobs Act – whether you are a single-income or a multiple-income family.

Let’s compare these numbers to the population figures we looked at before.

“The 75%” = People in the US who make $50K or less per year.
If you make $50,000/year before taxes, you lose $1000/year when the Payroll Tax Cut ends.
If the Jobs Act were passed, you’d keep your $1000 and raise it by $550, for an “extra” $129 per month ($1550/yr).

“The 66%” = $40K or less per year.
If you make $40,000/year before taxes, you lose $800/year.
(Examples: plumber; math teacher; or drug rep married to a part-time preschool teacher; or truck driver married to a floral designer, etc.).
Pass the law, keep your $800 and raise it by $440, for an “extra” $103 per month ($1240/yr).

“Since I already don’t have health insurance this means an increasingly unhealthy diet as well.”
“40 bucks would be 20 for gas and 20 for a past due bill.”
“$40 = month of communication for cellphone.”"
$40 is a healthy, home-cooked Monday-Friday dinner for my family.”
“You know, $40 a paycheck isn’t going to hurt my bottom line so much. It’s a dinner out for my family, a months worth of school lunches for my kids. We could stretch it out and cover those expenses. But that’s just us, we are blessed.”

“The 55%” = $25K or less per year.
(Example: military rank E4 (Corporal, Specialist, Petty Officer 3rd Class, Senior Airman).
If you make $25,000/year before taxes, you lose $500/year.
Pass the law, keep your $500 and raise it by $275, for an “extra” $65/month ($775/yr).

“The 33.5%” = $15K or less per year.
If you make $15,000/year before taxes, you lose $300/year (Example: full-time cleaning lady, bouncer, part-time dental hygienist).
Pass the law, keep your $300 and raise it by $165, for an “extra” $39/month ($465/yr).

“The 25.4%” = $10K or less per year.
If you make $10,000/year before taxes, you lose $200/year.
(Examples: full-time minimum wage worker in Wyoming or Georgia, $5.15/hr; or part-time $10/hr worker, working 50 weeks per year).
Pass the law, keep your $200 and raise it by $110, for an “extra” $26/month ($310/yr).

“Dinner and a movie with friends. Or I could cut down on my 401k contribution.”
“1/2 a textbook for next semester!”
“$40 is the cost of school lunches for 2 weeks for 2 kids.”
“1 case of diapers or a case of formula for my newborn twins.”
“Gas for my car for the month.”
“Don’t have a paycheck to take $40 from. Hanging on by a frayed thread.”

People in “the 66%” pay the same prices for groceries & heat & blood pressure pills & cell phones & diapers as people in “the 33.5%.” But some will get an extra $100, and others only $40, per month, and that only if we, the people, pass the Jobs Act.

Lose the Payroll Tax Cut instead, and now the math teacher will lose $67/month, while the lady who cleans his house will lose $25/month. (They still both pay $40/month for gas or cellphone or school lunches or 1/2 a textbook.)

If you’re a libertarian, that probably sounds fair… until you consider that it means the math teacher has $3266/month left over, while the cleaning lady has $1225/month left over. Which one has a better shot at buying the gasoline, diapers, school lunches, and blood pressure medicine they need every month?

It’s your basic flat-tax problem. Imagine if each were taxed, for example, a “fair and equal” 50%. The math teacher would still have $20K to live on for a year; the cleaning lady would only have $7,500 left to live on for a year. The difference in their “fair and equal” life chances is immediately evident. This is why we tax higher incomes at higher rates – it’s not as big an ultimate bite for those who are wealthier.

(Before you ask, my libertarian friend, no, the cleaning lady making $15,000/year is not eligible for “welfare” or Medicaid. She could, of course, get $16 a month – yes, that’s sixteen dollars – in Food Stamps [based on $400/month rent]. The math teacher would basically not qualify for anything, not even for $16, unless s/he were supporting five dependents.)

Why on earth is this discussion appearing in a doctor blog?

… Because I can prescribe an albuterol inhaler to treat your asthma, but I can’t buy it for you. It costs about $45/month. What if you decide your kid needs it more than you do? You’re not filling that prescription.

… Because I can prescribe birth control pills, but I can’t buy them for you. They cost about $30/month, unless you get fancy (then maybe $250/month). If you can’t afford them, then Plan B may be $50 – if you happen to have $50, right when you need it.

… Because a good antibiotic might be $30, so you might decide it’s better to wait and see if the cough and fever go away by themselves. (You didn’t have $100 for a chest x-ray, so we’re kind of guessing, anyway.)

… Because I’d like you to get a blood count and a metabolic panel (about $25 out of pocket), and also to take three basic supplements (multivitamin with minerals; vitamin D; fish oil – about $20 at the discount store), for your disabling fatigue and body aches. (Most doctors would shudder at what bare-bones medical care that is; some might consider it approaching malpractice, for failing to do a complete workup.) However, a one-month bus pass to get to work costs $50. You can’t buy both, so I just never hear back from you.

… Also, of course, because you can’t pay your doctor bill – either your $30 co-pay, or else your $50 out-of-pocket office visit. Maybe this means you don’t come in until you’re so sick you have no choice, but you still can’t pay me. This means I’m looking for a third moonlighting job. Without one, I won’t be able to afford to see you, either.

It’s not only about what $40 per paycheck means to me and my Facebook friends. It’s that an economic collapse is also a health problem – seriously, a BIG one – and I don’t have the tools I need to help you.

You know those cardboard-sign holders in the park? The ones the City Council just decided to disperse, by fair means or foul? We’d better get down there and join them.

Resources:
American Jobs Act/Payroll Tax Cut calculator:

http://www.whitehouse.gov/economy/jobs/we-cant-wait

Food Stamp benefit calculator for Oregon:

https://apps.state.or.us/fsestimate/

Nationwide Food Stamps income limits, based on household size:

http://www.fns.usda.gov/snap/applicant_recipients/eligibility.htm#income

To find your own “percentile”:

http://www.ssa.gov/cgi-bin/netcomp.cgi?year=2010

For your state’s minimum wage laws:

http://www.dol.gov/whd/minwage/america.htm#content

To see military pay scales:

http://www.navycs.com/2011-military-pay-chart.html

Estimated salaries:

http://www.simplyhired.com/a/salary/home

Income by race:

http://www.census.gov/compendia/statab/2012/tables/12s0701.pdf

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The Meatloaf Syndrome: “I would do anything…”

By | December 1, 2011

Okay. So I have all these patients who want to lose weight, reverse their diabetes or “prediabetes,” lower their blood pressure and cholesterol, and reduce their chronic pain, insomnia, and stress.

Neither they nor I are big fans of using prescription medication to do these things. They don’t want to take a weight-loss pill three times a day, an antidepressant, two blood-sugar pills three times a day (or three insulin shots a day), an ACE inhibitor and a diuretic, a statin, a narcotic and an NSAID (+/- a muscle relaxer), plus the stool softeners and antacids to counteract the effects of the pain meds, and a sleeping pill (or two) every night. They don’t even really want to take a handful of vitamins and “natural” supplements, three or four times a day. They just want to be well.

