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Category Archives: Neurology

Chocolate consumption is inversely associated with coronary heart disease

Cocoa and dark chocolate are rich in flavonoids and may lower blood pressure.

5,000 people aged 25-93 years participated in the National Heart, Lung, and Blood Institute (NHLBI) Family Heart Study.

Compared to subjects who did not report any chocolate intake, odds ratios for coronary heart disease (CHD) were:

- 1.0 for subjects consuming chocolate 1-3 times/month
- 0.74 for subjects consuming chocolate 1-4 times/week
- 0.43 for subjects consuming chocolate 5+ times/week

Consumption of non-chocolate candy was associated with a 49% higher prevalence of CHD comparing 5+/week vs. none per week [OR = 1.49].

Consumption of chocolate is inversely related with prevalent CHD in a general United States population.

References:

Chocolate consumption is inversely associated with prevalent coronary heart disease: the National Heart, Lung, and Blood Institute Family Heart Study. Djoussé L, Hopkins PN, North KE, Pankow JS, Arnett DK, Ellison RC. Clin Nutr. 2011 Apr;30(2):182-7. Epub 2010 Sep 19.
Image source: Wikipedia, public domain.

From Writer's Almanac:

Ode to Chocolate by Barbara Crooker (excerpt)

I hate milk chocolate, don't want clouds
of cream diluting the dark night sky,
don't want pralines or raisins, rubble
in this smooth plateau. I like my coffee
black, my beer from Germany, wine
from Burgundy, the darker, the better.

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Don’t just swallow, check the evidence first – it applies to diet, medications, and more

The wrong approach

According to the food conglomerate Danon: “Evidence is increasing that even mild dehydration plays a role in the development of various diseases.” It’s a campaign, sponsored by the producers of Volvic, Evian, and Badoit bottled waters, to get us all to drink more water.

But what and where is this evidence? A doctor replies: “This is not only nonsense, but is thoroughly debunked nonsense.”

The right approach

Worried by the fact that European guidelines classified almost all older people as being at high risk of cardiovascular disease, Norway has developed its own guidelines that use differential risk thresholds according to age.

Compared with the European guidelines, the total sum of life gained is about the same, but the number of patients treated is considerably lower.

How does clinical evidence work?

Ben Goldacre's Moment of Genius on BBC4 radio:

"Clinical trials in medicine are designed to be free from bias. They test, as objectively as possible, the effectiveness of a particular intervention.
When you bring the results of all these individual trials together, however, how do you weigh up what evidence is relevant and what is not? In 1993, a method of "systematic review" was introduced that enables us to get the clearest possible view of the evidence."

References:

Don’t just swallow, check the evidence first. Godlee 343. BMJ, 2011.

Image source: Plastic bottles before processing. Wikipedia, dierk schaefer, Creative Commons Attribution 2.0 License.

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Interesting Correlation: Fast Food Founders and Longevity

Jay Parkinson noted an interesting correlation between Fast Food Founders and Longevity:

- Ray Kroc (McDonald’s) died at age 82

- Jimmy Dean died at age 81

- Taco Bell founder Glen Bell died at 86

- Sonic founder Troy Smith died at 87

- Hardee’s founder Wilber Hardee died at 89

- Baskin-Robbins founder Irvine Robbins died at 90

- Carl’s Jr. founder Carl Karcher died at 90

- Frozen french fry mogul J.R. Simplot died at 99

- Murray Handwerker, credited with making Nathan’s Famous Hot Dogs into a well-known national chain, died at 89

"Fake foods are more affordable. It's enticing people to eat more because they think they're saving money when they're really just buying heart disease." 10 Questions for Jillian Michaels. TIME, 2010.

Comments from Google Plus (Jul 27, 2011):

Maf Lewis - I'm going to guess that most of them were American, rich and therefor some of the few that could get good healthcare in the USA.

Neil Mehta - Good point +Maf Lewis
In addition they probably did not eat the fare their restaurants dished out?

Ves Dimov - I would assume they didn't eat the items on their restaurants' menu regularly.

