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Six Things a Cardiologist Loves About Apple Watch Series 1 – None of Which Involve Health

The skeptical cardiologist stopped wearing his initial wearable piece of technology (a Garmin device that constantly prompted him to move, described here), within 6 months of purchasing it; it just wasn’t worth the effort of charging and putting on the the wrist.

I am not alone in finding FitBit type devices not worth wearing after awhile. ConscienHealth points out that sales and stock price of FitBit are down significantly.  Part of this is competition, part saturation of the market, but part must be due to individuals going through a process similar to mine.

The great promise that wearable fitness/sleep/activity tracking devices would make us healthier has not been fulfilled.

A recent study showed that among obese young adults, the addition of a wearable technology device to a standard behavioral intervention resulted in less weight loss over 24 months.

Taking the Apple Watch Plunge

However, knowing I was a fan of all things Apple, the eternal fiancee  bought me a Series 1 Apple Watch, which I have come to love. This love has little to do with how the device tracks my steps or my sleep or my pulse or my movement.

Let me count the ways I do love my Apple Watch…

  1. I can answer my phone without touching my phone or
    If I see a call is coming in from Hackert, my home security company, I have to take it no matter what I’m doing. Here I’m having a conversation about what set off my home alarm just using the Apple Watch

    having it near me or even knowing where my phone is.

    Since I’m constantly misplacing the damn thing, this is a surprisingly helpful feature. There is also the really cool aspect of walking around and having a telephone conversation  using my watch.

During a busy day of seeing patients in the office I typically will receive multiple calls from the ER or other doctors I have to talk to immediately.  Now, I can rapidly screen my calls with a tilt of my wrist and excuse myself to take the call. If I’ve been trying to get ahold of Dr. X to discuss a mutual patient, and he calls while I’m doing a transesophageal echocardiogram, I can have someone touch my watch instead of reaching into my pants for my iPhone, or searching in my office for it, or missing the call altogether.

 I’m missing much less important calls these days.

And although previously I would take calls while driving, the watch makes this process much simpler and therefore much safer.

2. Receiving and responding to text messages does not require accessing my iPhone.

Responding in detail to texts is as simple as touching the microphone icon on the Watch, speaking, then touching SEND. The translator works pretty well.

This doesn’t seem like that big of a deal, but again, the ability to rapidly scan incoming texts with just a tilt of the wrist greatly facilitates expeditious screening and processing.

The Apple Watch allows response via either audio recording (translated seamlessly and quickly to text) or pre-set standard responses or emojis.

 

3. “Hey Siri” function simplifies and makes hands-free and iPhone-free many useful tasks. For example:

  • To set a timer for my (heart-healthy) boiled eggs, I say “Hey Siri, set timer for 11 minutes.” Normally in this situation I avoid setting the timer because I’m too busy to grab my phone, open it, and find the timer app (I know I could use Siri on my phone, but that requires more effort).
  • If I suddenly remember I need to call someone while driving, the “Hey Siri” function allows making the call without taking my hands off the steering wheel.
  • If a brilliant idea for a blog post occurs to me while driving or walking through the hospital corridors, “Hey Siri” can take a note with ease.

4. Checking the time is a lot easier (I know, all watches do this, but I’ve haven’t worn a watch for about 20 years).

The lower left icon triggers the pinging of iPhone. Watch and iPhone must be “Connected” via either bluetooth and proximity or via being on the same WIFI network.

5. If I misplace my iPhone (this happens roughly once per hour when I am at home), I can “ping” it by pushing a button on my Apple Watch: follow the ping and “voila!” I have found my iPhone. Most of the time it is lying under a piece of paper or article of clothing within a few feet of where I’m working, but sometimes it is in an obscure corner for obscure reasons.

Here’s a true story which illustrates my tremendous absent-mindeness and the value of the “ping.”

I haven’t figured out how the Apple Watch knows this but when I’m getting ready to drive to work in the morning it automatically shows me something like this, advising me on the best route to take. Likewise, when I’m getting ready to leave work, it alerts me to best route home. It’s somewhat creepy. Is it keeping a log of my driving patterns?

I left my office Friday evening and after stepping outside I realized I did not have my iPhone in its usual location, the left front pocket of my pants. I searched the pockets in my pants and in the jacket I was wearing to no avail. I began heading back to my office believing that I had left it on my desk but then realized that I might have put it in my satchel. Not in my satchel. A bright idea then occurred to me: ping the iPhone to see if it was in the satchel, but hidden.

Sure enough I heard the iPhone ping. But it was not in the satchel; it was (for obscure reasons) in my shirt pocket (a place that apparently makes it undetectable to me).

6. Information on local weather is immediately available. I have configured my watch “dial” to show me the local temperature. Right now with a flick of my wrist I can see that it’s 17 degrees outside and I’m going to have to dress warmly. I’ve also configured my watch dial to tell me when sunrise/sunset is and what my heart rate is.

These last two things, although immensely interesting, are not that helpful.

Oh, excuse me, my watch timer is telling me my eggs are done.

Pingophilically Yours,

-ACP

P.S. I’m still in the process of evaluating the work-out/sleep/move/mindfulness features of Apple Watch and hope to write about it in the near future.

Feel free to share the things you love or hate about your Apple Watch below.

Paranoid Rumination From A Freshly-Minted Migraineur

As I sit here writing, I perceive a scintillating band of zig-zags in the shape of a reverse C on the left side of my visual field. I sense the scintillating reverse C with either, or both eyes closed, and I first noted it when the letters in the New Yorker article I was reading became obscured by the C. Attempts to focus on the crescent are futile:  it moves as I move my eyes or head. Within its body are vague browns, blacks and whites, and overall it is reminiscent of an Egyptian or Art Deco piece of art.