And very often they will say wistfully, “Gosh, I’d do anything to be healthy again.”

And I have taken to saying, “Anything? You would do anything?”

The reading I have done recently, and the patients I’ve talked to, at length (since most of my office appointments are an hour long, with plenty of time to talk), have convinced me that in many cases it is possible to improve health overall by making a very minor change in a person’s diet.

That change is, eliminating animal-based foods.

Here is my reasoning.

It appears that diets high in animal-based foods, even if they also contain some fruits and vegetables (and none of us really eat as many fruits and vegetables as we think – food diaries always suprise us!), produce a kind of generalized low-grade inflammation throughout the body.

What is inflammation? It is the most basic function of the immune system. In the popular military motif, the immune system “attacks invaders” to “defend the body.” (Of course the story is more complex that that – more like the complex relations between trees and grasses, fungi and worms, mammals and reptiles, birds and fish, all interacting within the same ecosystem. In this case, the ecosystem is a person’s own body.)

This interpretation of inflammation tells us that, among other things, the immune system over time tends to “mistake fatty deposits for intruders.” An alternative interpretation may be that, within the immune system, certain elements function to reduce excess/unnecessary fat cells, or to reduce the amount of lipid stored in fat cells. One of the effects of inflammatory cytokines, after all, is to produce “sickness behavior,” which includes loss of appetite. The whole story undoubtedly includes both, for complex organisms tend to have systems that both “attack” and “nuture.”

It appears that animal-based foods – meat, poultry, fish, milk, eggs – contain a fair amount of inflammatory mediators themselves. They are also very high-calorie, promoting obesity. The evidence is pretty good that a person, by not eating animal foods, can attain a healthy weight, normalize their body’s responses to nutrients (including cholesterol compounds and blood sugar), and reduce the effects of stress responses.

Of course there is plenty of anecdotal evidence of this. Witness the personal transformation of the average patient (overweight, with high blood pressure and cholesterol, and just not feeling very well) seen in the documentary about nutritionists leading the research in this field, Forks Over Knives. I myself know several people (and am married to one) who were surprised that, when they switched to a plant-based diet, they not only lost weight, but felt so much better than they had expected. Better energy. Better sleep. Better mood. And if they were under medical supervision, their doctors were likewise surprised and pleased.

My young and glamorous spouse notes, for the record, that he not only quit eating animal foods – he also quit drinking soda and eating chips and candy bars. He doesn’t smoke cigarettes, and never overdrinks. He doesn’t need to take any prescription medications or even vitamins, and he pretty much eats as much as he wants.

Is it difficult to quit eating animal foods? Depends. I have shopped and cooked for vegans for more than 15 years, in several different geographical locations (urban to rural), in several different family structures (all ages), and at several different income levels, including on food stamps. I developed some flexible strategies, and am currently putting together a cookbook to share them. But here are some basics:

~ If you live where I do, the stores and restaurants are all full of vegetarian versions of regular American fare, from vegan pizzas to vegan pot pies. There are 8 kinds of vegan milk, from soy to hemp, for your granola, not to mention a million soy yogurts. You may eat better than you ever have in your life.

~ If you live in an area that does not have so many options, you will probably want to concentrate on recipes from Asian, Mexican, and Italian traditions, leaving the meat out of the recipes, or substituting something, like tofu or mushrooms, for the meat. You’ll want to have a sandwich before you go out to a restaurant with your “meater” friends – because you may very well be limited to salad for supper. Forget about restaurant breakfasts, unless you love oatmeal and fresh squeezed OJ (yum).

~ If you are on a budget, rice and beans will be your mainstay for a while. Did you know you can make your own veggie burgers at home, from rice and beans (and other ingredients)? Frozen veggies are cheaper than fresh, and they keep better. (Skip the organic vegetables until you can afford them.)

~ Maybe you are on a budget, and do not have much time to spend in the kitchen. Get a new-used crockpot from the Salvation Army store – throw in a rice cooker, if you find one. (You can cook lots of things in it, not only rice.) Also look for plastic food storage containers, and buy a Sharpie (permanent marker, to date frozen foods.) You will be able to throw together soups and sauces before work or school, and they’ll be ready at the end of the day. Many of us cook a double recipe, and freeze half for another day. Canned beans, by the way, are instant, as opposed to dried, and they’re still cheap.

~ Does your family hate the whole idea? Too bad! Think about how much it will cost you – and them – to take 20 pills a day, because that’s where many of us are headed. Imagine how nice it would be, to feel strong and energetic again. Just because your family prefers to be less healthy doesn’t mean you should enable them. However, to ease the transition, you can temporarily commit to spending a little more on “meat substitutes” (like “garden burgers” and “tofu pups”). Put the soymilk in a pitcher or a reusable glass milk bottle, in the fridge. Put the vegan margarine in a butter dish or butter-crock. Be patient. It usually takes about 3 weeks for kids, and 8 weeks for grownups, to completely adjust to the change.

I wrote this article because, when I was telling my (meat-eating, soda-drinking) dad about my ideas, he said, “Is this just something you made up, or do others say the same thing?” I did a 20-minute Internet search on PubMed, the national scientific research database, and found these abstracts below (emphasis added). I got all excited. I hope you will, too.

The effects of a low-fat, plant-based dietary intervention on body weight, metabolism, and insulin sensitivity.
Barnard ND et al. Am J Med. 2005 Sep;118(9):991-7.
Department of Medicine, George Washington University School of Medicine, Washington, DC, USA.
This study investigated the effect of a low-fat, plant-based diet on body weight, metabolism, and insulin sensitivity, while controlling for exercise in free-living individuals. In an outpatient setting, 64 overweight, postmenopausal women were randomly assigned to a low-fat, vegan diet or a control diet based on National Cholesterol Education Program guidelines, without energy intake limits, and were asked to maintain exercise unchanged. Dietary intake, body weight and composition, resting metabolic rate, thermic effect of food, and insulin sensitivity were measured at baseline and 14 weeks.
RESULTS:
Mean +/- standard deviation intervention-group body weight decreased 5.8 +/- 3.2 kg, compared with 3.8 +/- 2.8 kg in the control group (P = .012). In a regression model of predictors of weight change, including diet group and changes in energy intake, thermic effect of food, resting metabolic rate, and reported energy expenditure, significant effects were found for diet group (P < .05), thermic effect of food (P < .05), and resting metabolic rate (P < .001). An index of insulin sensitivity increased from 4.6 +/- 2.9 to 5.7 +/- 3.9 (P = .017) in the intervention group, but the difference between groups was not significant (P = .17).
CONCLUSION:
Adoption of a low-fat, vegan diet was associated with significant weight loss in overweight postmenopausal women, despite the absence of prescribed limits on portion size or energy intake.