One McDonald's CEO was famous for eating at least one product of its company daily. Unfortunately, he died at 44, from metastatic colon cancer. This does not prove causation, of course.

http://en.wikipedia.org/wiki/Charlie_Bell

Mr Bell oversaw McDonald's "I'm lovin' it" advertising campaign and introduced successes such as McCafe.

http://news.bbc.co.uk/2/hi/business/4180627.stm

Robert Silge - +Maf Lewis They clearly were both rich and American, and we could add male and white, but stating that they are among the "few" that could get good healthcare is grossly overstating it.

Maf Lewis - +Robert Silge As there are around 25%-30% uninsured Americans and another 20%-30% who have significant restrictions on their health insurance, I would say that Americans that get good healthcare (as compared to other countries of similar wealth per capita) would be in the minority - hence the few. Even if my figure are way off, the difference between health care of the top few % in the USA and the rest is enormous.

Robert Silge - +Maf Lewis Define "significant restrictions". Every system of organized healthcare has significant restrictions on how you can get healthcare. A complete lack of restrictions would be unfettered capitalism, where you can get whatever you want if you can pay for it.

Look at the literature. There is an association between socioeconomic status and longevity in any society. It is admittedly more pronounced in the US than in some countries. Some western countries are worse still.

Ves Dimov - Lifespan and social status: Why your boss will probably live longer than you
http://goo.gl/DQJRR

Maf Lewis - +Robert Silge - I agree it's hard to define and be accurate with some of these points, but for me significant restrictions would mean that you have a limit by the amount insurance will pay out for a specific illness, or pre-existing conditions, or other small print such as your activities are deemed dangerous sports (climbing on a roof to fix and ariel), or even having insurance investigators look into your case to see if there is a loophole that will enable them to not fund treatment- something I and my family came across first hand in my 6 years living in the USA.

I would confidently say that general healthcare in the USA is substandard to that of France, UK, Germany, Australia New Zealand etc, but for the top few % it is possibly the best in the world... actually it's best for the top few % in any country who can go anywhere in the world and get anything done...

The USA has the highest standard of living but one of the lowest life expectancies of the top 10 richest (per capita) countries.. why? Healthcare.

Maf Lewis - I absolutely agree about social status/health in all countries. I think it's just a bigger gap in the USA, as with educations, income, everything.

Robert Silge - Yes, it is bigger in the USA than in other countries. This article is horribly out of date (as in, it looks at WEST Germany), so take it for what it's worth, but the relationship between income and lifespan was least pronounced in Sweden and Norway, worst in the US and UK (and W. Germany, but let's ignore that all together). http://www.bmj.com/content/304/6820/165.full.pdf

Are there more uninsured and under-insured than I would like? Absolutely. But I think you're looking at this upside down. Our ability to take care of the bottom of our society is undeniably poor. But the middle elements of society get good care. And I'm not even saying that this is the way things ought to be. But it's the way things are, and to say a minority of patients get good healthcare is inaccurate to me. I would fundamentally disagree that FEW people in the US get "good healthcare".

Maf Lewis - Ok, all good points Robert. Maybe if I said that the average person in the USA doesn't get as good health care as the top 10 richest countries (per capita)?

Maybe I'm bias because of my direct experience with health care in the USA (6 years), Australia (1 year), UK (30 years), France (on and off 20 years). Always the USA was more limited and slower.

Robert Silge - Well you certainly have more direct experience than I, and no one can argue with that. I think it would be accurate to say that the highs are higher and the lows are lower in the US. That probably applies to a whole host of aspects of life here. For better or worse it's what we do.

Maf Lewis - True, but my direct experience could a series of both good and bag luck;) I'm sure there are horror and hero stories in all counties.

Yes I think the extreme highs and lows do apply to most things, and in a weird way it's both the worst and also the best of the USA.

Maf Lewis - Just to make it clear (if I hadn't already) it's not the health care professionals in the USA that are the problem here, but the insurance industry, and healthcare for profit in general.

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Social media in medicine: How to be a Twitter superstar and help your patients and your practice

This is the key concept of a series of talks that I am scheduled to present at several national and international meetings in 2011-2012 (AAAAI and WAO):

- Cycle of Patient Education
- Cycle of Online Information and Physician Education

The two cycles work together as two interlocking cogwheels.

Cycle of Patient Education (click here to enlarge the image).

