BioMed Weekly

How to Find Health Coverage

May 1st, 2013

Courtesy of: The Lancet

by Anton Power

The Affordable Care Act was enacted on March 23, 2010 [1]. The reforms will take effect next year. Until that time, many young folks like myself will forgo insurance coverage, sometimes because of the prohibitive cost of coverage, and sometimes because of a perceived notion that we 20-somethings are invincible. Whatever the reason, going without insurance opens us up to unnecessary risk.

While I am not here to argue over the Affordable Care Act, I recognize that it may be in my interest to inform myself and my readers (especially the young ones) about how to search for coverage. Resources are out there, but they are difficult to understand and somewhat intimidating.

So, I asked myself. If I had no insurance, how could I find the most fair and affordable coverage today?

I did a search:

Underneath the Google Ads, the first search result was the federal HealthCare.gov website. I was attracted by the sub-category link, “Free or Low-Cost Care.”

I clicked on the link and was directed to this page:

Medicaid and CHIP

Obviously, Medicaid and CHIP are available for those who need it. But for someone like me who may be fresh out of college and healthy, I don’t think I qualify. However, just for curiosity’s sake, I’ll check it out.

In most states, folks with disabilities who are also on Social Security Income (SSI) automatically qualify for coverage through Medicaid. However, some states also have what the website calls “buy-ins” for disabled folks with higher incomes. Furthermore, what is defined as low income varies with the state. (Very frustrating and convoluted).

If you are a woman who was diagnosed with breast cancer through the Breast and Cervical Prevention and Treatment (BCPT) Medicaid program, you may be eligible for benefits regardless of income level.

If you are pregnant and have income under $20,000 annually, you receive free coverage. Again, this income level may be higher in your state [2]. (This is very relevant for people my age who are often starting families)

CHIP provides free coverage for children in a family of four with income of up to $45,000 [3].

Community Health Centers

Okay, next

Community Health Centers provide free or near-free primary care to everyone. However, this is obviously not the same as being covered. If a catastrophe occurs when I am uninsured, I may be liable for ALL costs.

Without insurance, using only community health centers, there are a few sparse options in my area for care. First and foremost, the Hill-Burton program [4] requires 170 hospitals in the nation to provide certain free care.

However, as with anything in our health care system, the program requires a 6-step after-the-fact application (that is unless you anticipate getting hit by a bus beforehand, in which case you are more than welcome to apply ahead of time). This application requires know-how that I feel many may not have the time or resources to navigate:

Private Insurance

Finally, the HealthCare.gov website provides a search for private insurance:

If I don’t have care through work, and I can’t first find state or federal programs which fit my need, I am left with purchasing my own private insurance to at least cover myself in case of an emergency.

For a novice insurance customer with no health problems, I am stunned that the first result that comes up in the search has a monthly fee of $154.00. The maximum out of pocket expenses I may be footing annually is $11,900.00. To put things into perspective, a college graduate may not have any savings at all to rely on. This is very expensive for a young person on a budget:

Don’t be fooled to think that this is the cheapest option for an individual plan. After playing around with the sort function at the top, I found a base rate of $124.00 with an out of pocket maximum of $6,000, under the “Estimate Month Base Rate Low-High” option. This is still expensive, but certainly more manageable.

A little digging finds that it is certainly possible for young folks like me to find health coverage that is workable. However, educating oneself on the subject may be difficult when you live on a month-to-month basis. American health care leaves some with many options, but perhaps the options convoluted understanding. Maybe eliminating confusion about health insurance will go a long way to get people in this country safe, healthy, and prepared.

Hippocrates Refusing the Gifts of Artaxerxes I (1792) by Anne Louis Girodet de Roucy-Trioson. Courtesy of: The Lancet

References

[1] Affordable care act tax provisions. (2013, April 30). Retrieved from http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions

[2] Medicaid. (n.d.). Retrieved from http://www.healthcare.gov/using-insurance/low-cost-care/medicaid/index.html

[3]CHIP. (n.d.). Retrieved from http://www.healthcare.gov/using-insurance/low-cost-care/childrens-insurance-program/index.html

[4]Hill-Burton Free and Reduced-Cost Health Care. (n.d.). Retrieved from http://www.hrsa.gov/gethealthcare/affordable/hillburton/index.html

The Debate over Medical Education

April 23rd, 2013

The closer I come to Orientation day at the University of New England College of Osteopathic Medicine, the more worried I become about… you guessed it, money.

Medical education is expensive. Let me stress this again, medical education is VERY expensive. Granted that many public medical schools do provide some funding for their in-state students, many like myself have to bear the weight of high tuition. It’s not necessarily a deterrent to pursuing medicine as a career (I’ve dreamed about this since I was a child), but graduating with a mortgage-size loan without a roof over my head is not a pleasant though.

As our nation debates over funding issues, new studies are beginning to support what most rational folks already asserted. High debt forces many medical students to seek higher paying specialties [1]. This fear causes the production of twice as many specialty physicians as primary care physicians [2].

The issues are complicated, but I believe that the solution is staring us in the face. As a nation, we cannot continue to ignore the importance of primary care. Health is about maintenance, not necessarily intervention. More incentives are needed for students interested in IM, Peds, Ob-Gyn, and FP.

Since there is so much information that is already concisely presented by professional authors, I will link to their articles directly:

[1] “Health Policy Brief: Graduate Medical Education,” Health Affairs, August 16, 2012.

I found the above article on MedScape, as well.

[2] Grayson, M. S., Newton, D. A. and Thompson, L. F. (2012), Payback time: the associations of debt and income with medical student career choice. Medical Education, 46: 983–991. doi: 10.1111/j.1365-2923.2012.04340.x

I also found article 2 here on MedScape.