Vegetarian diets and childhood obesity prevention.
Sabaté J, Wien M. Am J Clin Nutr. 2010 May;91(5):1525S-1529S. Epub 2010 Mar 17.
Department of Nutrition, School of Public Health, Loma Linda University, Loma Linda, CA 92350, USA.
The increased prevalence of childhood overweight and obesity is not unique to industrialized societies; dramatic increases are occurring in urbanized areas of developing countries. In light of the consensus that obesity is a significant public health concern and that many weight-loss interventions have been unsuccessful in the long term, an exploration of food patterns that are beneficial in the primary prevention of obesity is warranted. The focus of this article is to review the relation between vegetarian diets and obesity, particularly as they relate to childhood obesity. Epidemiologic studies indicate that vegetarian diets are associated with a lower body mass index (BMI) and a lower prevalence of obesity in adults and children. A meta-analysis of adult vegetarian diet studies estimated a reduced weight difference of 7.6 kg for men and 3.3 kg for women, which resulted in a 2-point lower BMI (in kg/m(2)). Similarly, compared with nonvegetarians, vegetarian children are leaner, and their BMI difference becomes greater during adolescence. Studies exploring the risk of overweight and food groups and dietary patterns indicate that a plant-based diet seems to be a sensible approach for the prevention of obesity in children. Plant-based diets are low in energy density and high in complex carbohydrate, fiber, and water, which may increase satiety and resting energy expenditure. Plant-based dietary patterns should be encouraged for optimal health and environmental benefits. Food policies are warranted to support social marketing messages and to reduce the cultural and economic forces that make it difficult to promote plant-based dietary patterns.

Anti-inflammatory effects of plant-based foods and of their constituents.
Watzl B. Int J Vitam Nutr Res. 2008 Dec;78(6):293-8.
Department of Physiology and Biochemistry of Nutrition, Max Rubner-Institute, Federal Research Institute of Nutrition and Food, Karlsruhe, Germany. bernhard.watzl@mri.bund.de
Inflammation is a pathological condition underlying a number of diseases including cardiovascular diseases, cancer, and chronic inflammatory diseases. In addition, healthy, obese subjects also express markers of inflammation in their blood. Diet provides a variety of nutrients as well as non-nutritive bioactive constituents which modulate immunomodulatory and inflammatory processes. Epidemiological data suggest that dietary patterns strongly affect inflammatory processes. Primarily the intake of fruit and vegetables as well as of whole wheat is inversely associated with the risk of inflammation. In addition to observational studies there are also data from human intervention studies suggesting an anti-inflammatory potential of these plant foods. At the level of bioactive compounds occurring in plant foods, primarily carotenoids and flavonoids seem to modulate inflammatory as well as immunological processes. In conclusion, there is convincing evidence that plant foods and non-nutritive constituents associated with these foods modulate immunological and inflammatory processes. By means of anti-inflammatory activities a plant-based diet may contribute to the lower risk of cardiovascular diseases and cancer. A high intake of vegetables, fruit, and whole wheat as recommended by all international nutrition authorities provides a wide spectrum of bioactive compounds at health-promoting concentrations.

Diet and inflammation.
Galland L. Nutr Clin Pract. 2010 Dec;25(6):634-40.
Foundation for Integrated Medicine, New York, NY 10010, USA. lgallandmd@aol.com
The emerging role of chronic inflammation in the major degenerative diseases of modern society has stimulated research into the influence of nutrition and dietary patterns on inflammatory indices. Most human studies have correlated analyses of habitual dietary intake as determined by a food frequency questionnaire or 24-hour recall with systemic markers of inflammation like high-sensitivity C-reactive protein (HS-CRP), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-?). An occasional study also includes nutrition analysis of blood components. There have been several controlled interventions which evaluated the effect of a change in dietary pattern or of single foods on inflammatory markers in defined populations. Most studies reveal a modest effect of dietary composition on some inflammatory markers in free-living adults, although different markers do not vary in unison. Significant dietary influences have been established for glycemic index (GI) and load (GL), fiber, fatty acid composition, magnesium, carotenoids, and flavonoids. A traditional Mediterranean dietary pattern, which typically has a high ratio of monounsaturated (MUFA) to saturated (SFA) fats and ?-3 to ?-6 polyunsaturated fatty acid (PUFAs) and supplies an abundance of fruits, vegetables, legumes, and grains, has shown anti-inflammatory effects when compared with typical North American and Northern European dietary patterns in most observational and interventional studies and may become the diet of choice for diminishing chronic inflammation in clinical practice.

The effects of diet on inflammation: emphasis on the metabolic syndrome.
Giugliano Det al. J Am Coll Cardiol. 2006 Aug 15;48(4):677-85.
Division of Metabolic Diseases, Center of Excellence for Cardiovascular Diseases, University of Naples SUN, Italy.
Reducing the incidence of coronary heart disease with diet is possible. The main dietary strategies include adequate omega-3 fatty acids intake, reduction of saturated and trans-fats, and consumption of a diet high in fruits, vegetables, nuts, and whole grains and low in refined grains. Each of these strategies may be associated with lower generation of inflammation. This review examines the epidemiologic and clinical evidence concerning diet and inflammation. Dietary patterns high in refined starches, sugar, and saturated and trans-fatty acids, poor in natural antioxidants and fiber from fruits, vegetables, and whole grains, and poor in omega-3 fatty acids may cause an activation of the innate immune system, most likely by an excessive production of proinflammatory cytokines associated with a reduced production of anti-inflammatory cytokines. The whole diet approach seems particularly promising to reduce the inflammation associated with the metabolic syndrome. The choice of healthy sources of carbohydrate, fat, and protein, associated with regular physical activity and avoidance of smoking, is critical to fighting the war against chronic disease. Western dietary patterns warm up inflammation, while prudent dietary patterns cool it down.

Association of metabolic syndrome risk factors with selected markers of oxidative status and microinflammation in healthy omnivores and vegetarians.
Sebeková K. et al. Mol Nutr Food Res. 2006 Sep;50(9):858-68.
Research Base of Slovak Medical University, Bratislava, Slovakia.
Conditions predisposing to metabolic syndrome (MetS) are associated with increased oxidative stress and inflammation. We studied, in vegetarians (n = 90) and omnivores (n = 46), the impact of the dietary regimen on the occurrence of MetS risk factors (RFs: BMI, blood pressure, glucose metabolism and lipid profile) in relation to oxidative status (advanced glycation end products (AGEs), advanced oxidation protein products (AOPPs), malondialdehyde, ferric reducing ability of plasma, vitamins A, E, C, beta-carotene and superoxide dismutase activity) and microinflammation (C-reactive protein, leukocytes and neopterin). The proportion of subjects without/positive for one or two MetS RFs was comparable between the groups. From the components of MetS only immunoreactive insulin levels differed significantly (95% CI: omnivores: 5.0-7.1 microU/mL, vegetarians: 4.5-5.4, p = 0.03). Omnivores had lower AOPP (omnivores: 0.29-0.36 micromol/g albumin, vegetarians: 0.36-0.52, p = 0.01) and beta-carotene levels than vegetarians, they consumed more calories, proteins, fat and saturated fatty acids, and less fibres, beta-carotene and vitamin C. Multiple regression analysis revealed vitamin E and AOPP levels as the most important independent determinants of MetS RFs. The vegetarian diet seems to exert beneficial effects on MetS RFs associated microinflammation. Whether the vegetarian diet may counteract the deleterious effects of elevated AOPPs and AGEs, remains to be elucidated.