Cycle of Online Information and Physician Education (click here to enlarge the image).

The first presentation was during the annual meeting of the Canadian Society of Allergy and Clinical Immunology (CSACI) and brought a lot of engaged, useful, and interesting questions. Feel free to use the images in your own presentations with credit to AllergyCases.org.

Byproducts of the Cycle of Patient Education

- Energy! (energized and engaged patients)
- Improved understanding of patient's condition, outcomes and quality of life
- Better physician-patient relationship
- Increased referrals to the practice, e.g. 2-5 new patients per week
- Savings for the health system
- Decreased ER visits and admissions

What is Return On Investment (ROI) of Cycle of Patient Education?

Calculated ROI:


- 2 new patients per week who come to the clinic directly from the blog/Twitter account
- $500 reimbursement for 2-3 visits (initial visit and 1-2 followup visits)
- 50 weeks x 2 patients = 100 new patients per year
- 100 patients x $500 = $50,000 per year

The best interest of the patient is the only interest to be considered

The purpose of the cycle is not to make money. As the Mayo Clinic CEO pointed out recently, Mayo Clinic intends to be the leader in social media in healthcare but this is not about competitive advantage, it is about the patient. The best interest of the patient is the only interest to be considered. Social media makes the union of forces more broadly practical than at any time in human history.

Social media for physicians: Do I really need to be on Twitter, Facebook and YouTube?

(the text below uses the specialty of allergy and immunology as an example, an edited version was published on the website of the World Allergy Organization where I write a monthly column)

It certainly looks like social media is taking over the world. Facebook is a “country” with more than 750 millions citizens. Twitter has more than 250 millions users. Google+ is the fastest growing web service and history and reached 25 million users in just one month after its launch. As an allergist, you may ask yourself, “Where is my place in all this? Do I have to be on Twitter? Do I have to use Facebook and YouTube to stay relevant?” The answer is yes.

Social media can provide a focused and time-efficient learning experience. Sharing relevant medical news with patients is just a click away. The paramount is to protect patient privacy at all times and to comply with your employer and professional organization guidelines. You can be a physician and a social media superstar at the same time. Here is how in 3 easy steps.

1. Use of Internet to learn and stay up-to-date

- Web feeds (RSS and Atom) work great for for targeted updates from journals, websites, and allergy/immunology news. RSS stands for Really Simple Syndication and consists of updates pulled from a particular website whenever something new is published. RSS feeds can be separated in different categories, e.g. asthma, allergic rhinitis, etc. Web-based RSS readers (Google Reader, Feedly, Flipboard) function as “inbox for the web”. You can get all sources delivered in one location - a web-based reader

- Blogs and Twitter accounts. A selected list of high-yield blogs and Twitter accounts of board-certified allergists/immunologists includes: @JuanCIvancevich (Juan C. Ivancevich, Buenos Aires, Web Editor of the World Allergy Organization), @wheezemd (Michael Blaiss, MD, Past President of the American College of Allergy, Asthma, and Immunology), @DrSilge (Robert Silge, MD, allergist/immunologist, Salt Lake City, Utah),
@AllergyNet ( John Weiner, allergist, clinical immunologist, Melbourne, Australia), @MatthewBowdish (Matthew Bowdish MD, allergist/clinical immunologist, Colorado), @allergydoc4kidz (Stuart Carr, allergist/immunologist, Canada), and the author’s own Twitter account at @Allergy.

- Podcasts for allergy and immunology education represent mobile-based MP3 files and services with automatic subscription. Free podcasts/videocasts are provided by COLA Allergy (ACAAI, http://childrensmercy.org/content/view.aspx?id=5979), Journal of Allergy and Clinical Immunology (AAAAI, http://jacionline.org/content/podcast), and World Allergy Organization (http://journals.lww.com/waojournal/Pages/podcasts.aspx).

- Persistent searches for topics of interests in allergy/immunology. You can subscribe to RSS feeds for "persistent searches" in PubMed and Google News for the topic of your interest, e.g. “oral immunotherapy for food allergy”.

- Text-to-speech (TTS). You can use text-to-speech to listen to journal articles at a later time. The text-to-speech programs convert the the text of a journal article into an MP3 file. A free program is Balabolka (http://cross-plus-a.com/balabolka.htm).