Fun Learning Tool

April 15th, 2013

I thought this was an interesting little online application developed by the American Osteopathic Association (AOA) to disseminate information about Osteopathic medicine and physicians. I subscribe to the AOA newsletters and view their articles on The DO fairly frequently. April 15-20 is the National Osteopathic Medicine (NOM) Week, so it’s appropriate for me to help spread the word about my future profession. Who in our nation wouldn’t benefit from knowing that there are, in fact, two routes for medical education and licensing. Does it matter much to a patient? Is there any real difference between the two licensing bodies, considering that they must both adhere to the same moral and legal obligations? Perhaps not, but this information should be common knowledge. It’s unfortunate that it is not.

Since I am moonlighting as an SAT II and AP teacher, many of my friends and acquaintances are full time teachers. I hope to direct them to these fun resources throughout the entire week. Click on the image below to be redirected to a micro-site developed by the AOA for their annual NOM Week event. I’ve also included their lesson plan HERE that goes along with the interactive class:

The Cycle of Violence in Our Homes

April 11th, 2013

by Anton Power

When my father was growing up in New York City in the 1960’s and 70’s, he once told me that spousal abuse was so prevalent in neighborhoods all over Queens, that it was considered the norm. When he told me that, I remember thinking, ‘how can someone do that to a family member they love?’ Crime went unpunished in those days, and women suffered for it for generations. Times have changed, and our society no longer ignores the plight of women in a violent wedlock.

Most spousal abuse is categorized under an umbrella term, Intimate Partner Violence (IPV). However, the dynamic between married and non-married couples is certainly different. This leads us to question why spousal violence is often termed categorically for both married and non-married couples. What factors create a violent domestic atmosphere? If violence today is no longer seen as acceptable, why does spousal abuse still occur? Furthermore, does abusive behavior have a cure?

As with anything, the answers are always complicated. Certainly socioeconomic factors play a strong role in spousal violence. Alcohol and drug abuse, and the inability to maintain a long term employment are all major risk factors of IPV (Kuriacou, 1999). Hispanic and African American groups are at greatest risk of being uninsured (Fronstin, 2010). Extrapolating from this information and making the assumption that uninsured populations are often at lower socioeconomic statuses in the United States, we can assert that these groups are also at highest risk of domestic violence. However, controlling for alcohol abuse, and socioeconomic factors shows that only African American populations were still reporting higher incidence of spousal violence (Neff, 1995). Furthermore, when controlling for approval of violence, age, and economic factors in Hispanic populations, their rate of spousal abuse was the same as anglo-saxon populations (Kantor, 1994). All of this evidence can be summarized as follows; although spousal violence can be attributed in part to some common risk factors such as family finance and substance abuse, there are clearly more complicated factors involved.

To many in the United States, marriage is a cultural norm that dictates certain perceived assumptions about the roles of spouses. Individual financial obligations are now joint, responsibility is also diffused. However, in terms of the study of spousal abuse, financial and cultural norms have very little to do with violence as we have previously mentioned.

In other words, with respect to spousal violence between married and unmarried couples, there is little difference in cause. Simply living in the same community ties two people together socially and financially. Even when abuse occurs between unmarried couples, family ties and ties to the community, do not allow the abused woman to simply pack up her bags and leave town. In the same way, simply being married does not prevent the wife from leaving the house.

The most common characteristic similarities between abusers in the IPV category is being the recipient of abuse as a child (Ireland, 2009), and witnessing spousal abuse as a child (Rosenbaum, 1981). These are the factors that the current understanding of spousal violence identifies in abusers, when all other factors are equal.

Interestingly, violent behavior and the risk factors presented above are indicators of Borderline Personality Disorder (BPD), which is defined as “emotional dysregulation, impulsive aggression, repeated self-injury, and chronic suicidal tendencies,” caused by both genetic factors and averse childhood experiences (Lieb, 2004) (Waltz, 2003). Not all people with BPD have suicidal thoughts, and not all may be abusers, however the clinical signs are definitely characteristic of the disorder.

What this means is these are fairly well understood behavioral issues, and there are fairly well established treatment options for abusers. Criminalization, although justified, does not go far enough to solve the underlying error in behavior. As we all know, any person with behavioral issues who is incarcerated will then be released and simply repeat the act if not first given the skills and knowledge to cease the abusive cycle.

Beyond incarceration, two treatments which have been shown to be efficacious with decreased recidivism are Group Therapy, and Social Skills Training (part of the Dialectical Behavioral Therapy protocol). The purpose of this type of therapy is to understand patients’ behavioral disorders, and learn coping skills such as role-playing rehearsals, instruction on behavior, and feedback from peers (Waltz, 2003) (Palmer, 1992) (Frederiksen, 1976). Concomitant medication and one on one therapy will help stifle the cyclical abusive behavior (Blum, 2008). Improving socioeconomic factors for Americans will also go a step further to relieve pressure on already at risk abusers. Finally, by identifying child abuse as a risk factor of spousal abuse later in life will ultimately help prevent the ongoing abuses which are continued through generation from one father to the next.