Anti-inflammatory effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis.
Adam O et al. Rheumatol Int. 2003 Jan;23(1):27-36.
Medizinische Klinik Innenstadt der LMU, Ziemssenstrasse 1, 80336 Munich, Germany.
Patients with rheumatoid arthritis (RA) improve on a vegetarian diet or supplementation with fish oil. We investigated the effects of both dietary measures, alone and in combination, on inflammation, fatty acid composition of erythrocyte lipids, eicosanoids, and cytokine biosynthesis in patients with RA.
Sixty-eight patients with definitive RA were matched into two groups of 34 subjects each. One group was observed for 8 months on a normal western diet (WD) and the other on an anti-inflammatory diet (AID) providing an arachidonic acid intake of less than 90 mg/day. Patients in both groups were allocated to receive placebo or fish oil capsules (30 mg/kg body weight) for 3 months in a double-blind crossover study with a 2-month washout period between treatments. Clinical examination and routine laboratory findings were evaluated every month, and erythrocyte fatty acids, eicosanoids, and cytokines were evaluated before and after each 3-month experimental period.
RESULTS:
Sixty patients completed the study. In AID patients, but not in WD patients, the numbers of tender and swollen joints decreased by 14% during placebo treatment. In AID patients, as compared to WD patients, fish oil led to a significant reduction in the numbers of tender (28% vs 11%) and swollen (34% vs 22%) joints (P<0.01). Compared to baseline levels, higher enrichment of eicosapentaenoic acid in erythrocyte lipids (244% vs 217%) and lower formation of leukotriene B(4) (34% vs 8%, P>0.01), 11-dehydro-thromboxane B(2) (15% vs 10%, P<0.05), and prostaglandin metabolites (21% vs 16%, P<0.003) were found in AID patients, especially when fish oil was given during months 6-8 of the experiment.
CONCLUSION:
A diet low in arachidonic acid ameliorates clinical signs of inflammation in patients with RA and augments the beneficial effect of fish oil supplementation.

Diet and cancer
Drew, J. World J Gastrointest Pathophysiol. 2011 August 15; 2(4): 61–64.
Rowett Institute of Nutrition and Health, University of Aberdeen, Greenburn Road, Bucksburn, Aberdeen, AB21 9SB, United Kingdom.
Obesity and associated reduced consumption of plant derived foods are linked to increased risk of colon cancer as well as a number of other organ specific cancers. Inflammatory processes are a contributing factor but the precise mechanisms remain elusive. Obesity and cancer incidence are increasing worldwide, presenting bleak prospects for reducing, or preventing, obesity related cancers. The incidence of these preventable cancers can be achieved with greater understanding of the molecular mechanisms linking diet and carcinogenesis. Janice Drew has developed a research program over recent years to investigate molecular mechanisms related to consumption of anti-inflammatory metabolites generated from consumption of plant based diets, the impact of high fat diets and associated altered metabolism and obesity on regulation of colon inflammatory responses and processes regulating the colon epithelium. Comprehensive strategies have been developed incorporating transcriptomics, including the novel gene expression technology, the GenomeLab System and proteomics, together with biochemical analyses of plasma and tissue samples to assess correlated changes in oxidative stress, inflammation and pathology. The approaches developed have achieved success in establishing antioxidant and anti-inflammatory activity of dietary antioxidants and associated genes and pathways that interact to modulate redox status in the colon. Cellular processes and genes altered in response to obesity and high fat diets have provided evidence of molecular mechanisms that are implicated in obesity related cancer.

Again, that was a very simple twenty-minute internet search, not even using any special doctor resources! There is lot of data to support this approach. My mission is to spread the word, and give you ideas on how to make it easy. Because if you say, “I would do anything,” I’ll take you up on it!

Stay tuned for Dr Leigh’s “inflammation transformation” cookbook, appearing here sometime soon (ish).

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“flexible” spending, now breeding inflexibility

By | November 23, 2011

Do you have a job? Does your job provide medical insurance? Does your medical insurance also allow “flexible spending”?

Back in the day, you may have enjoyed being able to buy nutritional supplements and over-the-counter remedies with your “flex.” But guess what? The rules have been changed by the IRS and by your insurance corporation. While the new rules allow the 1% to retain more of your paycheck (which makes them happy), they are proving to be a hassle for doctors and patients.

The new rules do not allow you to purchase preventive items using flex dollars from your paycheck. They now must be prescribed by your doctor to treat a stated illness. These items include:
– nutritional supplements including fiber, vitamins, minerals;
– health club memberships, exercise equipment, or shoe orthotics;
– acne treatments and sunscreen;
– acid-reflux medications;
– vaccinations;
– a blood pressure monitor for home use, baby aspirin to prevent heart attacks, omega-3 fatty acid sources;
and others (such as cosmetic surgeries and electrolysis, which may seem like luxuries to some, and necessities that affect earning power, to others).

“No problem,” you think, “I’ll just have my doctor prescribe them.” And as a friendly doctor, I cheerfully go ahead and write you a prescription for some of these.

However, when you send it in, we’re both surprised to find it is declined. The insurance company now demands a letter from your doctor explaining what medical diagnosis is being treated with the requested items.

There are two problems with this situation.

The first is that there might not be a diagnosis. Since the rules specify that the purchase can not be for prevention, the diagnosis can not be “to prevent heart attacks and strokes,” “to prevent vitamin deficiency,” “to monitor blood pressure to prevent need for blood pressure medication,” or “to achieve and maintain healthy body weight, muscle mass, and strong bones.”

Instead, the diagnosis is going to have to be, “Abnormally high cholesterol” (unless your cholesterol has been normal), “Vitamin/mineral deficiency” (unless this has not been established), “High blood pressure” (unless your blood pressure has so far been normal), “[Medical] obesity,” or “Osteoporosis/osteopenia.”

This means that a.) you are going to have a potentially pre-existing condition entered into your permanent insurance record (if it isn’t already there), and/or b.) you are going to need extra testing to establish the diagnosis, and a comprehensive treatment plan to manage the condition.

This is what our system favors over simple prevention. This is what our system considers worth paying for.

That’s only half of the problem.

For the doctor, who very often is not aware of each insurance corporation’s special “flex” rules, it is very likely to mean 1/2-1 hour per patient (reviewing charts to show that the prescriptions are medically justified, writing prescriptions and explanatory letters, dealing with claims denials), for each time the patient wants to use their own money, from their flexible spending account. The typical family doctor has 2500-3000 patients. An employed person may want to use their flex plan once or twice every year. Unless the doctor or his helpers memorize the rules for each employer’s “flexible” insurance policy, it’s going to be a major hassle.

This all comes on top of the many hours spent by medical practices in dealing directly with insurance corporations, trying to get paid for the services they’ve already given (dollars the patient and their employer already handed over to the insurance corporation):

– Doctors, 3.4 hours per week, mostly obtaining prior authorizations;
– Nurses/medical assistants, 20.6 hours per physician per week (>13 hours per week obtaining prior authorizations);
– Medical clerical workers, 53.1 hours per physician per week (billing and obtaining prior authorizations);
– Practice administrators, 163.2 hours a year (managing contracts, settling disputes with insurances, etc.).

