Links for Wednesday, October 17, 2018: TV's first drug ad, does mold really make us sick? and big-ass Canadian pumpkins

Behold: the first television drug ad in the US

It was taken down after 48 hours. And now the US is one of only two countries worldwide to allow direct-to-consumer advertising of drugs.

Science has yet to prove that mold makes us sick

I grew up in a farmhouse that was originally an in-ground house and, well, you know how this ends. The basement, which was originally just called “the house,” leaked like a sieve. This led to chronic, unrelenting nighttime exposure to mold in the nooks and crannies of the place. I never felt like it made me sick, but relatives tell me it makes them feel bad. It’s a bummer that medicine can’t tell them whether they’re wrong or right.

 Wikipedia

Wikipedia

Canadians (Canadians!) are racing to grow their first one-ton pumpkin

In my day, we were happy with an orange decorative guord that you could hold in your hands and gently disembowel for purposes of internal illumination. We didn’t want anything to do with these monsters that gain 50 pounds a day to deform under their own weight and need a forklift for transportation. But I do admire they’re trying to do it a different way:

“…weights in the United States and Europe have long passed 2,000 pounds. In Canada, where regulations prohibit some of the chemicals used elsewhere, they have yet to hit this mark. Getting there has become a point of national pride.”

FYI: Pumpkinnook.com tells me the current world record is owned by German Mathia Willemijn at 2,624.6 lbs in October, 2016:

 Pumpkinnook.com

Pumpkinnook.com


Links for Monday, October 15, 2018: Uber quantifies the curb, non-yelling coaches, criminal malpractice, and handlebar shapes

Uber—not a bus company—has proposed a formula for optimization of curb space that makes buses look pretty good:

(quoting directly from the article)

Activity/(Time x Space)

“Activity” is the number of passengers using the curb space by a specific mode, “time” is the duration of their usage, and “space” is the total amount of curb footage dedicated to that use.

Here’s the example that the consultants use in their report, where a 20-foot length of curb is used for four hours as a parking spot by a single car carrying two people:

2 passengers/(4 hours x 20 feet) = .025 passengers/hour-feet, or 0.5 passengers per hour per 20 feet of curb

But if that space is instead used as part of an 80-foot bus stop serving 100 people in that four-hour block, the equation looks like this:

100 passengers/(4 hours x 80 feet) = .3125 passengers/hour-feet, or 6.25 passengers served per hour per 20 feet of curb

Clearly, the bus stop is a better use of public space. And naturally, those Uber cars that don’t take up curb parking look good, too. No surprise there, considering the source.

John Gagliardi is dead, which means that the Nick Saban school of coaching just got a little stronger. That’s a tragedy

My antipathy toward football is cresting (just search for “football” in this site and you’ll see why). But who can argue with a philosophy like this one?

“Gagliardi essentially preached a philosophy of anti-coaching, one that prized self-reliance and self-motivation and abhorred cruelty and authoritarianism. These were not bullshit, repackaged, supposedly out-of-the-box ideas like you find coming out of Silicon Valley. Gagliardi’s philosophy was deeply HUMAN, and deeply trusting. It also happened to be highly effective, so much so that similar techniques are now widely used in parenting books, academic teaching, and other fields.”

One thing the best coaches I’ve had did well—in sports, medicine, music, or other—was to make me feel good about what I was doing. They made me feel good about the process of improvement, no matter my starting point in terms of skill. They essentially told me, “I know you’re a person who tries hard. Let me help you direct that effort in the way that will get the most out of your foundational ability.”

A Texas neurosurgeon was so bad at his job that he got life in prison

When I was a resident, a local doc prescribed so many narcotics to so many patients at such outrageous doses that admitting one of his patients was a near certainty on any overnight call shift. But what did the guy in wasn’t that he was committing malpractice on a daily basis; it was that he improperly supervised his wife as a mid-level provider, leading to money laundering and conspiracy convictions.

We in medicine do a bad job of policing our own. The surgeon who body-checked Dr. Death away from the operating table in Texas deserves major credit.

On a lighter note, What Bars? lets you compare the shape, drop/rise, and weight of a few dozen different handlebars

Links for Tuesday, October 9, 2018: Overtreatment of subclinical hypothyroidism, altruism and specialty choice, and Roman wiping technology

Treating your TSH level of 10 mIU/L with thyroid hormone probably won’t make you feel better

But your doctor will probably try to talk you into it, anyway (paywall):

“Although current guidelines are at first sight cautious with treatment recommendations, more than 90% of persons with subclinical hypothyroidism and a thyrotropin level of less than 10 mIU/L would actually qualify for treatment. However, results of this meta-analysis are not consistent with these guideline recommendations.”