Essay submitted for the Charles R. Ullman & Associates scholarship competition, 2013, www.divorcelawnc.com

References

[1]Kyriacou, D.N., et al. (1999) Risk Factors for Injury to Women from Domestic Violence. The New England Journal of Medicine, 341, 1892-1898. DOI: 10.1056/NEJM199912163412505

http://www.nejm.org/doi/full/10.1056/NEJM199912163412505

[2] Fronstin, Paul, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2010 Current Population Survey (September 1, 2010). EBRI Issue Brief, No. 347, September 2010. Available at SSRN: http://ssrn.com/abstract=1682249

[3]Neff, J.A., Holamon, B., Schluter, T.D. (1995) Spousal violence among Anglos, Blacks, and Mexican Americans; The role of demographic variables, psychosocial predictors, and alcohol consumption. Journal of Family Violence, 10(1), 1-21.

http://link.springer.com/article/10.1007/BF02110534#page-1

[4]Kantor, G.K., Jasinski, J.L., Aldarondo,E. (1994) Sociocultural Status and Incidence of Marital Violence in Hispanic Families. Violence and Victims, 9(3), 207-222.

[5]Ireland, T.O., Smith, C.A. (2009) Living in Partner-violent Families: Developmental Links to Antisocial Behavior and Relationship Violence. Journal of Youth and Adolescence, 38(3), 323-339.

http://link.springer.com/article/10.1007/s10964-008-9347-y

[6] Rosenbaum, A., O’Leary, K.D. (1981) Marital Violence: Characteristics of Abusive Couples. Journal of Consulting and Clinical Psychology, 49(1), 63-71. http://www.eric.ed.gov/ERICWebPortal/search/detailmini.jsp?_nfpb=true&_&ERICExtSearch_SearchValue_0=EJ241995&ERICExtSearch_SearchType_0=no&accno=EJ241995

[7]Lieb, K., et al. (2004) Borderline personality disorder. The Lancet, 364 (9432), 453-461.

http://www.sciencedirect.com/science/article/pii/S0140673604167706

[8]Waltz, J. (2003) Dialectical Behavior Therapy in the Treatment of Abusive Behavior. Journal of Aggression, Maltreatment & Trauma, 7(1-2), 75-103. DOI: 10.1300/J146v07n01_05

http://www.tandfonline.com/doi/abs/10.1300/J146v07n01_05

[9]Palmer, S.E., Brown, R.A., Barrera, M.E. (1992) Group Treatment Program for Abusive Husbands: Long-Term Evaluation. American Journal of Orthopsychiatry, 62(2), 276-283. DOI: 10.1037/h0079336 http://onlinelibrary.wiley.com/doi/10.1037/h0079336/abstract

[10]Frederiksen, L.W., Jenkins, J.O., Foy, D.W., Eisler, R.M. (1976) Social-Skills Training to Modify Abusive Verbal Outbursts in Adults. Journal of Applied Behavior Analysis, 9(2), 117-125. DOI: 10.1901/jaba.1976.9-117

http://onlinelibrary.wiley.com/doi/10.1901/jaba.1976.9-117/abstract

[11] Blum, J. (n.d.). (2008). Retrieved from http://www.nimh.nih.gov/science-news/2008/group-therapy-program-offers-meaningful-gains-for-people-with-borderline-personality-disorder.shtml

Data: Oy!

February 27th, 2013

by Anton Power

Conducting research in a clinical environment can be frustrating. Case Report Forms are designed by perfectionist researchers in order to gather every piece of relevant data that is possible. They are designed to anticipate most questions from company executives, regulators (like the FDA), future employees who are less familiar with the research than the original designers, and so on. In other words, we play the long game.

With that said, it continues to amaze me how many incomplete forms I have seen coming from trial sites. No matter, researchers have an ace up their sleeve to deal with these sorts of issues. They are called Queries.

Here’s how they work; every mistake that is identified will then require a Query which subsequently requires the investigator’s clarification and signature. All that skimming, and you end up with more work. But I digress.

I’m sure that once I’m on the other side of this flurry of emails and snail-mail, I may understand.

Questionable Data:

- Is the value a 0 or a 6? Please write legibly.

- Is it really that difficult to measure a patient’s circumference three times? The protocol called for triplicates. The researchers specifically left space for that third measurement, not an N/A. It is not N/A unless the investigator suddenly loses the function of his/her arms and can’t wrap the measuring tape around the patient’s waist that last time.

- If something out of the ordinary occurs, record it!

Hypothetically: A patient is told to stand in place with a textbook on their head. If at 3 minutes after the experiment starts, the book begins to shake, record it! Don’t just record, “Book fell at 5 minutes.” That doesn’t tell the whole story (and may require one of those pesky Queries). How did it fall (a bird landed on the patient’s head, a gust of wind from the open window, fatigue)? Where did it fall (direction may indicate asymmetry)? Finally, let’s not forget replicates!

- Refrain from qualitative analogies that cannot be interpreted by others.

Case in Point: What the hell is a “Caramel Macchiato” mole?! Is it symmetric? Does the color vary? I don’t know, but I’m sure I’ll get the gist next time I go to Starbucks! I’m glad it doesn’t look like my Matcha Latte…

- Finally, if a questionnaire instructs to pick ONE out of five choices, please don’t pick two or anything in between.

On a More Serious Note

The most talked about, and most important, issues that affect clinical trial research are small sample size, problems with designing a proper control, and the duration of trial follow-ups are often shorter than ideal.

Sample size limits the statistical power of an experiment, and thus its reproducibility. Often the greatest barrier to producing good clinical data is cost (the more study participants, the more the research sponsors have to pay for equipment and time). Another prominent contributor to small sample size is finding enough patients willing to participate. The latter issue is especially relevant for studies on rare diseases/disorders, and when risk to a patient is too great.

Unfortunately, this often leads to the discovery of side effects after a drug or device is approved. If sample size is small, the rare occurrences are overlooked. However, even if sample size is greater than recommended, these side effects may still not present in your sample population.