…Allow me to humbly add that in old-fashioned single-doctor micropractices like mine, most or all of those jobs (and hours) belong to one physician – on top of patient visits, phone calls, diagnostic reports, emails, prescription refill requests, and faxes.

Now you know why your doctor either sounded so snippy, or so tired, when you mentioned your “flexible” spending account! If you asked every doctor in the United States whether they’d rather be providing direct patient care, or arguing with insurance companies about whether they should pay for a bottle of baby aspirin, I bet I know what they would tell you.

I’m currently fighting this problem by understanding the “flex” rules, and figuring out how to explain them in plain language to patients, to try to avoid long drawn-out insurance battles – and I don’t get snippy, because I know how it is.

But really, recognizing the fundamental differences between the interests of the health-insurance-corporate 1%, and the interests of the ordinary-patient-who-wants-to-prevent-illness 99% – and acting on that understanding – is the only thing that will ultimately solve these problems.

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The 99%, part 2 – with a word from Gandalf

By | October 28, 2011

In my last post, I talked about the true situations of those who call themselves “The 99%.” You may have wondered: what does all this have to do with doctoring?

I live in western Oregon. My town is very white – 82% White. Three times more people identify as multiracial than as Black. The reason I mention this is that White people often presume that economic collapse doesn’t significantly affect “people like us.” (Of course, the Depression has gone on for many decades without ceasing, due to the ongoing conditions of White supremacy, for people of color. But they don’t live in this town, much.)

The biggest employers are the hospitals and schools, but as you can imagine, there are only so many hospital-and-school jobs to go around.

The per capita income (which means “per-person,” including folks who aren’t earning, like babies) in my town is around $21,000 per year. A lot of my patients come from surrounding towns where the per-capita incomes are $13-14,000 per year. (All 2010 numbers, from Wikipedia.)

City-data dot com also reports that in 2009 (which in retrospect looks like a pretty good year), 22% of people in my town lived below the poverty line, relative to 14% statewide. Most of them were men and women aged 18-24. I mention this because I have been hearing a lot of people supposing that the young people calling themselves “the 99%” are privileged trust-fund kids who don’t feel like working for a living.

About two-thirds of folks below the poverty line in my town work part-time, rather than being totally jobless. The U-6 unemployment rate for Oregon (including everybody unemployed and under-employed) is just about 18%.

This is a town where every major intersection has multiple folks holding cardboard signs on multiple streetcorners. “Veteran – Two kids at home – Need gas money to Portland – Will work for food – Anything helps – God bless.” There are fewer when the weather is nice. (If they were lazy “trustafarians,” there’d be more.) One youngish, sad-looking guy held a sign saying, “Just shoot me.” It gave me chills.

I have a lot of patients who’ve been struggling for a long time. They’re mostly not that old – because I don’t have a contract with the government agencies that fund health care for older people. (Most older folks are sticking with the better-subsidized large group practices.) They may not be that old – but many are sick.

The sicker a person is, the more difficult it is for them to navigate the system – to obtain health care, medicine, food, equipment to help them see and hear, and housing with power and water, much less information, communications, transportation, education, and the things in life that contribute to mental health, like connection to friends and family, decent clothes, the resources to properly care for companion animals.

It seems normal, now, to not have many of these things listed above – because it is common. (I would argue we should not consider it “normal.”) Most able-bodied well folks who do have those things, view the lack, in others, as not terribly significant – they presume the problem is temporary.

Do you take these things for granted? Do you know how you’d provide them, if you lost your income? If you were too sick to work? Are these things you’ll need in the future, but don’t know when? Are you ready to go without them?

timely medical advice and treatment
over-the-counter and prescription medicines
home health supplies, e.g. blood sugar meter strips, colostomy bags
glasses
dental care and/or dentures
hearing aids
food – buying, cooking, storing
safe housing with power, water, and privacy
communications: phone and/or internet
access to news and information
transportation
decent clothes, and resources to keep them clean and mended
decent winter shoes and a winter coat
access to a supportive family/friend network
a reliable, responsible babysitter
veterinary care for sick animals
psychological and spiritual guidance
beauty

Folks who go without many or most of these – and I know many, many, many – they’re pretty worried the condition is permanent. Once you start to fall behind, these days, you fall farther and farther, and faster and faster. There aren’t any jobs for people who have been sick, or out of work for a long time, or who are older. There isn’t any readily-available social assistance. Freaked-out taxpayers think it would be a good idea to legislate away the assistance programs that used to be available.

You might wonder why “the poor” aren’t all on Medicaid. You might not know that in our state, eligibility is awarded by periodic lottery; about 52,000 people are on the list; many more would qualify, by income, but haven’t put themselves on the list. Recent lotteries awarded about 2,500 slots, but only about half of those chosen actually received Medicaid.

Lots of folks I know are moving in with relatives, doubling/tripling up; people are living in other people’s driveways, and not for free; they’re giving up making payments on loans, mortgages, “Care Credit” cards; some are resorting to moneymaking schemes that are against the law; others are resorting to schemes that victimize the desperate, the ignorant, the foolish – things they never would have imagined themselves doing.

Folks are stressed and depressed, drinking heavily, eating too many French fries, smoking, fighting. Folks are hurt and angry. These conditions are all significant health risks.

As Gandalf said, we must do what is in us to uproot the evil in the fields that we know.

The main one I know is the health and well-being of the people in my practice.

Almost half of them pay out of pocket for the care I give them, usually around $100 per hour-long visit. (They don’t have insurance, or are “under-insured.”) Those who need a lot of home or office visits (for example, weekly or monthly), which would be prohibitively expensive if paid for visit by visit, are supposed to chip in $50 per month. Many of them can’t even manage that, mostly because they are sick.

We have a lot of stuff we’re working on, together. Their care includes a lot of records review, research, consultation with specialists, and other behind-the-scenes doctor work. It’s going well! Except that I’m obliged to work an extra job or two, to keep the office open.

The other just-more-than-half of the patients in my practice have health insurance. They pay $15-30, usually, for a visit, and often also a percentage of my fee (“co-insurance” – often comes as a nasty surprise a couple months after the visit). They don’t visit as often, because, for the most part, they are healthier; after all, they’re still employed, so they must be healthier.

In 2011, the average yearly cost of employment-based insurance is about $5,429 ($921 out of pocket) – $15,073 for a family, 9% higher than last year ($4,129 out of pocket).

Those are the numbers I find online, but they don’t square with what my patients tell me – for example, a young University parent with two kids recently told me that they and the University together pay $1400 per month for their policy.

If my spouse and I were to get individual (not employer-subsidized) health insurance, a quick run through the quotes calculator shows our monthly bills would be, for example, with our local biggest insurers, $900-950/month – with $1000-2500 deductibles (out-of-pocket expenses to be paid before insurance “kicks in”).