I have a friend in Brooklyn, a flaneur, and one in Florida, a raconteur; I have now become a migraineur: one who suffers from migraine headaches or, in my case, the visual or tactile hallucinations known as migraine aura that precede the headaches.

I go to my bookshelf and find Oliver Sacks’ book “Migraine: Understanding a Common Disorder, which I purchased long ago when I was not a migraineur (primarily to complete my collection of Sacks’ unique and brilliant writing).  On page 62, figure 2b, I find a drawing which closely approximates what I’m “seeing.”

An artistic depiction of migraine aura which was similar to mine. Original source is unclear.

I had asked Siri to start the timer on my Apple watch when I first noticed the visual disturbance, and now note that at 16 minutes 32 seconds, my vision was back to normal. At 25 minutes 16 seconds, I experienced a very subtle ache in my left frontal region which persisted for 5 minutes.

I have observed patients with severe migraine headaches: suffering from nausea, intense pain, photosensitivity and requiring dark and sleep and powerful analgesics to cause remission. I am fortunate because my after-aura headaches, if any, are minimal and brief.

The first time I experienced the visual hallucination was five years ago. I was not blogging then, but made a detailed note of the experience, complete with paranoid rumination on brain testing and side effects of MRIs. What follows is the transcript with the comments of the present day skeptical cardiologist in green or red.

“I had a crazy day Thursday. I gave a talk to the echo lab from 7 to 8 AM and then rushed over to the hospital to see the most urgent of the 9 inpatients I had. I had seen 4 patients by the time I got paged to see my first patient in the office. I headed over there and saw 6 patients . Then I hurried back to the hospital to grab the EKGs I was supposed to read that day. I was a little stressed because I needed to read these and try to see more of my inpatients before heading over to the outpatient testing facility which I had to be at by 1230 to supervise stress testing. I sat down in my hospital office and started reading the EKGs. After I had read a few, I became aware of a defect on the left side of my vision. It felt like when you have looked at a bright light and it leaves a residual on your retina.
At first I thought it was due to the fact that i was reading the EKGs with only the desk lamp on my left on. I turned on the overhead light and it didn’t help. I then realized that I had a hockey puck shaped defect in my left visual field in both eyes. When the defect covered key portions of the EKG, I couldn’t read it. It was filled with a jagged, prism like filling. Otherwise I felt fine. My first thought was that I was having a scintillating scotoma and that this was a migraine aura. Other things seemed much less likely-TIA for example. I called Dr S, my favorite neurologist, on his cell phone and told him what was going on. He suggested I visit him in his office right then. His office was in 400 East which would necessitate a right turn from my office. Instead, I took a left turn down to the West office building, took the elevator up to the fourth floor and finally realized my mistake when all I could find were office numbers that ended in W. (At the time young Dr. P felt this disorientation was related to the aura but perhaps it was due to distraction) By the time I reached his office twenty minutes after the visual symptoms started, they had resolved.
Dr. S did a neuro exam and history, and concluded that I most likely had a migraine aura but thought that I should get an MRI to be certain there was no structural brain disease. After I left his office I began feeling slightly nauseated with a slight headache. Over the next two hours the headache became a moderate frontal headache associated with a sense of fatigue.
I got the MRI yesterday and Dr. S thinks it is normal, although the radiologist read it as showing small subcortical defects which could be consistent with “chronic migraine, small vessel disease, or demyelinating process.”
I almost didn’t get the MRI. This is one of the classic situations in medicine where the history and physical alone makes the diagnosis with near certainty (young Dr. P is correct, see what Choosing Wisely says here), but because a very small number of cases might have something more serious (a brain tumor or vascular lesion in this case ), (perhaps also fueled by medical legal concerns and patient’s love of fancy tests) an expensive imaging test is ordered.
If you took 1000 people with my symptoms and the normal neuro exam with low atherosclerotic risk factors, and did brain MRIs on them, the vast majority of findings would be incidental, probably false positives (I believe young Dr. P made up this statistic but the national migraine center in the UK says :

“The main problem with MRI scans is ‘looking for a shilling and finding a sixpence,’ in finding abnormalities that are unrelated to headache, entirely by chance. The risk of a minor abnormality of no medical significance is 1 in 4. The risk of a chance abnormality that might need treatment is about 1 in 40. Once these ‘incidentalomas’ have been found, the patient may then find it difficult to obtain insurance (for example travel) and there is often a temptation to repeat the scan time and time again to check that the ‘incidentaloma’ is not changing..)

False positives lead to unnecessary anxiety in patients and in some cases unnecessary testing (Dr. S told me that he sees tons of patients who have had normal MRIs with readings similar to mine who are convinced they have MS) (MS=multiple sclerosis, a demyelinating process. Although my MRI was read as having abnormalities possibly due to a “demyelinating process” I must not have had one because  6 years later I have had no other symptoms)) and in some cases unnecessary additional testing.