Are altruistic students more likely to choose lower-paying specialties in medicine?

This paper is complex and paywalled, and I won’t pretend to understand it. But yes, it does seem that altruism is related to choosing lower-paying specialties and more underserved areas:

 <$300,000 per year is defined as a lower-paying specialty, which calls my career choices into doubt.

<$300,000 per year is defined as a lower-paying specialty, which calls my career choices into doubt.

How did ancient Romans wipe without toilet paper?

Let’s all share a collective shiver at the thought of a communal, stall-less bathroom with sponges on sticks, shall we?

Links for Wednesday, September 5, 2018: docs are nervous about weight loss meds, risky low-carb diets, why I'm not a pediatrician, and continuity of care is good

Why don't more docs prescribe weight loss medications?

Speculation: 1) cost (and by extension, prior authorization requests); 2) residual fear from fen-phen, as one of the docs interviewed alluded to. We can surely put this to bed, since the current crop of meds has been on the market much longer than fen-phen had been when its harm was revealed; 3) nihilism. Five percent weight loss is meaningful from a medical perspective, but unless the doc is consciously, prospectively measuring outcomes like blood pressure, lipids, and fasting sugars, it won't knock her socks off. Patients won't be thanking her for getting them ready for bikini season; and 4) the old Risk Evaluation and Mitigation Strategy (REMS) for Qsymia was such a PIA that it scarred some docs to prescribing these meds.

Can we stick a fork in low-carbohydrate diets? (Ba Dum Tss)

What's a 32% increase in mortality among friends? Investigators (in a study that, to my knowledge, has not yet been published, so caveat emptor) found an association between the lowest quartiles of carbohydrate intake and death:

 NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers.&nbsp;

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

Remember: we can't draw causality from this. There is some chance that people who are sick and more likely to die from heart disease, cancer, or stroke are more likely to adopt low-carbohydrate diets. But it doesn't seem likely. The people at highest risk in this study were those over age 55 and "non-obese."

Reason # 1,001 I'm not a pediatrician:

Can. Not. Do. It.

Special shout-out to the 100 cell phone text alerts during the video. 

If lack of continuity is a mark against telemedicine, then it's a mark against the hospitalist model in general

Links for Tuesday, August 21, 2018: patients love good news. And weed. Patients love weed.

Patients liked a blood pressure app better because it was inaccurate

If I were to pick a single study that wraps all my angst about medicine up into a tidy bow, it would be this one:

"...user enjoyment and likelihood of future BP monitoring were negatively associated with higher-than-expected reported systolic BP. These data suggest reassuring app results from an inaccurate BP-measuring app may have improved user experience, which may have led to more positive user reviews and greater sales."

A better writer could hold forth on how doctors (and devices?) are so bad at giving negative but meaningful information to patients that patients simply avoid the process altogether, leading patients to seek a relationship with their doctors that more resembles that between a shaman and a subject than that of a modern, informed, dynamic doctor-patient exchange of information.

*head explodes*

Dr. Robert Badgett, on seeing this study, reminded me of a quote by Voltaire:

"The art of medicine consists in amusing the patient while nature cures the disease."

I certainly feel like I'm in the entertainment business some days.

With wider availability of cannabis comes wider use and wider abuse

"Public-health experts worry about the increasingly potent options available, and the striking number of constant users. 'Cannabis is potentially a real public-health problem,' said Mark A. R. Kleiman, a professor of public policy at New York University. 'It wasn’t obvious to me 25 years ago, when 9 percent of self-reported cannabis users over the last month reported daily or near-daily use. I always was prepared to say, ‘No, it’s not a very abusable drug. Nine percent of anybody will do something stupid.’ But that number is now [something like] 40 percent."

I knew guys in college who were stereotypical "potheads," and I think my bias at the time was that all but a few of them would be reined in by the relative difficulty of getting the drug (not that it was difficult). Now that the reins are off, we're stuck addressing possible solutions to the problem. This is not an argument for going back to hard-core criminalization. As Annie Lowrey points out, the US still arrests more people for marijuana offenses than it does for all violent crimes combined. That seems, shall we say, excessive. 