If and when we met our deductible, and the insurance “kicked in,” we’d still have 20-30% coinsurance and the $20-30 copay – after we shelled out $1000-2500, on top of the monthly premium bill. (For example, the standard $180 office visit would cost $56-84 out of pocket.) This is quite typical.

The reason I go into this detail is that many people have no idea how much of their earnings “automatically” disappear from their paychecks for health insurance – and don’t add up the true cost of doctor visits, with insurance. When the bills arrive, they have repeated “sticker shock” (and often blame the doctor, rightfully or wrongfully).

I have written about this before, and received a flood of helpful advice about how to obtain “cheap” insurance. But that’s not my point. I am addressing this issue as a physician who is committed to social justice, not as a consumer asking for advice on how I can most efficiently line the pockets of corporations.

For a family in “The 66%” – for example, the math teacher mentioned in part one of this entry – health insurance can be 12% or more of their income, considering deductibles, copays and coinsurance.

For the $4,280 they spent this year, they could have had 40-50 visits in the office with me.

55.3% of the nation has health insurance through their employers.

Why do people go along with this stuff?

Folks really want to have health insurance, not so they can see me – as I mentioned, they could be seeing me for $50 a month, rather than $5,000 a month. They want it so they will be “covered” if Something Terrible happens. And they know people to whom Something Terrible has happened. Appendicitis! Gallstones! Bike crash! Car crash! Cancer! They hope that “coverage” will equal “care.”

However, the jury is out on whether their individual policy would really come through for them in the event of Something Terrible.

As Wendell Potter, the crusading insurance whistleblower, wrote in his blog earlier this month, “[Among the] 546 comments that had been posted on the “We are the 99 percent” Tumblr site… 262 of the comments mention such problems as getting denials for doctor-ordered care from their insurance companies and having to forego treatment because of hefty out-of-pocket costs.”

Even when insurance does pay, people are left with large bills. Later, it remains to be seen whether the person is able to continue receiving insurance. For example, the other day I was told about a very healthy young employed person (a spouse of a patient) who was denied insurance altogether because they had had a minor knee operation for a sports injury – an incompletely “covered” procedure they are still paying off. I know a person who broke their neck in a fall; they recovered, but their insurance premium doubled, and they had to give it up, and go “bareback.”

In order to afford coverage, people usually sign up for the biggest deductible they can tolerate. They know they’ll have to pay for everything out-of-pocket – but it’s the only way they can afford the monthly premium bill.

This means that they delay coming into my office, and try to get medical advice and treatment, as much as they can, over the phone with me. If they make it to the end of the year without having to pay too much out of pocket – without realizing any benefit from the insurance they and their employer pay so much for – they feel like they’re ahead.

If and when they do come in, it’s often with a long list of health worries that are out of control – often a long list of health worries that they ask me to spin, or cover up, in their records, so the insurance won’t find out they have something that might raise their rates.

(And here, once again, I’m not asking for advice! I recently received a whole bunch of advice from other doctors, about how to better spin and cover up medical issues in medical charts. This is not something at which I long to become an expert.)

A large number of my insured patients prefer to get most of their care from alternative practitioners who are outside the insurance system altogether. Their naturopath, chiropractor, homeopath, and craniosacral therapist, in addition to bringing their own specialized skills to the table, do not reek of the insurance trap, and are managing conditions under the insurance radar.

Patients often trust them more than medical doctors, because they believe doctors are universally in cahoots with an oppressive system that has much to do with cash and little with care. And, often against the available evidence, they believe alternative practitioners universally are not.

Meanwhile, back in the land of “The 1%,” insurance corporations (including those which doctors avoid the most carefully – cf. class action lawsuits for price fixing and not paying doctors) are projecting huge profits:

Humana, $9,250,000,000 (that’s billions) in the past three months alone.
(CEO made $6,100,000 in 2010. That’s millions. He is “The 0.00139%.”)

UnitedHealth, $25,450,000,000 in the past three months alone.
(CEO made $10,100,000 in 2010. He is “The 0.00037%.”)

WellPoint, $15,200,000,000 in the past three months alone.
(CEO made $13,400,000 in 2010. She is “The 0.00037%.”)

Cigna, $5,460,000,000 in the past three months alone.
(CEO made $15,200,000 in 2010. He is “The 0.00037%.”)

Aetna, $8,330,000,000 in the past three months alone.
(CEO made $20,700,000 in 2010. He is “The 0.00005%.”)

The Wall Street Journal, in reporting this, chirps, “The ongoing sluggish pace in operating rooms and doctors offices likely helped third-quarter earnings of U.S. health-insurance companies.”

In other words, when you’re afraid that medical care will drive you into the poorhouse, your insurance company realizes pure profit. You pay and pay and pay them, and you get nothing in exchange – unless you count partial, and temporary, relief from the nagging fear of Something Terrible.

So here is what I see.

A lot of folks who are clobbered, either suddenly or in slow motion, by the economic collapse. They have great difficulty staying in good health, or recapturing good health, because of no money. They may or may not be employed.

And a lot of insured folks spending huge amounts of money without even knowing it, so that corporations and their CEOs can rake it in. They’d like to stay in good health, or recapture good health, but may postpone medical care that might help with these, because “coverage” is not care. Don’t even get me started on the many folks who are staying in jobs that are making them sick, because they’re afraid to lose their insurance.

Isn’t there any way both of these groups of people can get the medical help they need, in a way they can afford? I’d argue that primary care, preventive care, is one way.

But I also really think we need to stop playing with insurance corporations. And I don’t think we can wait for Washington to provide national health. And much as I am fond of the colorful costumed, radical and knowledgeable folks camping out on Wall Street, I can’t wait for the powers-that-be to listen to them, either.

I am not primarily concerned with erecting giant policy-laden structures. I am concerned about particular people that I know. They are my neighbors. They need help today. I would like to help them to help each other.

“…so that those who live after may have clean earth to till. What weather they shall have is not ours to rule.” – Gandalf

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The 99%, part 1

By | October 28, 2011

This what I have been saying all along: Most of the folks who say they are “The 99%” have very little in common with the actual “The 99%” – even though they almost all characterize themselves as “the lucky ones.” They usually have much more in common with the 80, 70, 60, 50, 40, 30%.
See http://wearethe99percent.tumblr.com:

“I am a 26 year old man, I have a 2 year old son. I have worked for Wells fargo and JP Morgan Chase, both of those jobs were outsourced overseas and I was forced to sign a non disclosure agreement to get a severance package. I now work at a hospital where for the past 2 years they haven’t given out raises and as of January 1st 2012 i will be laid off due to the economy… When my debt to income ratio collide and i can no longer afford food or rent, I’ll get a third job and see what happens.”

“I worked a great job for a few years and then did MBA to try and achieve ‘the dream’. Took out over $50,000 in student loan debt. Got a job on LaSalle St. after the MBA and became one of the 1%. After 8 years, Boss got a better job and shut down the company. Can’t find a new job because I am in my 40’s, competing against well qualified people 10 years younger than me. 2 years of draining my savings and I am back in the 99%. I did what America told me to… I am sending this from an anonymous email and am afraid to show my face in case my former 1% friends see me.”