As I was lying in the MRI gantry listening to the “ratatat “of the scanner, I wondered if we really know the consequences of rearranging the molecules of brain tissue with giant magnetic fields.
Dr. S  had ordered the MRI with gadolinium. I recalled seeing adds from law firms seeking “victims” of MRI scans (one man was awarded 5 million dollars after developing nephrogenic systemic fibrosis after one dose of gadolinium (NSF). I knew that gadolinium had been linked to some really serious disorders. The tech had said nothing to me about adverse effects of the “dye” she would be using. My nose began itching like crazy, then my left eyelid. I couldn’t scratch until I emerged from the scanner. After the initial images were done and I was brought out of the scanner, I scratched my face like crazy and asked the tech if there were any side effects from gadolinium.
“Why yes, she said, you can have severe allergic reactions,” but we’ve only had a couple.” Also, she said, there is some disorder… she couldn’t remember the name or what it did but knew that it was only a problem if you had kidney failure or had diabetes and were over the age of 60.
As I was lying in the scanner after receiving the gadolinium, I began trying to estimate what risk I would be willing to assume in this situation. The disease you can get if you have severely impaired kidney function and receive gadolinium is nephrogenic systemic fibrosis.
Would I accept a 1 in 1/1000 chance of NSF in exchange for diagnosing something other than migraine 1/1000 times? I couldn’t and can’t easily and logically make that call. I have no idea how patients can make these decisions.

Cephalgiacally  Yours

-ACP

Here’s a video of an aura similar to mine (one of many posted at visual migraine animation)

Migraine experiences have served as a major source of artistic inspiration in both past and contemporary painters, sculptors, film-makers and other visual artists. Check some of their work out at migraine aura foundation.

 

 

 

Treatment of Palpitations Due To Benign PVCs: Potassium, Magnesium and Lifestyle Adjustment

In a previous post, the skeptical cardiologist pontificated on the causes and evaluation of the most common cause of palpitations: premature ventricular contractions or PVCs.

The vast majority of these common extra beats turn out to be benign (meaning not causing death, heart attack or stroke), and most patients with sufficient reassurance of this benignity (often accompanied by significant caffeine reduction), do well. These people usually continue to notice the beats either randomly, or with stress, but they recognize exactly what is going on and are able to say to themselves “there go my benign PVCs again,” and aren’t worried or bothered.

A small percentage of patients that I diagnose with palpitations due to benign PVCs continue to have symptoms.

Part of my initial evaluation involves checking potassium, magnesium, kidney function, and thyroid levels.

Potassium Supplementation For PVCs

Low potassium levels (hypookalemia) have been clearly associated with an increase in ventricular ectopy. Patients who take diuretics like hydrochlorothiazide (HCTZ, often used for high blood pressure) or furosemide (Lasix, often used for leg swelling or heart failure), are at high risk for hypokalemia with potassium levels less than 3.5 meQ/L.

Hypokalemia can also develop if you are vomiting, having diarrhea, or sweating excessively. There are lots of other infrequent causes including excess licorice consumption. The body regulates potassium levels closely, due to its importance in the electrical activities involved in cardiac, muscular and neurological function.

The normal range of potassium (K) is considered to be 3.5 to 5 meq/L , however, I have found that PVCs are more frequent when the potassium is less than 4.

Most of my symptomatic PVC patients with potassium less than 4 find significant improvement with potassium supplementation.  I usually give them a prescription for potassium chloride (KCl) 10-20 meq daily to accomplish raising the level to >4.

An alternative to potassium supplements is ramping up how much
screen-shot-2017-03-02-at-6-18-48-pm screen-shot-2017-03-02-at-6-19-11-pmpotassium you consume in your diet. Most patients I talk to about low K immediately assume they should eat more bananas, but lots of fresh fruit and vegetables contain as much or more K than bananas.

The charts to the right show that a medium tomato contains as much K as a medium banana with a third of the calories. Avocados are a great source of K and contain lots of healthy fat. Yogurt (and I recommend full fat yogurt, of course) is a great source as well.

If you have  kidney disease you are much more likely to develop hyperkalemia, or high K, and you want to avoid these high K foods. Potassium infusions are used as part of a “lethal injection” in executions because extreme hyperkalemia causes the heart to stop beating. (In fact, Arkansas is hurrying to execute 8 men between April 17 and 27 utilizing KCl.  According to deathpenaltyinformation.org: “The hurried schedule appears to be an attempt to use the state’s current supply of eight doses of midazolam, which will expire at the end of April. Arkansas does not currently have a supply of potassium chloride, the killing drug specified in its execution protocol, but believes it can obtain supplies of that drug prior to the scheduled execution dates”)

Lifestyle, Stress  and PVCs

It’s probably time I revealed that I have PVCs. I feel them as a sense that something has shifted inside my chest briefly, like my breath has been interrupted, like my heart has hiccoughed. If I didn’t know about PVCs and hadn’t made the diagnosis very quickly by hooking myself up to an ECG monitor in my office, I know I would have become very anxious about it.

I know exactly what causes them: stress and anxiety. And this is the case for many patients. Stress activates our sympathetic nervous system, causing the release of hormones from the adrenal gland that prepare us for “fight or flight.” These hormones stimulate the heart to beat faster and harder and often trigger PVCs.

I rarely get PVCs these days, as the major source of stress in my personal life has gone away. This is also a typical story my patient’s relate: troubling palpitations seem to melt away when they retire or change to less stressful occupations, or as they recover from depression/anxiety/grief related to death of loved ones, divorce or illness.

You can’t always control external stresses, but several factors in your lifestyle are key to managing how those stresses activate your sympathetic nervous system and trigger troubling PVCs.

Dr. Mandrola lists as Steps 5-8 (Steps 1-4 are reassurance) for PVC treatment his “four legs of the table of health”:

: good food, good exercise, good sleep and good attitude. Cutting back on caffeine and alcohol, looking critically at the dose of exercise, going to bed on time, and smiling are all great strategies for PVCs.