Developing proper controls for a trial is tricky and depends on what the sponsor wishes to study. A common question often arises over how to develop a control for an experiment that requires the patient to be aware of who is being treated? You can’t fake an operation. If the sponsor or regulator requires quantitative data, this is not necessarily a problem. However, how do you control for qualitative measurements like feelings and opinions?

Finally, the duration of a trial and follow-ups is not simply an issue of money. The longer the experiment, the greater the chance a patient will stop participating, or simply fall outside of the established eligibility criteria, and miss appointments. These issues cannot always be anticipated. What one week looks like excellent, consistent trial, may become a nightmare to coordinate next week.

Despite the sarcastic tone in the beginning of this article, these three issues are continuously being addressed as new trials begin and old ones are reassessed. That’s the nature of research; answers often lead to more questions.

Lead, Blood, and Aggression

February 13th, 2013

Peter Paul Rubens (1577-1640)

by Anton Power

The fall of the Roman Empire, so they say, was caused not by the Barbarian tribes that sacked its sacred city, but by Plumbum (Lead). [1] Wine brewed in Lead pots and water carried by Lead pipes and sinks, was preferentially drunk by the Roman aristocracy possibly causing severe mental impairment and increased aggressive behavior.

We’ve all heard the story of lost Arctic sailors who, from desperation, consumed food from rusted cans. They were found on the ice, years later, sitting prone in the snow without blankets to keep themselves warm. They just sat and died; Thus the legacy of lead.

I even remember myself as a child in quaint sub-urban Russia building a small fire to melt our lead fishing weights inside matchboxes. We thought nothing of it.

With that said, Lead poisoning has been well known throughout the western world for millennia. And although America has moved away from unsafe industrial practices, and longevity generally improved over the last century, studies again and again have shown that children (the most vulnerable group) are still at risk from toxic exposure.

How much lead exposure have children had historically?

Since the 1970’s when Lead use became well regulated by the government, the mean Blood Lead Level (BLL) has decreased in children from birth to five years of age from 15-18ug/dL in 1970 to 2-3ug/dL in 1994. [2] It is even lower today on average of about 2ug/dL. [3] The threshold for which Blood Lead Levels in children are considered worrisome is 10ug/dL, while BLL of more than 70ug/dL are considered extremely high. [4][5]

With that said, before the 1970’s, lead was commonly used in household paint, gasoline, and not regulated in fumes from factories. So, it can be assumed that adults who were children pre-1970 or so had much higher BLL.

What are the negative effects of lead poisoning at different levels? Why is this important?

Since children are still developing, Lead toxicity harms them most. Toxic exposure at an early age directly affects cognitive ability during adulthood. In children, the most at-risk group is age 2 with a average BLL of 10ug/dL, and lowest at age 10 with a average BLL of 3ug/dL. [6] This is likely due to increased time spent in tactile contact with the ground, among other factors.

When a full-scale IQ test is used to quantify cognitive ability, children with BLL between 5.0-9.9ug/dL had IQ scores 4.9 points lower than children with BLL levels below 5.0ug/dL. There is also a strong correlation between IQ scores during adulthood and IQ scores between 57 months and 10 years of age. [6] Thus, lead exposure can have a direct effect on the cognitive ability of a person in the long-term.

Furthermore, non-acute lead toxicity has been directly associated with increased crime rates and decreased High School Graduation rate (a factor the researchers of the cohort US study decided was quantifiable and meaningful). 68% of children currently graduate from High School on time, with a mean BLL of 2ug/dL during early childhood. If BLL were below 1ug/dL for every child, an projected 91% of children would graduate on time.[3]

What is considered a safe level of Lead exposure?

In fact, there is no “safe” level of Lead exposure. Comparison between the normal population and children and adults who have been exposed to higher levels of Lead shows a strong quantitative link between exposure and mental capacity, even after taking confounding factors into consideration. The steepest negative slope for IQ related scores was found between 1-10ug/dL (the higher the BLL, the lower the IQ), which is well within the tolerance level which is considered safe by the government today. However, a more gradual slope was observed below 1ug/dL. [3]

The main source of Lead in the United States is from smelters and battery manufacturers. So, geographical proximity to these industries increases risk. However, even moving away from contaminated soil regions and factories does not completely reduce the risk of cognitive impairment. Lead has been known to become sequestered in bone, thus prolonging exposure to the metal. This is because after exposure, there is a 5-19 year half-life for Lead concentration in bone. [7] That is, half of the original amount that was sequestered in the bone structure is removed after this amount of time.

Nationally, the highest risk groups have consistently been families with below poverty-line incomes, and Black non-Hispanics over the past four decades. [8]

How does Lead affect the brain?

Understanding how lead affects learning and behavior is still under investigation. However, one likely mechanism has been proposed. The neuron specific Protein Kinase C (PKC) gamma is activated by Calcium ions (Ca2+) and participates in neurotransmission at the synaptic junctions predominantly in the Cerebellum, Hippocampus, and Cerebral Cortex. An important feature of learning, Neuronal Plasticity, has been observed in these regions. [9]

There are two key features of Neuronal Plasticity:

1) Long Term Potentiation (LTP); increase in enhancement of response to stimuli (speeding up).

2) Long Term Depression (LTD); inactivation of activity in response to stimuli (a slowing down).

Lead has been shown to displace Calcium ions from the PKC activation site, thus disrupting the neurotransmission process which is normally regulated by Calcium.[10]

This is the crux of the issue. Lead affects development and learning. Lower attention span, increased aggression, and thus more crime and less education. If Lead can bring down one of the world’s longest-living civilizations, what chance do we stand?