“I went to school out of state full-time last fall. My dream was to become an educator to help shape the future of our children, and ultimately our country’s. Although thankful to have one, I took a $4 and hour pay cut when I started my new part-time job. By the end of the school year I was getting less than 14 hours per week. Now, I am living with my parents again (my Dad works 2 jobs, even without me in the house), college is on the back burner, and I am over $20,000 in debt to an incomplete degree. I am currently jobless and have been searching for close to 3 months… 99%.”

Who else are in “The (roughly) 99%”?

Individuals who make $500K/year or less, in The 99.4%
(Male baseball player, cardiologist, President of the United States).

Individuals who make $250K/year or less, in The 99.1%
(Airport CEO, Supreme Court Chief Justice, neurologist).

Those who make $200K/year or less, in The 98.6%
(pediatrician, State governor, Congressman).

“i came back to school to finish my degree because i wasn’t going to be another single mom statistic… we are the lucky ones: i have a car (and was able to get a loan to buy it). my daughter is in preschool through a federal grant program… we eat well, thanks to food stamps… we have a laptop and a camera… i make a ‘living’ on borrowed money. we are the 99%.”

“My grandmother died of colon cancer when she was in her 30s. My uncle nearly died at the same age, but he pulled through. Another uncle ended his own life when he was diagnosed. My mother and I haven’t had cancer, but we’ve both had our colons removed… I had my surgery when I was 17, and I’ve needed semi-annual checkups ever since then. They’re about $600 even with the insurance I won’t have again for another year. I earn just over the national minimum wage. My husband has insurance through his job, but he can’t cover me because, well, I’m a man, and we live in Texas. My mother, my family, everyone I love… We are the 99%.”

“The 81.4%” make less than $60K per year.
Do you identify with the 99%, or the 81.4%?

“The 75%” make less than $50K per year.
Do you identify with the 99%, or the 75%?

“The 66%” make less than $40K per year.
Do you identify with the 99%, or the 66%?

“Sixteen & ‘gifted,’ I put myself through college… I had to drop out at 19 because it became too expensive. I’ve worked at a grocery store for 7 years… 6 months ago, my hours were cut. I had to supplement my checks with vacation hours. They ran out fast. So did my credit cards… I had to give up paying my credit cards & loans to afford rent & food. I am now over $40k in debt, & struggling to save up enough for a bankruptcy lawyer. I am 25, & 2 months pregnant with my first child. We are the 99%.”

“My school is in ruins. There are holes in the wall, vandalism in the entryway & bathrooms & halls, and we don’t have textbooks. We are a ‘last ditch’ school. There isn’t a single student who’s not disabled, mentally ill/unstable, or who didn’t flunk/get expelled from their old schools. This school is all we have left, and our parents can’t take us anywhere else if it fails due to the lack of funding. We need help. We are the 99%. Please, at least put us through high school.”

Representative members of “The 66%”:
Plumber $37,000
Math teacher $36,000
Sous chef $34,000
Auto mechanic $30,000
Repo man $28,000
Nursing assistant $27,000
Apartment maintenance worker $24,000
Delivery driver $19,000
Line cook $17,000
Cleaning lady $16,000
Bouncer $14,000
Counterfeiter (no data)
Astrologer (no data)
Undocumented-worker “coyote” (no data)
“Exciting opportunity! Great area!” (??) $33,000

If you are an E4 (Corporal, Specialist, Petty Officer 3rd Class, Senior Airman) who enlisted in 2008 when the economy collapsed, you probably make $25,476 yearly, and are in “The 55%.”

“I am a veteran that lost most of a leg in Afghanistan (at age 18)… I am a College Graduate with a ‘good job,’ I am a lucky one. I am able to pay my bills most of the time. We still live check to check. My (almost) wife is a teacher who pays for books for her classroom, she buys the supplies… Between the two of us we have 60K in student loans. We share a three bedroom apartment with family… I am ashamed I can’t provide for my family. I am the 99% and we are watching you.”

“I became a sex worker in part because I was caring for my grandmother and couldn’t afford to balance her, a job, and university. Thanks to my education, however, I am overqualified for most of the jobs I apply for. I’ve just come out of an unpaid internship because it was my only hope towards paid work… I am the 99%.”

If you are a minimum wage worker in Oregon, working full time hours, you will count yourself very lucky to earn:

$8.50/hr x 40hr per wk x 85% of gross as take-home$
x 50 weeks per year (allow 14 days unpaid for illness/absence)
= $14,450 per year.
You are in “The 33.5%” (under $15K/yr).

Minimum wage worker in Illinois = $8.25/hr > $14,025 = also “The 33.5%”.
Minimum wage worker in most states = $7.25/hr > $12,325 = still “The 33.5%”, though $2K poorer.
Minimum wage worker in Wyoming or Georgia, $5.15/hr > $8,755 = unfortunately, “The 25.4%” (under $10K/yr).
Disabled person receiving SSI, $674/month > $8,088 = also, unfortunately, “The 25.4%”.

“In 2007, my wife and I both worked good jobs. We are both educated, we didn’t use credit cards, and qualified for a decent home loan. I worked for the Auto industry managing car loans. When cars collapsed, the bailout went to the manufacturers – not to dealerships… I lost my home, lost car, my life savings spent on the birth of my son because we had no health insurance. We did everything we were supposed to do to have a successful life.

“I’m back in school, and it’s expensive but the only one that would take a 40 year old law student was a private school. Debt is mounting fast… We live with my parents, who also lost most of their savings.

“My wife was laid off this week. By the end of this month, we will be totally broke. I don’t know how I can finish this semester. Half a law degree is worthless – but I’m already $25K in debt… What did I do wrong? Where was my mis-step? What was my big mistake?… I am the 99%.”

Oh, and by the way, “The 50%”: What is the median income for people of color in the US? At the median, half of the people in the group make more, and half make less:
$23,738 is the median for Black men; $19,470 for Black women.
$22,256 is the median for Hispanic/Latino men;
$16,210 for Hispanic/Latina women.

What’s my point? 99% does not tell the whole story. 1% might tell most of the story, but 99% doesn’t. The story of the people who use the term the 99% is a story of terrible precarity. The story of the 1% is the story of terrible exploitation.

What does all of this have to do with doctoring? Stay tuned.

To find your own percentile:

http://www.ssa.gov/cgi-bin/netcomp.cgi?year=2010

For your state’s minimum wage laws:

http://www.dol.gov/whd/minwage/america.htm#content

To see military pay scales:

http://www.navycs.com/2011-military-pay-chart.html

Estimated salaries:

http://www.simplyhired.com/a/salary/home

Income by race:

http://www.census.gov/compendia/statab/2012/tables/12s0701.pdf

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Like a tap on the shoulder from your old self

By | September 27, 2011

Reconsider what you absolutely can never do again on account of your chronic pain.

Sometimes not-trying (because we are sure we already know the sad result) is what really stops us.

A fortuneteller once told me, “Try to get back to who you were, before you decided you needed to protect yourself.”

I know that you are capable of amazing feats.