Of these four table legs, I consider regular aerobic exercise the most important, and modifiable factor for PVC reduction.  Aerobic exercise improves mood and increases the parasympathetic (the calming component of the autonomic nervous system) activity, while lowering the output of the sympathetic nervous system.

The three factors that I find essential to handling the demanding and stressful job of being a cardiologist: restful sleep, regular, aerobic exercise and lots of love from my eternal fiancee (who also has occasional PVCs!)

watchos3-breathe-app-animation-wrap
Apple Watch trying to get me to breathe (something I ordinarily don’t do). According to Apple (my comments in parentheses) “Mindfulness is a state of active, open attention on the present. When you’re mindful, you observe your thoughts and feelings from a distance (my favorite way to think and feel) without judging them good or bad (even if I’m thinking about robbing a bank?). Instead of letting your life pass you by, mindfulness means living in the moment (a really boring moment) and awakening to experience (or lack thereof). (Apologies to SH :))

Beyond sleep and exercise there is a plethora of techniques that purport to help individuals deal with stress: yoga, meditation, and progressive muscular relaxation, among them.

Apps touting methods for relaxation abound these days.  My new Apple Watch is constantly advising me to engage in a breathing exercise for a minute at a time. I don’t find any of these techniques helpful for me (I haven’t found a good way to shut my brain down without falling asleep), but they may work for you.

Magnesium, Snake Oil and PVCs

Patients will find that the internet is rife with stories of how this supplement or vitamin or herb dramatically cures PVCs.  You can be assured that a sales pitch accompanies these claims and that the snake oil being promoted has not been proven effective or safe. Because symptomatic PVCs like most benign, common and troubling conditions (lower back pain, fatigue, and nonspecific GI troubles come to mind),  are closely related to mood and wax and wain spontaneously; the placebo effect proves powerful. In such conditions, snake oil and charlatans thrive.

Magnesium is enthusiastically hyped on the internet for all manner of cardiovascular problems including PVCs. Even Dr. Mandrola, who I respect quite a lot as an EP doc who promotes lifestyle change and who is definitely not a quack, lists his step 10 for PVCs (apologetically) as follows:

  • Step 10 (a): Please don’t beat me up on this one. Some patients report benefit from magnesium supplementation. I have found it helpful in my case of atrial premature beats. Let me repeat, I am not promoting supplements. Healthy patients with benign arrhythmia might try taking magnesium, especially at night. Don’t take magnesium if you have kidney disease. And if you take too much, watch out for diarrhea.

Most of the internet’s top quacks, however, greedily market and glowingly swear by magnesium.  A Google search for magnesium cardiovascular disease yields 833,000 entries and the first page is a Who’s Who of quackery, including Dr Mercola (strong candidate for America’s greatest quack), Dr. Sinatra (see here, currently in the semifinals for America’s greatest quack cardiologist), NaturalNews and Life Extension (see here). This totally unsupported and dangerous blather from the Weston Price Foundation is often repeated and is typical:

(magnesium) Deficiency is related to atherosclerosis, hypertension, strokes and heart attacks. Deficiency symptoms include insomnia, muscle cramps, kidney stones, osteoporosis, fear, anxiety, and confusion. Low magnesium levels are found in more than 25 percent of people with diabetes. But magnesium shines brightest in cardiovascular health. It alone can fulfill the role of many common cardiac medications: magnesium inhibits blood clots (like aspirin), thins the blood (like Coumadin), blocks calcium uptake (like calcium channel-blocking durgs such as Procardia) and relaxes blood vessels (like ACE inhibitors such as Vasotec) (Pelton, 2001).

Magnesium levels are very important to monitor in hospitalized and critically ill patients, especially those receiving diuretics and medications that can effect cardiac electrical activity.

However, for individuals with normal diets and palpitations due to PVCs, there is scant evidence that it plays a significant role in cardiovascular health.

The MAGICA study looked at supplementation with both magnesium and potassium (in the active treatment group, daily oral dosing consisted of 2 mg of magnesium-dl-hydrogenaspartate (6 mmol magnesium) and 2 mg of potassium-dl-hydrogenaspartate (12 mmol potassium) daily. The dose was chosen to increase the recommended minimal daily dietary intake of magnesium (12 to 15 mmol) and potassium (20 to 30 mmol) by ∼50% in addition to usual diet ) in 307 patients with more than 720 PVCs per hour and normal baseline K and Mg levels.

The patients receiving magnesium/potassium supplements showed a decrease of 17% in frequency of PVCs but no improvement in symptoms.

A 2012 study in a Brazilian journal evaluated magnesium pidolate (MgP) in 60  patients with both PVCs and premature atrial contractions (PACs). The dose of MgP was 3.0 g/day for 30 days, equivalent to 260 mg of Mg elemental.

93% of patients receiving MgP experienced improved symptoms compared to only 13% of patients recieiving placebo. Both PVC and PAC frequency was reduced in those receiving MGP, whereas they increased by 50% in those receiving placebo.

This small study has never been reproduced, and the main results table makes little sense. It would not have been published in a reputable American cardiology journal and cannot be relied on to support magnesium for most patients with benign PVCs or PACs.

Drug or Ablation Treatment of PVCs: Usually Not Needed

A small percentage of my patients require treatment with beta-blockers which reduces the effects of the sympathetic nervous system on the heart. Very rarely, I will use anti-arrhythmic drugs. And every once in a while, very frequent PVCs resulting in cardiomyopathy require an ablation.