I've had several Impossible Burgers. They're amazing

A few years ago I made a choice to eat very little meat. Everyone who comes to a this dietary decision gets there for one of several reasons. For some, it's a matter of animal welfare. For me, it was the impact of excessive meat intake on my personal health: meat, particularly red meat and processed meat like bacon, has been linked to increased risk of heart disease, cancer, and other diseases. Plus, beef in particular is astonishingly carbon-intensive; were people to forgo only red meat in favor of beans (while, mind you, continuing to eat pork and poultry), the U.S. would come very near Paris Accord carbon emissions goals, all without a change in driving habits or other energy production from fossil fuels, and without a change in efficiency. 

Giving up meat for me was astonishingly easy. I don't miss it. Were you to ask me to give up sweeteners, we'd have a problem. I like desserts more than I should, and despite my frequent screeds against bug juice, I have an occasional caffeine-free Diet Coke. But no meat? No problemo. Part of the reason for this is that we've had a big increase in the availability of meat substitutes in the past decade or so. This doesn't affect me so much as it affects people who eat with me. I can make meals that are almost meat that I can serve to carnivorous friends and family without feeling like I'm depriving them of anything. But hamburgers, the quintessential American food, have been a problem. I've tried multiple veggie patties and black bean patties. They're all mostly okay, but they're no substitute for real meat. You have to have in your mind that you're not eating a hamburger to enjoy them. You tell yourself, "This is a good veggie burger," but you can never convince yourself that you're eating a real-for-real hamburger.

Then I heard about Impossible Foods and their bleeding vegan hamburgers. I was intrigued, but there was no place near home for me to try one. But last summer I was in Houston a week or two before Hurricane Harvey. We found a Hopdoddy just west of Rice Stadium:

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This was directly adjacent to Rice's semi-famous 1/3 mile "Bike Track," whose popularity I assume is at least partly due to the apocalyptic artillery-grade roughness of the surrounding streets. Hopdoddy was pushing the Impossible Burger hard:

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But that didn't mean they didn't have the customary pile o' beef in their kitchen:

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And it didn't mean that when I ordered on the waitress wouldn't say I was "brave." But when it arrived, so far, so good:

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My burger looked like a million bucks. But I didn't get a chance to find out if my burger bled; it was well-done:

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Impossible Burger has the look and feel of beef. It has the mouthfeel of beef. It just does. For all intents and purposes from the consumer end, this is beef. I tried a bite of my son's regular patty for a taste test. I'm a bit of an unreliable witness here; my enthusiasm for meatless foods taints my impression of these things. But honestly, the only difference was that his real burger was saltier. I suspect Impossible keeps the salt content lower to avoid dryness.

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I liked the one I ate so much that I convinced my then-ten year-old daughter, a notorious carnivore, to try one. She will eat veggie patties, begrudgingly, the way somebody who's tasted whole milk will settle for almond milk on her cereal if they don't have a choice. But after tasting mine, she was enthusiastic to get her own. And she's had several since.

The primary ingredients are wheat, coconut oil, potatoes, and heme. Heme is part of the molecule that carries oxygen in your bloodstream: "hemoglobin." Impossible gets its heme in the form of soy "leghemoglobin." Their website says they chose it because of taste and lack of allergenicity. I suppose this means people won't get a rash if they eat it. Not that I knew hemoglobin allergies were a big problem.

If you're the anti-GMO type (I'm most certainly not), beware that Impossible's leghemoglobin is produced by a genetically modified yeast. But it is 100% vegan. It's not gluten-free, which is a bummer for the small fraction of the population with celiac disease. For the remaining 99% of us, it's neither here nor there. Impossible burger patties are kosher.  Halal are anticipated later this year.

My second Impossible Burger was in Washington, D.C., for a work trip. My daughter's, ironically, came with bacon:

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My wife's medium-rare (not ordered that way, but delivered that way) patty gave us a chance to taste the heme without the searing. It definitely loses something. The seared heme is important: 

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I tried to convince my daughter that the tater tots were also "Impossible," but that since they were naturally made of potatoes the impossible factor was figuring out how to make them out of animals. She didn't buy it: 

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Impossible Burgers are now served in more than 1,500 restaurants. Since April, White Castle has been selling Impossible Sliders for just $1.99. After trying Impossible Burgers myself, I'm convinced that meat production in the way we've been practicing it for the past 100 years has an expiration date. We simply won't tolerate the health and environmental consequences of it when we have alternatives that are this good. I'm not here to tell you that Impossible Burgers represent any kind of achievement. Quite the contrary: as good as they are, they're just the beginning. Meatless "meat" is the worst today that it ever will be. It will only get better from here. Next phase vegetarian chicken? Faux eggs? Faux seafood