References

[1] Wilford, J. N. (1983, March 17). Roman empire’s fall is linked with gout and lead poisoning. New York Times. Retrieved from http://www.nytimes.com/1983/03/17/us/roman-empire-s-fall-is-linked-with-gout-and-lead-poisoning.html

[2]Nicolescu, R., Petcu, C., Cordeanu, A., Fabritius, K., Schlumpf, M., Krebs, R., Krämer, U., & Winneke, G. (2010). Environmental exposure to lead, but not other neurotoxic metals, relates to core elements of ADHD in Romanian children: Performance and questionnaire data☆, ☆☆☆Study approval: This study has been reviewed and approved by the Ethics Committee of th Environmental Research, 110 (5), 476-483 DOI: 10.1016/j.envres.2010.04.002

[3]Muennig, P. (2009) The social costs of childhood lead exposure in post-lead regulation era. Arch. Pediatr. Adolesc. Med. 163(9), 844-849. Retrieved from: http://archpedi.jamanetwork.com/article.aspx?articleid=382153

[4]Ryan, J.A., Scheckel, K.G. (2004) Peer reviewed: reducing children’s risk from lead in soil. Environ. Sci. Technol., 38(1), 18A-24A. Retrieved from: http://pubs.acs.org/doi/abs/10.1021/es040337r

[5]Meyer, P.A., Pivetz, T. (2003) Surveillance for elevated blood lead levels among children—united states, 1997—2001. MMWR Surveillance Summaries, 52 (SS10), 1-21. Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5210a1.htm#top

[6]Mazumdar, M., Bellinger, D.C., et al. (2011) Low-level environmental lead exposure in childhood and adult intellectual function: a follow-up study. Environmental Health, 10:24. DOI: 10.1186/1476-069X-10-24 http://www.biomedcentral.com/content/pdf/1476-069X-10-24.pdf

[7]Rabinowitz, M.B. (1991) Toxicokinetics of bone lead. Environ. Health Perspect, 91, 33-37. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1519353/

[8] Concentrations of lead in blood. (2011, December 03). Retrieved from http://yosemite.epa.gov/ochp/ochpweb.nsf/content/blood_lead_levels.htm

[9]Saito, N., Shirai, Y. (2002) Protein kinase c gamma (pkc gamma): function of neuron specific isotype. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/12417016

[10] Bressler, J., Kim, K.A. (1999) Molecular mechanisms of lead neurotoxicity. Neurochem. Res., 24(4), 595-600. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/10227691

Drinking is Healthy

January 26th, 2013

by Anton Power

I find it difficult sometimes explaining to my younger friends and students that I drink alcohol every day. I believe I’ve identified the issue; it’s a matter of perspective. I see alcohol as a relaxing evening, good food, and good times. My friends (the students especially) see clubs, flashing lights, and hangovers. Perhaps it’s an American thing, I’m not an expert. The way I grew up, food and alcohol was synonymous. In the minds of many young people, drinking is a very separate activity from eating.

So, we have laws and restrictions. Death from alcohol poisoning is epidemic in many parts of the world. Like many things, this wonderful, flavorful beverage is seen in the media as a monster. Again, a matter of perspective. Beverages are drunk for the flavor by some and for the escapist effect by others.

An Incomplete Picture

Calorie counting has become a common practice in many developed nations. The focus on obesity once again stifles the wonder and fulfillment of the simple things, the good things, and our pallet (a subject of personal importance).

The BBC recently published an article, fervently warning readers to avoid alcoholic drinks. In this article, the concept of “empty calories” was introduced to make wine and beer drinking seem like vices, thus ignoring the beneficial qualities of various drinks.

Quantifying caloric intake is not the be-all end-all of a well balanced diet. Far from it! Screaming at down from a mountain in regards to how much to drink misses the purpose of drinking in the first place.

So, how much should we have? Some (in moderation) like everything else in life.

To counter some of the misconceptions about alcohol, and to further stress the importance of quality over quantity in regards to alcoholic beverages, I present below some of my findings.

The French Paradox

For several decades, researchers studying Coronary Heart Disease (CHD) in developed nations saw a paradoxical trend in relation to food consumption in some regions of France that seemed counter to reports in every other geographical region. Although residents of France consumed, on average, the same amount of saturated fats as the rest of the world, study subjects who consumed the daily average alcohol level of 20-30 grams of wine a day had a decreased risk of CHD by 40%. [1]

This effect was most pronounced in red wine drinkers. In fact, when over 13,000 men and 11,000 women were monitored for the type of alcohol consumed (controlling for education level, and smoking status), a strong relationship was discovered between choice of alcoholic beverage and risk of CHD. While heavy drinkers who avoided wine were at an increased risk of all causes of death (p=0.007), drinkers who regularly consumed wine had lower mortality related to CHD and cancer than their non-wine drinking counterparts (p=0.004). [2]

This study did not compare drinkers to non-drinkers to identify if risk was still lower relative to non-drinkers. However, other studies have been conducted to answer this question. A study examining 75 previous studies conducted between 1965 and 1998 in England concluded that 30 grams of alcohol consumed a day increased concentrations of High Density Lipoproteins (HDL) cholesterol by 3.99mg/dL, apoliprotein AI by 8.82mg/dL, and triglycerides by 5.69mg/dL. These biological markers reduced the estimated risk of CHD by 24.7% for every 30 grams of ethanol a day. Furthermore, this downward trend of risk continues to decrease up to about three drinks per day. [3]

Biological markers are corollary trends that are good predictors of certain disease risks. [4]

To recap; heavy alcohol consumption is deleterious to your health (big surprise), however moderate drinking is good. This effect seems even more pronounced with wine.

Why is wine healthy?