However, the vast majority of patients with benign PVCs, in my experience, feel drastically better with a simple non-pharmacological approach consisting of 4 factors:

  • Reassurance that the PVCS are benign
  • Caffeine (or other stimulant) reduction
  • Lifestyle adjustment with regular aerobic exercise
  • Increased potassium intake to keep K >4

Ectopically Yours

-ACP

 

 

 

Beware The Bitter Almond

As part of the Health Nuts Project, the skeptical cardiologist has been evaluating walnuts, hazelnuts and almonds which he plans to put in packets and distribute to patients and readers.

Previously, we discovered that most raw almonds from the US have been fumigated with a chemical called propylene oxide and that roasting almonds creates potentially carcinogenic chemicals.

Consequently, after considerable searching, I purchased raw organic almonds from a company called NutsinBulk. These turn out to be from Spain (where pasteurization of almonds is not required) and are quite tasty.

As I was munching on one of these almonds I suddenly noticed an incredibly bitter taste causing me to spit the chewed almond out. My first thought was that this almond had gone “bad” in some way. Perhaps a mold had crept into it. Looking at the pieces I had spit out, however, I could see no discoloration or other visible difference from the “normal” almonds.

Subsequent experimentation has revealed that about one in ten of these almonds is incredibly bitter and there is no way to predict this from  the external appearance of the almond.

The Source of Bitter Almonds

The sweet almond  that we are used to eating in the US is produced from one type of almond tree (Prunus amygdalus var. dulcis) and does not contain poisonous chemicals. However, the bitter almond that I encountered comes from a different type of almond tree (Prunus amygdalus var. amara).

Prunus amara trees were likely the original almond trees but over time the sweet almond trees have been selected for and now dominate. According to the LA Times and Paul Schrade, who provides bitter almonds to restaurants:

Until recent decades, most Mediterranean almond orchards were grown from seed, and the shuffling of genes resulted in a mix of bitter almond trees among the sweet. Growers liked to keep a few bitter trees around because they helped to pollinize the sweet varieties. The inclusion of bitter nuts gave snackers occasional unpleasant surprises, but they deepened the flavor of marzipan, almond milk and glazes for cakes. In Italy, bitter almond paste was traditionally used to make crisp amaretti cookies, and bitter almond extract flavored amaretto liqueur. In Greece, bitter almonds are used in soumada, a sweet syrup. (apparently cooking or adding alcohol eliminates the toxic cyanide)

There’s little large-scale cultivation of bitter almonds left in Spain and Italy, mostly just scattered trees remain, but it is still possible to buy raw bitter almonds at European specialty markets. Morocco and Iran now lead in commercial production of bitter almonds.

What Makes The Almonds Bitter: Amygdalin

The source of the bitterness is amygdalin:

A recessive gene causes bitter almond trees to produce in their shoots, leaves and kernels a toxic compound called amygdalin, which serves as a chemical defense against being eaten. When amygdalin is moistened, it splits into edible benzaldehyde, which provides an intense almond aroma and flavor, and deadly hydrocyanic acid, a fast-acting inhibitor of the respiratory system.

A variety of sources confirm that:

The lethal dose of raw bitter almonds depends on the size of the nuts, their concentration of amygdalin and the consumer’s sensitivity. But scientists estimate that a 150-pound adult might die from eating between 10 and 70 raw nuts, and a child from ingesting just a few.

YIKES!!!When I read this I was shocked. Could it be that consuming 10 of these raw  biter almonds would kill me.? How could I distribute these potentially lethal edibles to my patients?

Amygdalin (Laetrile) , Alternative Cancer Therapy and Quackery

In addition to bitter almonds, significant amounts of amygdalin are found in the stone fruit kernels of apricots, peaches and plums. A synthetic form of amygdalin called Laetrile achieved great notoriety in the 1980s as a cancer treatment. Although research had shown the chemical to be ineffective, it was embraced by “alternative” healers who claimed it was a “natural” cure for cancer which was being suppressed by a conspiracy between the US FDA, big pharma, and the the medical community.

Steve McQueen, suffering from pleural mesothelioma sought the care of a delisted American holistic orthodontist practicing in Mexico, William Kelley. The NY Times reported:

In July 1980, McQueen secretly traveled to Rosarita Beach, Mexico, to be treated by Mexican and American doctors using Dr. Kelley’s regimen. He received not only pancreatic enzymes but 50 daily vitamins and minerals, massages, prayer sessions, psychotherapy, coffee enemas and injections of a cell preparation made from sheep and cattle fetuses. McQueen was also given laetrile, a controversial alternative treatment made from apricot pits.

Although we hear little about Laetrile these days, like most snake oil it is still promoted by alternative medicine. For example, The notorious quack Dr. Mercola still promotes the idea that laetrile is a safe and effective treatment of cancer on his web site with a post that has been viewed over 700,000 times.