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NSAIDs, the fetal heart, and prostaglandins

By | September 26, 2011

I think this issue – which started out as a rather lengthy email – will be interesting to the perinatal interest group at large. Some midwives were having a discussion about NSAIDs, and they considered that you don’t take them during pregnancy because it’ll cause a bleed. But there’s more to it than that, so I wrote this discussion. Inflammatory cascades are a special interest of mine, and I prescribe NSAIDs for inflammatory pain daily (unless the patient is pregnant!), and I also treat folks for the ill effects of NSAIDs daily.

NSAIDs = non-steroidal (i.e., not prednisone) anti inflammatory drugs.
Examples: aspirin/Exedrin (and Alka-Seltzer!), naproxen/Aleve, ibuprofen/Advil, indomethacin/Indocin, meloxicam/Mobic, ketorolac/Toradol (injectable for migraine), diclofenac/Voltaren, and oh so many more.

They all basically work by reducing the amount of prostaglandin production in the body.

Prostaglandins are made from arachadonic acid (like Arachne, the first spider-woman) that is derived from recycling cell membrane phospholipids. They are made by all kinds of cells all over the place.
The enzymes that make the prostaglandins are called cox-1 and cox-2.

Cox-1 is “turned on” all the time (is “constitutional”) and is just always doing its work. It makes prostaglandins that you need all the time – for example, to make a protective mucus coating for the stomach wall, and to keep platelets sticky so they will clot properly.

Cox-2 is only turned on as needed (is “inducible”). It makes prostaglandins that create inflammation, the immune system’s most basic response.

You’ll note that blocking all prostaglandin synthesis, in order to quell fever, swelling, pain, etc., will also block the “good” PGs, like the ones that promote the stomach’s mucus lining (ibuprofen > stomach ulcers) and that keep platelets sticky (baby aspirin a day > blood thinner, for clot-risk patients). So if you could only block cox-2, you’d have it made, right?

Unfortunately, cox-2 blockers were found to cause heart attacks and were yanked from the market (cf. Vioxx). They caused *too much* cox-1 “good prostaglandin” effect, including too much platelet stickiness in the coronary arteries of older folk.

Those pointy blue-green things are monkey wrenches, representing
the activity of cox 1/2 enzymes. The yellow thing is a former chicken,
but even if you’re vegan, you’ll get it by recycling old cells

Another “good” PG, made via cox-1, keeps “the ductus” open. We love “the ductus”! You used to have a ductus, and it rocked. It’s gone now.

The ductus arteriosus allows fetal blood flow to bypass the lungs. The high pressure of the direct blood flow would be too much for the delicate fetal lung vessels. (The fetus doesn’t even need lungs, because s/he has the placenta.)

Where is it located? The ductus connects the pulmonary artery (remember, all arteries travel away from the heart, so the pulmonary [lung] artery carries blood from the gentle right heart into the delicate lungs) to the aorta (connects to this giant artery from the strong left heart to the rest of the body – as big as a garden hose!).

The ductus is just a little shunt – some of the blood does trickle out to the lungs, but most bypasses them and goes directly to the rest of the body via the aorta.

After birth, you need the ductus to close, so that ALL the blood from the right heart can go to the lung capillaries, and be oxygenated by the air in the air sacs.
But before birth, you need the ductus to take some of the pressure off those delicate lungs.

The process of closing the ductus is part of the newborn’s “transition” to terrestrial life, and it can take hours or days. Almost all close in the first 4 days, roughly corresponding to full milk production by the mom, interestingly (to me).

VERY nice, if somewhat wordy (have your dictionary nearby, when you read it) summary of these changes, in outline form, at this link.

[Note another major heart specialization for aquatic life, the foramen ovale, a hole between the right and left heart. This also takes a lot of the pressure off the lungs, reducing the amount of blood flow from the right heart to the lungs, and shooting it directly to the muscular left ventricle, instead. The foramen ("for-AY-mun") can take 3 months post-birth to close, and in a lot of adults it still isn't all the way closed, and doesn't really cause any problems most of the time. The third fetal shunt is the ductus venosus, which protects the liver from too much placental blood flow. Wikipedia has a good entry on that one.You'll like it if you are especially captivated by placental circulation - I know I am...]

So there are two things that can go wrong with the ductus.
1. It can fail to close, causing a “patent ductus arteriosus.” This creates a noisy heart murmur and a poorly oxygenated baby. Watch for it in Downs kids (about 40% of them can have it).
2. It can close too soon, subjecting the lung vessels to too much pressure in utero, so they get kind of scarred up and don’t work very well after birth. These newborns have respiratory distress from prolonged high blood pressure in the lung vessels. On an x-ray, the chest has “clear lung hypertension” as opposed to meconium aspiration syndrome, which shows as a cloudy white x-ray. (Meconium aspiration can cause high blood pressure in the lung vessels, a.k.a pulmonary hypertension.)

What keeps the ductus open? Prostaglandins. You can give prostaglandins if you need to keep the ductus open (for example, if the infant will need chest surgery, and they need the blood supply to bypass the lungs).

What closes it? Lowered sensitivity to prostaglandins (normal), or less prostaglandins overall (not normal).

Earlier in fetal life, the ductus is more sensitive to prostaglandins; near birth, is less sensitive. Which makes sense, because these PGs are produced constitutively, i.e., all the time, not as needed. They are also produced by ductus cells themselves. So the only way to control their effect is to control sensitivity to them (by changing the number of prostaglandin receptors that are able to respond to prostaglandins).

We all start out as water babies
…remember?

If your lady takes enough NSAIDs to stop inflammation (stop a fever, stop inflammatory pain e.g. arthritis, etc.), then she might be taking significant enough doses to affect the ductus. This has been shown by some studies – not many – but it’s more than a theoretical risk. Some folks say it’s okay to take them til the 3rd trimester, or until week 35, or such. The ductus may be more strongly affected as maturity and birth approach. I tell folks just not to take them during pregnancy. They can take acetaminophen or whatever instead.

Bonus question: Why are NSAIDs specifically called nonsteroidal? Answer: Because steroids, i.e. cortico-steroids (made in the cort-ex of the adrenal glands from chole-ster-ol) also block prostaglandin synthesis, but at an earlier stage. They have a lot of side effects, for other reasons. So the development of NSAIDs was a big advance over steroid antiinflammatory drugs.

Bonus question #2: Why are they called prostaglandins? And why does intercourse with a man make my menstrual cramps better at first, then worse later? Answer: Ha ha! Prostaglandins were first discovered in semen and got their name from prostatic fluid. Playtime amuses you, but later prostaglandins make your uterus and cervix cramp. NSAIDs are #1 for uterine and cervical muscle pain – shame you can’t use em for labor.

Bonus question #3: Dr Leigh, what do you give pregnant ladies for pain? Answer: topicals, acetaminophen (which is not an NSAID), selected PO herbal remedies, or narcotics. You have to look closely at what the woman’s individual issues are, but for the most part, these are safer than NSAIDs.

Bonus question #4: Does this mean NSAIDs don’t present a hemorrhage risk? Answer: See paragraphs 3 & 4 above!

Thanks for playing!

Gratuitous photo of me and my
camera-shy boy-pren

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