Resveratrol (RSV), otherwise known as 3,5,4-trihydroxy-trans-stilbene, is found in highest concentrations in red wine, and to a lesser degree in white wine. [5]

RSV has been shown to have cardioprotective properties as an antioxidant (by decreasing lactate dehydrogenase levels), and a vasodilator by increasing nitric oxide (NO) in blood. [6]

It has also shown promise as a potential treatment for Alzheimer’s disease (AD). AD is onset by the buildup of neuritic plaques (neurofibrillary tangles and amyloid-beta). RSV has anti-amyloidogenic properties preventing the formation of neuritic plaques in the brain. However, due to its low solubility in water and relative instability, developing a potential drug delivery system has been a challenge. Furthermore, controlling how much of the drug reaches the target receptors, and how quickly it clears the system, allow drug makers to make an effective drug.

One novel way of delivering RSV to patients involves the use of nanolipoparticles (NLP) or nanocapsules. These nano-scale, self-assembling structures consist of a lipid bilayer encased in a peptide shell. [7]

Courtesy of: LLNL.gov

In the past, individual drug molecules would float freely and bind ineffectively to target receptors. This is partly an spatial orientation issue. If the drug is not facing an intermembrane or a cytosolic receptor properly, no signaling will occur. NLPs partially circumvent this problem by automatically orienting several drug molecules like Resveratrol in the same direction. This not only makes the drug more effective, but also requires less of the drug molecule to be present in whatever pill or aerosol will be administered to the patient, thus making the production of the drug cheaper.

Alcoholic beverages are not only wonderful adjuncts to an evening meal, but also an excellent source of health when used in moderation.

References

[1]Renaud, S., de Lorgeril, M. (1992) Wine, alcohol, platelets, and the French paradox for coronary heart disease. The Lancet, 8808 (1), 1523-1526. Retrieved from: http://www.sciencedirect.com/science/article/pii/014067369291277F

[2]Gronbaek, M., Becker, U., et al. (2000) Type of alcohol consumed and mortality from all causes, coronary heart disease, and cancer. Annals of Internal Medicine, 133 (6), 411-419. Retrieved from: http://europepmc.org/abstract/MED/10975958

[3]Rimm, E.B., Williams, P. (1999) Moderate alcohol intake and lower risk for coronary heart disease: meta-analysis of effects on lipids and haemostatic factors. BMJ, 319, 1523. Retrieved from: http://www.bmj.com/content/319/7224/1523

[4] Singh, V. (2011, December 11). High hdl cholesterol (hyperalphalipoproteinemia) . Retrieved from http://emedicine.medscape.com/article/121187-overview

[5]Wu, J.M., Wang, Z.R., et al. (2001) Mechanism of cardiprotection by resveratrol, a phenolic antioxidant present in red wine. International Journal of Molecular Medicine, 8 (1), 3-17. Retrieved from: http://europepmc.org/abstract/MED/11408943

[6] Hung, L., Chen, J. (2000) Cardioprotective effect of resveratrol, a natural antioxidant derived from grapes. Cardiovasc. Res., 47 (3) 549-555. http://cardiovascres.oxfordjournals.org/content/47/3/549.full

[7]Frozza, R., Bernardi, A., Hoppe, J., Meneghetti, A., Matté, A., Battastini, A., Pohlmann, A., Guterres, S., & Salbego, C. (2013). Neuroprotective Effects of Resveratrol Against Aβ Administration in Rats are Improved by Lipid-Core Nanocapsules Molecular Neurobiology DOI: 10.1007/s12035-013-8401-2

[8] Alcohol calories ‘too often ignored’. (2013, January 01). BBC. Retrieved from http://www.bbc.co.uk/news/health-20874204

Vaccines: Myths and Realities

January 15th, 2013

Courtesy of: CDC

by Anton Power

When I was a teenager, I believed that my strong immune system would protect me from the fevers and weakness that brought so many of my classmates down. I was naiveté and secretly hoped that I could have a week off from school, but I know better now. Those of us who are fortunate to never have to deal with the worst of childhood diseases don’t recognize the ever-present danger that our peers live under, even in a post industrial nation like the United States. Not everyone is so lucky. Not everyone has the luxury of health.

Over the years, I’ve come across several myths attributed to vaccines. Healthy living will not always protect us from infections because we always come in contact with other people and the environment.

There is also no guarantee that just because I do not display the symptoms of a disease, I can’t pass it on to someone with a compromised immune system. The less fortunate always suffer, and I can’t live with the knowledge that I may have caused that suffering. This is why I take the flu shot every year; it’s worth the free conscience.

Influenza

No vaccine is perfect. Often, when it comes to the influenza virus, an educated guess is the best we can do to protect ourselves for the next season. By observing changes in the genetic makeup of various strains, the most commonly seen strains are then attenuated or inactivated and converted into a vaccine which teaches our immune system to recognize the antigens present and produce antibodies (our secondary immune system at work).