You Can Die From Eating Bitter Almonds

Certainly, there is considerable evidence that Laetrile can be toxic or lethal but bitter almonds can also cause lethal cyanide poisoning. A case report describes a woman with colon cancer who turned down potentially curative surgery/chemotherapy and turned to alternative treatments including Laetrile.  A helpful friend gave her a bag of bitter almonds for their “medicinal properties”, whereupon the woman consumed a slurry composed of 12 ground up almonds with water. Within 30 minutes she developed  severe cyanide poisoning with vomiting, abdominal pain, pulmonary edema, severe lactic acidosis and  loss of  consciousness.
Analysis of the bitter almonds showed they contained on average 6.2 mg of cyanide per almond. It is estimated that a lethal dosage of cyanide is 50 mg or 0.5 mg per kg body weight, thus the calculation that 10 almonds could kill someone weighing  60 kg or 132 pounds.
My  Search For Healthy Almonds Continues
The small amount of cyanide one gets from consuming a single bitter almond seems to have little effect. (Although the Mediterranean diet nutritionist Conner Middelman-Whitney , who spent time in Europe and encountered bitter almonds occasionally says that she does remember a weird, numb sensation in the mouth when they were consumed.)  It’s extremely unlikely that one of my patients would consume 10 of the bitter almonds (without reflexively spitting them out as I did) in a short period of time.
When I have consumed them I noticed no adverse effects but after such an encounter I stopped eating the almonds for the day.
However, I’m not interested in testing that theory. (Ability to taste amygdalin or smell cyanide varies between individuals, thus I can’t be certain that the bitter taste would serve as a reliable warning.)
Therefore,  I’ve concluded that I’m not going to distribute these potentially lethal almonds to my patients and will be removing them from the Dr. Pearson Health Nuts Packages.
My search for non-fumigated, non-cyanide-laced , non-carcinogenic almonds continues!
Cyanogenically Yours,
-ACP
N.B. Famous deaths from cyanide poisoning include Hitler and Alan Turing.

 

 

Saguaro National Park: Hidden Gem Among The National Treasures

There are 56 National Parks (NPs) in the  U.S. and prior to last week, the skeptical cardiologist had visited 13 of them,  none of which were plant-based. Only 4 NPs as far as I can tell are created specifically to preserve a plant species. Three of them are in California, two of which are concerned with really large redwood trees. I haven’t visited Sequoia  or Redwood National Park in California but I’ve been to Muir Woods National Monument north of San Francisco and apparently (per the eternal fiancee’) I wasn’t suitably impressed by the immensity of the coastal redwoods (Sequoia Sempervirens) that grow in their enormity there. Perhaps if I had seen the giant sequoias (Sequoiadendron Giganteum) which grow on the western slopes of the Sierra Nevada mountains my jaw would still be dropped.

The skeptical cardiologist is more impressed by the intrinsic beauty, joshua-treecolors, and complexity of the shapes and textures of the branches and leaves of trees rather than their giganticness. I am enthralled just watching trees blown by the winds.

The third  California plant-based NP is based on an odd looking but not terribly tall tree called the Joshua Tree which grows in the Mojave desert in Southern California.

I’ve always wanted to visit Joshua Tree  National Park because one grand_theft_parsons-3472of my musical heroes, Gram Parsons, died from a morphine overdose in room 8 of the Joshua Tree Inn near there. After he died, his body was stolen at Los Angeles International  airport by his  road manager and his assistant and taken to the Nationa Park and set on fire. There is an interesting (if you are a Gram Parsons fan) movie entitled Grand Theft Parsons based on this adventure.

The only non-California plant-based NP is Saguaro (pronounced sa wah roo)  NP (SNP) unknownwhich exists on either side of Tucson, Arizona. Since no famous rock stars were cremated in SNP and no best-selling albums by U2 feature the saguaro cactus on the cover, the park remains relatively unknown.

 

However, after hiking at SNP last week I can attest to the dscn0252photogenicity of the saguaro,  the largest cactus in the U.S. and the beauty of the Sonoran desert, the only location where they grow. The saguaro (Carnegiae Gigantea)  reaches sixty feet in height and can live for 200 years. They only sprout arms when they are 50-75 years old.

Since my kids became old enough to appreciate hiking and nature I have tried to focus family vacations on visits to National parks. I can’t think of any more valuable experience for them than hiking in some of the most beautiful places on earth and experiencing diverse and fascinating flora and fauna.  And all of this comes at a ridiculously low price for the user.

For example, because I’m 62 years old I qualify for a Lifetime senior pass to all National parks and monuments. Cost? 10$!!!! I’m finally seeing the perquisites of becoming a senior citizen.

Since the National Park Service was created in 1916 it has grown to protect 88 million acres, 43,000 miles of shoreline, 85,000 miles of rivers and streams, 12,000 miles of trail and 8,500 miles of road in more than 400 national parks, sites and monuments.

I sure hope the vision of prior Presidents, Congressman and ardent conservationists (all praise be to Teddy Roosevelt!) who established the federal system that protects these national treasures continues.

Gigantically Yours,

-ACP

 

How To Spot a Quack Health Site: Red Flag #1, Primary Goal Is Selling Supplements

During the process of compiling the Cardiology Quackery Hall of Shame, the skeptical cardiologist has recognized that the #1 red flag of quackery is the constant promotion of useless supplements.

Such supplements typically:

-consist of “natural” ingredients

-are a proprietary blend of ingredients or a uniquely prepared single ingredient, and are only available through the quack

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And you thought Vital Red referred to Putin! *Individual results will vary according to the strength of the placebo effect

-have thousands of individuals who have had dramatic improvement on the supplement and enthusiastically record their testimonial to its power

-have no scientific support of efficacy or safety

-despite the lack of scientific data, the quack is able to list a series of seemingly valid supportive “studies”

-aren’t checked by the FDA

-apparently cure everything from heart disease to lassitude

I received an email today purportedly from a reader complimenting me on my post on the lack of science behind Dr. Esselstyn’s plant-based diet. The writer thought I would be interested in the work of a Dr. Gundry.

I clicked on the one of the numerous links that were provided andscreen-shot-2017-01-15-at-10-59-10-am based on the appearance of the home page of Dr. Gundry’s website, I feel confident that he is a quack.

Yes, there it is. Red Flag #1: an immediate and aggressive attempt to sell lots of useless supplements.

I didn’t spend a lot of time perusing Gundry’s website, but I read enough to enter him into my contest for America’s Greatest Quack Cardiologist.

Sadly, Dr. Gundry used to be a well-respected cardiac surgeon.screen-shot-2017-01-15-at-11-12-06-am (what is it about cardiac surgery that makes so many turn to quackery?)

Gundry’s life story is typical of the physician who has given up actually helping patients with real medicine and resorted to shilling untested snake oil to gullible people.

“I left my former position at California’s Loma Linda University Medical Center, and founded The Center for Restorative Medicine. I have spent the last 14 years studying the human microbiome – and developing the principles of Holobiotics that have since changed the lives of countless men and women.”

Need I mention that “holobiotics” is (?are) not real.

If any readers have more candidates to nominate for the soon-to-be-announced honor of America’s #1 Quack Cardiologist please forward their names to me.

Bonohibotically Yours,

-ACP

After writing this, I googled “red flag of quackery” images in the foolish hope that I might find a useable image. Lo and behold the image I featured in this post turned up courtesy of sci-ence.org. Here it is in all its glory, courtesy of Maki

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Female Frenchmen Flagrantly Flock To Franklin

Traffic on The Skeptical Cardiologist doubled from 2015 to 2016 despite a significant drop in output in the middle of the year. WordPress provides  its bloggers with statistics on visits and views that are disturbingly  addictive.  For example, people from 160 different countries viewed my blog in 2016 including one from Reunion,  a country with which I was totally unfamiliar. See if you can spot it in this map of EU Oversease Countries and Territories.

eu_oct_and_omr_map_en

After reading  about this tropical island in the Indian Ocean, I’m pondering flying there to frolic on its unique beaches and search for the one Reunion inhabitant who clicked on my blog.

I suspect this Reunionista was directed to my site as were hundreds of Frenchmen (although potentially sexist, the term is gender neutral) one day  in November by this link to my post on examining the heart of Franklin Delano Roosevelt.

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I have no idea why but if any of my French speaking/reading readers cares to enlighten me I will be eternally grateful. And if any female Frenchmen read this let me know if Samuel Johnson was correct when he said  “A Frenchman must be always talking, whether he knows anything of the matter or not; an Englishman is content to say nothing when he has nothing to say.”

Bonsoir

-ACP

What Can America Learn From Australian Gun Laws?

In April of 1996, a 28-year old man murdered 35 people in Tasmania primarily utilizing a Colt AR-15 rifle (a lightweight, 5.56×45mm, magazine-fed, air-cooled semi-automatic rifle with a rotating bolt and a direct impingement gas-operation system.)

This event led to public outcry in Australia and  bipartisan passage of a comprehensive set of gun regulation laws (the National Firearms Agreement (NFA)).

In the 20 years since the law was put into place (1997-2016), there has not been a single fatal mass shooting in Australia.

In the 17 years prior to the NFA enactment 13 mass fatal shootings (defined as ≥5 victims, not including the perpetrator) occurred in Australia.

An analysis of this process was recently published in JAMA.

Australia’s 1996 NFA mandated:

  • the ban and buy-back of semiautomatic long guns.
  • licensing of all firearm owners and registration of firearms.
  • that  persons seeking firearm licenses  must document a “genuine need,” have no convictions for violent crimes within the past 5 years, have no restraining orders for violence, demonstrate good moral character, and pass a gun safety test.
  •  uniform standards for securing firearms to prevent theft or misuse, record-keeping for fire arms transfers, purchase permits, and minimum waiting periods of 28 days.
 I agree with the comments in an accompanying editorial written by Daniel Webster of the John Hopkins School of Public Health, Center for Gun Policy and Research(:gun-regulation.)

Research evidence should inform the way forward to advance the most effective policies to reduce violence. However, research alone will not be enough. Australian citizens, professional organizations, and academic researchers all played productive roles in developing and promoting evidence-informed policies and demanding that their lawmakers adopt measures to prevent the loss of life and terror of gun violence. Citizens in the United States should follow their lead.

-ACP

N.B. Of the 46 mass shooting since 2004, 14 featured assault rifles, including Newtown, Aurora, Orlando and San Bernardino. Apparently there are 10 million AR-15 type rifles in private hands in the USA and as Vox has pointed out

“the AR-15 is caught in a cycle. The more it’s used in high-profile mass shooting cases, the more people want to ban it. The more people want to ban it, the more AR-15s are sold. And the more AR-15s are sold, the harder it becomes to create a ban that would be able to stop the next tragedy.”

For more on assault-style rifles you can view this Washington Post video created after the Orlando shootings.
//www.washingtonpost.com/video/c/embed/28d02e8e-3118-11e6-ab9d-1da2b0f24f93

Cigarette Smoking Kills: Should Missourians Vote Yes To Raise Cigarette Taxes?

Recent statistics show that cigarette smoking is  responsible for 167, 133 cancer deaths annually in the US or 29% of all cancer deaths.

Cigarette smoking also kills annually in the US  160,000 people by promoting cardiovascular disease.

Thus, from a health standpoint we should be doing everything possible to stigmatize and make more difficult cigarette smoking.

One approach to this is to tax cigarettes, raising the financial burden of smoking. Across the US, therefore, states have added cigarettes taxes which average 1.65$ per pack.

My state of Missouri has the lowest state tax on cigarettes of 17 cents per pack. Multiple ballot attempts to raise this amount have failed in the past.

However, on this Tuesday’s ballot there are two competing options that we can  vote on that will raise cigarette taxes: Amendment 3 (raises cig taxes  60 cents and earmarks funds for a newly created Early Childhood Education and Research Fund) and Proposition A (raises taxes 23 cents and earmarks funds for infrastructure.) (Links are to Ballotpedia, a reputable source of information nationwide.)

I’ve been researching both of these proposals over the last few days since receiving an email from a physician colleague urging  me to vote no on Amendment 3. Remarkably, a coalition of health organizations (The American Cancer Society Cancer Action NetworkAmerican Heart AssociationAmerican Lung Association in MissouriCampaign for Tobacco-Free KidsHealth Care Foundation of Greater Kansas City and Tobacco-Free Missouri) has come out against the propositions to raise cigarette taxes with the following statement :

Small increases to the tobacco tax – like the proposals being considered – will generate new revenue, but will not keep kids from becoming addicted to cigarettes or help adults quit.Tobacco taxes work when the price increase is substantial enough to motivate current smokers to quit and prevent kids from starting. A dime here or there is not sufficient. Tobacco companies are adept at finding ways to absorb small tax increases through adjusted pricing. What’s worse, these marginal increases could hamper future efforts; promising profitable returns for the tobacco industry at the continued expense of Missourians’ health…

Tobacco products in Missouri are too cheap and the health costs are too high. Our state is long overdue for a tobacco tax increase, but it needs to be one that will make a difference and save lives. A meaningful tobacco tax increase – of $1.00 per pack or more – has proven time and again to be an effective way to reduce tobacco use, cut healthcare costs and generate state revenue.[7]

Our local public radio station had a good discussion recently which is summarized here.

I found the PRO comments of Jane Dueker particularly persuasive as summarized below:

PRO: Jane Dueker wants people to vote “Yes” on Constitutional Amendment 3. Here are her main points:

Jane Dueker is a proponent of Constitutional Amendment 3.
CREDIT KELLY MOFFITT | ST. LOUIS PUBLIC RADIO
  • This tax would provide $300 million in funding for early childhood education, healthcare and smoking cessation programs. Right now, Missouri can’t even fund the K-12 Foundation Formula, so any extra funding is needed for early childhood education.

  • By filing this as an amendment, we were able to make a constitutional “lock box” that would keep the legislature and special interests from taking money that is specifically dedicated to this fund, like what happened with lottery funds.

  • Right now, only 3 percent of 4-year-olds in Missouri are in a publicly-funded preschool. Missouri is behind states like Oklahoma with 76 percent, Illinois with 27 percent and Arkansas with 38 percent.

  • Higher tobacco taxes have failed in 2002, 2006 and 2012. This is more reasonable and we don’t have a clause that says another tobacco tax could not be added on top of this one to give that “sticker shock” to consumers.

  • This closes a loophole that kept cheap cigarette companies from paying their fair share into a 1998 court settlement to recover some of state governments’ tobacco-related health-care costs. Now, smaller tobacco companies would pay a 67-cents-a-pack hike on low-cost cigarettes in addition to the 60 cent tax on all cigarettes. This would give Missouri $1 billion annually we currently don’t get. Missouri is the only state that hasn’t closed this loophole and the state is a “dumping ground” for the cheapest cigarettes in the country.

  • Groups that oppose this either think the tax is not high enough (health groups) or that they don’t get money from this fund (pro-choice and research institutions).

  • Missouri’s Foundation Formula public school funding starts at kindergarten and cannot fund early childhood education. This money could go to public or private early childhood education entities in a way it would not be distributed through the foundation formula.

  • $15-30 million dollars would be raised through this tax that would go to smoking cessation programs.

  • The fund will be administered by a board of unelected people because they have special experience in early childhood education. A “person of faith” is required on the board because of their position as a community anchor.

At this point, I’m leaning toward voting yes on Amendment 3 but confused as to why RJ Reynolds is supporting it to the tune of 12 million dollars and the “good guy” health organizations oppose it. I’d appreciate any input/comments on this from readers. I strongly urge everyone to read and learn as much as you can about the issue before walking into the voting booth.

By the way, I recently observed this Canadian cigarette package img_7957which I think excellently conveys the horror of cigarette smoking.

Truthily Yours

-ACP

Some more  stats to ponder from the CDC

Cigarette smoking causes premature death:

  • Life expectancy for smokers is at least 10 years shorter than for nonsmokers.
  • Quitting smoking before the age of 40 reduces the risk of dying from smoking-related disease by about 90%.

Exposure to secondhand smoke causes an estimated 41,000 deaths each year among adults in the United States:

  • Secondhand smoke causes 7,333 annual deaths from lung cancer.
  • Secondhand smoke causes 33,951 annual deaths from heart disease.

The Name For The Nuts Poll: Part Deux

The results of my request for reader input on naming the mixed nuts based on the PREDIMED study I plan to give out to my patients are hot off the presses.

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The winner of the pre-specified names was “Pearson’s Health Nuts.”

Second place went to my personal favorite “Dr. P’s Stroke-bustin’ Nuts.

However, readers submitted some suggestions not in the poll:

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And I had one patient bring in her suggestion with a design already created!:

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and one sketch out her suggestion on what appears to be a post-it note:

img_7959
I’ll term this heart (symbol)NUTZ in the poll

Consequently, I’m soliciting your input into a revised poll that incorporates some of the newer suggestions.

There is much excitement here at mixed nut central because the non-fumigated raw almonds have arrived!

Polldaddily Yours

-ACP