- Clinical cases and practical questions are available from the World Allergy Organization Journal, AllergyCases.org (disclaimer: the author is the founder of the website), AAAAI Ask the Expert (http://aaaai.org/ask-the-expert.aspx).

2. Use of Internet and computers for patient education

- Patient education diagrams - web- and iPad/tablet-based diagrams are well-received by patients and doctors in training. The the author's survey at the allergy clinic of the University of Chicago showed a 95% patient approval rate for iPad use for patient education. The diagrams used in the study are available here: Diagrams for Patient Education.

- Videos for patient education can be viewed on tablet or netbook. The videos can be streatmed from the physician's website or downloaded locally. Targeted videos can be used for patient education before and during the visit, for example, “what to expect from your visit at the allergist office”, “how to use an inhaler”, etc. There is a continuum of education - start at the office (tablet or netbook), then continue at home (web-based videos and selected educational brochures and links).

- Ready-made patient education brochures can be printed from allergist's website. A custom-made search engine can generate brochures on demand, e.g. Medline Plus.

3. Use of Internet to promote your practice and collaborate

- Start a website for free (WordPress.com or Blogger.com). Start a Twitter account and professional Facebook page for your practice.

- Setup persistent searches for your name/practice on Google, Twitter, etc. and subscribe to RSS for automatic updates. You can address questions and concerns whenever they arise.

- Use Google Docs for research collaboration, creating diagrams for patient education, office calendar, and spreadsheets.

Risks of social media use by physicians

Physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just as they would in any other context. When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content first to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities (Source: AMA Policy: Professionalism in the Use of Social Media, 2011).

Advice for Physician Who Use Social Media for Professional Purposes
- Write as if your boss and your patients are reading your blog every day
- Comply with HIPAA, e.g. never publish any identifiable information without patient permission
- Consider using your name and credentials on your blog and other social media accounts
- If your blog is work-related, it is better to let your employer know.
- Inquire if there are any employee social media guidelines. If there are, comply with them strictly.
- Use a disclaimer, e.g. "All opinions expressed here are those of their authors and not of their employer. Information provided here is for medical education only. It is not intended as and does not substitute for medical advice."

Summary

Social media is here to stay and is fast becoming the dominant way of information consumption and sharing for the general population and patients. Allergists have to be on social media to stay relevant and to provide meaningful service to patients.

The author can personally confirm the benefits of the approach outlined above. Dr. Dimov has used social media for professional purposes for more than 7 years while on staff at Cleveland Clinic and the University of Chicago. During that time his websites have had more than 8 million page views and attract daily 16,000 RSS subscribers, 9,000 Twitter followers and 2,600 visitors.

There are other physicians who are even more popular on social media and make the stats above look minuscule. You can be one of them. It benefits both your patients and your professional life.


RSS bundles of medical news

You can use the following RSS bundles to subscribe to medical news items. The bundles are exported from my personal Google Reader page. They update automatically several times per day. When in Google Reader, just select the ones that you find interesting and share them on Twitter. Feel free to add your own comments to some of the tweets.

Top Twitter Doctors

This is a list of the Top Twitter Doctors arranged by specialty in alphabetical order - feel free to add your own suggestions. The list is open to anybody to edit:

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Restraint technique could be fatal: Forcing a detainee to bend over while seated can lead to death

Researchers found that the hold, forcing a detainee to bend over while seated, can massively cut lung capacity.

They placed 40 volunteers in chairs and then leaned them forward, bringing their face close to the lap. They used arm holds and applied a small amount of force to prevent the volunteer from attempting to return to a normal sitting position. In the worst cases, the lungs' capacity was almost halved.

"Imagine that from the perspective of the security staff. They feel you struggle and they will feel that you are getting angry. They will apply more force to manage your resistance. It becomes a vicious circle."

References:

Restraint technique could be fatal, research suggests. BBC.

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Chiropractic Neurology – Video

This innovative technique is helping deal with challenges like dyslexia and ADD. It's a technique that precisely adjusts areas of the nervous system without using pharmaceutical drugs.

Read more:
Chiropractic Neurology - Video

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