Attenuated vaccines are produced from similar, but non-virulent strain viruses. Thus, they do not cause the symptoms that are commonly associated with the virulent strain disease. One of the first examples of vaccine use was in fact an attenuated virus (Cowpox), first administered by Edward Jenner in 1796, to help fight the variola (Smallpox) virus. [1]

In recent years, there has been some concern about influenza vaccine causing the onset of Guilain-Barre Syndrome. This syndrome causes temporary paralysis, is usually onset following an infection, and the mechanism of action is not well understood. Guilain-Barre Syndrome strikes about one (1) out of every 100,000 people. [2]

Several studies have been conducted to assess this possibility, all coming to the same conclusion. One such study in Quebec, Canada, assessed the risk to be one (1) new case of Guilain-Barre attributed to the influenza A (H1N1) vaccine for every 1 million vaccinations. [3] However, compared to the risk of mortality associated with influenza (41,400 deaths in the U.S. every year), the benefit certainly outweighs the risk. [4]

Measles-Mumps-Rubella (MMR)

For the past three decades or so, there have been accusations of MMR vaccines factoring in the rise of autism. A possible cause of this misinformation may originate with a temporal association between the time of vaccination and the diagnosis of the disorder. Autism is usually identified at 18-19 months in children, and MMR vaccine is currently administered at 12-15 months. [5]

A UK study gathered clinical data from 498 autism-stricken children between 1979 and 1999 in order to study any link between the two occurrences. MMR vaccine was introduced to the UK in 1988, so the study essentially compared pre-1988 and post-1988 trends in age and incidence rates in the kingdom. Using International Classification of Disease, tenth version (ICD10), 214 subjects were identified to have core autism, 52 had atypical autism, and 27 had Asperger’s syndrome. A steady increase in autism cases from 1979 to 1999 was observed. However, no sudden change in occurrence was reported after the administration of MMR vaccine began. There were no correlated age changes in diagnosis, and no trends at all. [5]

The reality is this: 894,134 cases of Measles occurred in 1941. In 2000, there were 86 thanks to the MMR vaccine. [6]

Hepatitis B

There have been some assertions that the Hep. B vaccine causes Multiple Sclerosis (MS). Although MS is not entirely well understood, recent studies identified the presence of Myelin Basic Proteins (MBP) associated with the Myelin sheath on axons in the Central Nervous System. [7] The current theory states that MBP assist in the demyelination of the axons in the brain, causing the onset of MS symptoms.

White blood cells don’t usually attack our own proteins. However, similarities between some foreign bodies (like viruses) and our native proteins can sometimes confuse the immune system. When there is an increase in MBP, the blood-brain barrier becomes more porous, allowing the white blood cells to enter the brain and begin attacking myelin attached to MBP. This can be attributed to similarities between the MBP structure and the human herpesvirus-6 (HHV-6) antigen structure, which suggests a possible cause of the T-cell cross-reactivity. However, the structure of the Hepatitis B vaccine antigen and the MBP antigen are completely dissimilar. This makes the assertion that the Hep. B vaccine causing MS unfounded. [6][8]

Vaccine Side Effects

As noted previously, there are certainly side effects to vaccines. However, in all cases, the benefit drastically outweighs the risk. We have all experienced the swelling, redness, and mild pain at the injection site following vaccination. This is normal, and self-limiting (disappears over time). Diptheria and Tetanus shots, and the acellular pertussis vaccine (DTaP) can cause fevers, erythema, swelling, and pain at the injection site. [6]

Varicella (Chickenpox), trivalent inactivated Poliovirus (IPV), and MMR vaccines have trace amounts of antibiotics, which have on occasion caused anaphylaxis is patients with allergies to these antibiotics. Furthermore, some children have allergies to eggs. Influenza vaccine is cultured from chicken embryo fibroblast tissue, thus it may not be advisable to administer the flu vaccine in this situation. [6]

Some vaccines do have trace amounts of the preservative Thimerosal (antiseptic and antifungal) which contains ethyl mercury. It is not dangerous, but multiple shots with vaccines which contain Thimerosal can produce higher levels of mercury in the bloodstream than recommended in infants. Thus, vaccinations for Hepatitis B have on occasion been delayed until the infant is larger. A non-Thimerosal containing vaccine can be used. [6]

As a final note, do yourself and friends a favor this season; get vaccinated!

References

[1] Center for Disease Control and Prevention, Emergency Preparedness and Response. (2003). Smallpox vaccine overview. Retrieved from website: http://www.bt.cdc.gov/agent/smallpox/training/overview/

[2] Guillain-barre syndrome definition. (2011, May 28). Retrieved from http://www.mayoclinic.com/health/guillain-barre-syndrome/DS00413

[3]De Wals P, Deceuninck G, Toth E, Boulianne N, Brunet D, Boucher RM, Landry M, & De Serres G (2012). Risk of Guillain-Barré syndrome following H1N1 influenza vaccination in Quebec. JAMA : the Journal of the American Medical Association, 308 (2), 175-81 PMID: 22782419

[4]Dushoff, J., Plotkin, J.B. (2006) Mortality due to influenza in the united states-an annualized regression approach using multiple-cause mortality data. Am. J. Epidemiol., 163(2), 181-187. http://aje.oxfordjournals.org/content/163/2/181.full

[5]Taylor, B., Miller, E., et al. (1999) Autism and measles, mumps, and rubella vaccine: no epidemiological evidence for a causal association. Lancet, 353, 2026-2029. Retrieved from: http://www.morrisonlucas.com/GL/vaccines/Lancet_353_2026_autism_and_measles_no_evidence.pdf

[6]Sanford, R.K. (2002) Vaccine Adverse Events: Separating Myth from Reality. American Family Physician, 66 (11), 2113-2121. Retrieved from: http://www.aafp.org/afp/2002/1201/p2113.html

[7]Genain, C.P., Cannella, B., et al. (1999) Identification of autoantibodies associated with myelin damage in multiple sclerosis. Nature Medicine, 5, 170-175. Retrieved from: http://www.nature.com/nm/journal/v5/n2/abs/nm0299_170.html

[8]Tejada-Simon, M.V., Zang, Y.C. (2003) Cross-reactivity with myelin basic protein and human herpesvirus-6 in multiple sclerosis. Ann. Neurol., 53 (2), 189-197. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/12557285

I Dream of Health

January 13th, 2013

by Anton Power

Despite the advances in medicine over the last twenty years in the United States, access to care for many individuals remains a major issue. Although most individuals in my nation do receive benefits of some form, and have primary care physicians at their disposal, there remains a disparity among millions who are not insured. Without insurance, even the most basic treatments can be prohibitively expensive. With the recent financial meltdown across the globe, many of the issues we face in the United States have been magnified.

What is life like in the United States without health insurance?

The lack of insurance coverage (whether it is provided publicly or through private insurance companies) decreases the likelihood of receiving preventive health services such as consultations and planning, and diagnostic services [1]. Preventive care is important because insured individuals are 50% less likely to see null results in biopsies, when tested [2]. This has impacted the health and quality of life of many Americans since the inception of modern evidence-based medicine, because even though quality care has been available for a long time, the issue that often keeps longevity in our nation low is access to services. Hospital mortality is 1.2 to 3.2 times higher among the uninsured compared to privately insured individuals [3]. What’s more, improved health has been associated with an increase in an individual’s income by 15%-20%. Whether this is correlative or cause-and-effect has yet to be determined.

However, this is not just an issue that affects a subset of the population; the vitality of an individual can also affect the whole health care system. The uninsured are more likely to seek care in outpatient clinics and emergency departments (29%-75% are less likely to undergo procedures [3], possibly because of cost)[4], ultimately increasing the patient’s out-of-pocket expenses and putting unnecessary burden on the emergency health services that are often over-capacity and unable to provide the high level of patient care that is often expected, as a result. In addition to capacity issues, hospitals may never be reimbursed for their services, but are simply expected to absorb the cost associated with the care.

In 1990, 34.7 million people were without insurance in the United States [5]. With a population of 248.7 million at the time [2], this is 13.95 percent of the nation who could otherwise be receiving top-notch care. This is in contrast to the 2010 data showing an increase in uninsured individuals to 49.9 million people [6] with a population of 308.4 million[7]. This is 16.18 percent of the country, an increase of 2.23 percent over the past 20 years. Obviously, the recent recession may have contributed to this detrimental change because at the turn of the century, the uninsured population decreased to 33 million adults with a population of 270.3 million (12.2 percent) [8].

The demographic differences between 1990 and 2010 have been for the most part unchanged among the uninsured. However, the recession has exaggerated the differences somewhat. The highest uninsured population has historically been Hispanics, with 26.1% uninsured in 1990 and rising to 33.9% in 2010. The black population has been the next largest to be uninsured, with 12.4% in 1990 and 22.6% in 2010. This clearly shows disparity among different racial groups, since the white population has continued to be the least likely of the three to be uninsured with 9.3% in 1990 and 14.1% in 2010 [4] [9].

Age is also an important category, since young adults (between 18 and 25) are far less likely to carry health coverage. This is possibly due to the nature of their work as they begin their careers, or any other of several factors such as being less likely to have health problems. Although, the young adult population has seen the most dramatic increase in lacking coverage, from 19.9% (18-25 year olds) in 1986, evenly distributed among males and females [4], to 40% among men and 19.9% among women in 2009 [9].

This dismal picture of health care disparity can stop any reader in their tracks. Not only is the lack of access left wanting in the United States even more then it was 20 years ago, but the disparity is not uniform among the national population. This shows some clear, and persistent, racial divides among working individuals and how medical treatment is distributed.

Given the decline in insurance coverage, legislators have proposed several solutions over the past few years to address this issue in the recession stricken nation. Although national health care remains elusive and a distant dream, measures have been recently implemented to increase coverage for individuals who cannot afford insurance, and force many employers to offer benefits to uninsured workers. What this means for the quality of care, and how a sudden influx of newly insured persons will change the current system remains to be seen.

References

[1]

Hadley J (2003). Sicker and poorer–the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income. Medical care research and review : MCRR, 60 (2 Suppl) PMID: 12800687

[2] U.S. Census Bureau, (n.d.). Population change and distribution (C2KBR/01-2). Retrieved from website: http://www.census.gov/prod/2001pubs/c2kbr01-2.pdf

[3] Hadley, J., Steinberg, E. P., & Feder, J. (1991). Comparison of uninsured and privately insured hospital patients. Journal of the American Medical Association, 265(3), 374-379. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=384770

[4] Freeman, H. E., Aiken, L. H., Blendon, R. J., & Corey, C. R. (1990). Uninsured working-age adults: characteristics and consequences. Health Services Research, 24(6), 811-823. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065602/?page=6

[5] Himmelstein, D. U., Woolhandler, S., & Wolfe, S. M. (1992). The vanishing health care safety net: new data on uninsured americans. International Journal of Health Services, 22(3), 381-396. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1644504

[6] U.S. department of health and human services. (2011, September 13). Retrieved from http://aspe.hhs.gov/health/reports/2011/CPSHealthIns2011/ib.shtml

[7] Schlesinger, R. (2009, December 30). U.s. population 2010: 308 million and growing. Retrieved from http://www.usnews.com/opinion/blogs/robert-schlesinger/2009/12/30/us-population-2010-308-million-and-growing

[8] npg.org. (1999, Jun 04). Retrieved from http://www.npg.org/facts/us_historical_pops.htm

[9] Fronstin, Paul , Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2010 Current Population Survey (September 1, 2010). EBRI Issue Brief, No. 347, September 2010. Available at SSRN: http://ssrn.com/abstract=1682249

Image courtesy of: County of Los Angeles Office of AIDS Program and Policy. Retrieved from: http://publichealth.lacounty.gov/aids/HealthcareReform.htm

Immunize your kids!!!!

January 13th, 2013

Forthcoming: myths about vaccines.

In the meantime: