Getting a Medical Device? Read This.

“First of All, Get a Second Opinion” is the title of Holly Finn’s most recent column in last Saturday’s Wall Street Journal.  She cites the same article I have already discussed about doctors being overly deferential toward each other and goes on to say that we are more cautious about buying blue jeans or flat-screen TV’s than about opting for medical procedures.  The main part of the article is a discussion of the second-opinion industry, which has grown up in recent years and whose services are increasingly covered by medical insurance.  Advances in medical technology mean that a patient’s data can be shared instantly with experts around the country with a response available in a couple of days.  The piece concludes with some sobering statistics.  “In an estimated 60% of cases, an alternate treatment is recommended – often one that’s more conservative and cheaper.”  At one second-opinion firm, 6 out of 10 cases reviewed had been misdiagnosed or mistreated.  At one breast clinic, second opinions led to the cancellation of 73% of 1053 surgeries in favor of less-invasive options.  This article really hit a nerve with several doctors who commented on the article and took offense at both its content and its tone.

 

Coincidentally, the night before, I had watched an episode of the PBS program “Need to Know” that dealt with medical devices.  The show, reported by Medical Correspondent Dr. Emily Senay began with an interview with Linda Gross, a former nurse, who had had a mesh device surgically implanted to correct pelvic organ prolapse.  The procedure and its consequences have been a disaster for Gross and her family and resulted in a lawsuit against the manufacturer.  Dr. Senay later spoke with Dr. Gregory Curfman, Senior Executive Editor of The New England Journal of Medicine, who said that more testing needs to be done to ensure the safety and effectiveness of such devices.  The response from a representative of the organization of medical device manufacturers was that the approval procedure should actually be faster in order to promote innovation.  

Jeff Greenfield, host of the program, then interviewed Dr. Josh Rising, who is Project Director of the Medical Devices Initiative at the Pew Charitable Trusts.  Dr. Rising, a diabetic himself, has an implanted insulin pump to regulate his blood sugar.  He said that there have been problems not only with mesh devices but also with implantable defibrillators, and metal-on-metal hip replacements.  He said that in Australia there is a registry of hip and knee replacement devices that has made it possible to track the outcomes for patients who had had the devices implanted.  Based on information from the registry, doctors in Australia stopped using metal-on-metal hip replacements years before they did in the US.  If a similar program were instituted here, according to Dr. Rising, both safety and innovation would benefit.  On the safety side, devices that caused problems could be taken off the market; for device manufacturers, there would be a source of information on how the current devices are doing so that they could plan for the next generation of products.

Smiling Makes Life Easier - Really!

While doing P90X I noticed that some of the people in the class smile a lot, especially when they are doing tough moves.  This made me wonder whether smiling could make strenuous exercise easier.  I started trying it and it seems to help; it feels as though there is a slight barrier between you and the ache in your abs or wherever.   

A couple of days later I saw an article, “Stress-Busting Smiles,” in the Wall Street Journal that talks about recent research showing that smiling can reduce stress and alleviate depression.  A big, broad grin (“the Duchenne Smile”) seems to do the most good but even a minimal “Pan Am Smile” can be beneficial.  Apparently the inverse is also true.  In one study, a group of 74 patients diagnosed with depression were divided into two groups: one group received Botox injections to prevent them from frowning; the other group were given placebo injections.  Of the Botox group 27% went into remission from their depression, as compared with 7% of the placebo group.  ☺

Biotin and Psoriasis Again

Last year I wrote about how I started taking biotin, a member of the B-vitamin group, to help my fingernails and found that it helped my hair and skin as well.  I had developed little painful, crusty spots on my elbows which I thought were psoriasis.  Not long after I started taking biotin the spots disappeared, leaving little scars.  

Now I’m sure it works, at least for me.  Recently I went on a trip and didn’t bring quite enough biotin with me.  I was only off it for 3-4 days but when I got back the painful, crusty spots were reappearing on my elbows.  I went right back to the biotin and the spots dried up.  I’m concerned about psoriasis not only because it is painful and unsightly but also because it seems to be linked with heart disease, which runs in my family.  So maybe by doing something good for my skin I’m also helping my heart.  I wish someone would research all this so we could understand it better.  Medical websites say that biotin deficiencies are rare; I suspect that this is because testing for biotin deficiencies is rarely done.

More Help for Sore Muscles: The Thumper

The Thumper Sport

I still like foam rollers for working the soreness out of large muscle groups like the back and the upper legs because the weight of your body helps you to work into those areas (see “Foam Rollers:  Help for Sore Muscles”).  But for smaller body parts, like the very top of the back and the biceps muscles, the rollers aren’t much help so I decided to try a percussion massager.  The first one I got was a HoMedics device for about $40.  It worked pretty well but started making an ominous noise after a couple of months so I took it back to Bed, Bath, and Beyond (thanks to their liberal returns policy).  That experience was enough to persuade me that these machines can really be useful so I decided to invest in a Thumper.

This massager is the descendant of the first deep muscle percussion massager, produced in 1974, which was based on research by Canadian chiropractor Lyman Johnson.  The Thumper is still made in Canada and the company now produces a whole line of massage-related products, including one for horses! I got the simplest one, the Sport Percussive Massager, which came with good instructions, including a DVD demonstrating its use.  The only drawback is that the Thumper is pricey; I paid about $140 on Amazon.  On days when I don’t use the foam roller I use the Thumper on my back, arms and legs, and even my hands and feet.  You hold it on each spot for less than a minute so the whole process doesn’t take long.  It definitely loosens up stiffness and helps me to relax in the evening.  It seems to be well made and has a two-year warranty, an indication that the company is serious about quality.  

Four years ago Mark Tarnopolsky a neurometabolic researcher at McMaster University injured a hamstring in a waterskiing accident.  He was so impressed with the effects of massage in improving his condition that he decided to explore the underlying mechanisms that cause it to work.  “They found that massage reduced the production of compounds called cytokines, which play a critical role in inflammation. Massage also stimulated mitochondria, the tiny powerhouses inside cells that convert glucose into the energy essential for cell function and repair.”  So massage both suppresses inflammation and promotes faster healing.  “Basically, you can haveyour cake and eat it too,” said Tarnopolsky.  Researchers found no basis for the claim that massage removes lactic acid from muscles.

When to Question Your Doctor: A Cautionary Tale

Most people are in awe of physicians.  Medical doctors are smart, well educated, and devote their working lives to helping others.  The least we can do, it would seem, is not to add unnecessary complication to their already-overstressed schedules by disagreeing with them.  The current New England Journal of Medicine has an important article, “SpeakingUp — When Doctors Navigate Medical Hierarchy,” by Ranjana Srivastava of the Monash Medical Center in Australia. 

It turns out that not only patients are intimidated by physicians; doctors are also intimidated by other doctors so that they do not always speak up when they sense that something is wrong.  Medical professionals are especially loath to interrogate those whom they perceive as outranking them in the medical profession’s pecking order.  Srivastava, an oncologist, was unwilling to express her sense of uneasiness about a patient to the surgeon about to operate on him.  Her account of the incident and its consequences is honest and moving.  
  
The message I took away from this article is this:  if something bothers you, speak up.  Be respectful, ask reasonable questions, but don’t keep silent.  To this I would add:  if the doctor becomes annoyed or brushes your reservations aside, get a second opinion.

Abdominal Migraines

My paternal grandmother would sometimes get abdominal pain severe enough to send her to the emergency room.  She had a number of exploratory surgeries that turned up nothing until finally, in her seventies or eighties, she said, “No more surgeries.”  My father used to get migraine headaches.  I don’t get those, but once in a great while (about every seven years) I get an abdominal migraine.  Usually at night after a big meal, maybe under stressful circumstances, I will get painful spasms below my navel (about 7 on a scale of 1 to 10), accompanied by sweating, vomiting, and diarrhea until my whole system is cleared out.  After that the pain continues; I can’t keep down any food or liquid; and of course I can’t sleep.

In 1989 that happened and I went to the emergency room.  That time I was lucky because the doctor there knew what this was.  He checked a few things, had an x-ray taken, and sent me home with pain medication.  He didn’t tell me the name of the condition; I found that out later for myself.  I stayed in bed the next day and after that I was fine.  Seven years later it happened again and I called my regular doctor.  I said, “I know what this is.  Please give me something for the pain and I’ll be OK in a day or two.”  My doctor was skeptical and wanted to be extra cautious.  She had me check into the hospital and lined up a surgeon.  The hospital ran various tests, found nothing, and let me go after a couple of days.  The next time, just as the pain was starting, I took a generic Pepcid AC (famotidine) and the pain stopped in its tracks: apparently this is the right thing to do.

Many doctors believe that only children get abdominal migraines but this seems to be wrong.  I get them, my grandmother probably did too, and I know at least one other adult who does.  In adults an abdominal migraine is probably mistaken for a stomach virus or food poisoning.  For people who get them often it probably makes sense to carry the pills around, just in case.

I get various kinds of muscle spasms too.  The best fix for these is to wet a washcloth with the hottest water you can stand and press it against the knotted up area.  Sometimes this has to be done a couple of times but after that the muscle will relax.  I’ve read that muscle spasms can be caused by deficiencies in any of various minerals.  I take potassium, magnesium, and calcium and the blood tests for these indicate that I’m where I should be.  Evidently this is just part of my genetic inheritance.

The Latest on Stilbestrol

In today’s paper I read about the Melnick sisters, whose suit against Eli Lilly and Company went to trial this week.  The sisters charge that a Lilly product, diethylstilbestrol (DES), which was given to their mother during four of her pregnancies, caused their breast cancers.  DES was given to pregnant women in the 1940’s and 50’s to prevent miscarriage.  It was later taken off the market when it was found to cause a rare type of vaginal cancer in the daughters of women who had taken the medication.  It was also found not to prevent miscarriage.

The circumstantial aspects of the Melnick case are compelling.  Four of the daughters developed breast cancer in their forties after their mother took DES during those pregnancies.  A fifth daughter, who did not receive in utero exposure to the drug, has not had cancer.  On the other hand, the pregnancies took place during the 1950’s; medical records no longer exist; and Lilly was not the only company that produced stilbestrol.  In addition, the prescribing doctor failed to follow Lilly’s recommendations, which called for using the drug after three or more consecutive miscarriages.  The Melnicks’ mother evidently did not have successive miscarriages.  

In “Stilbestrol and Me” I discussed my own experience with DES.  My mother’s doctor prescribed the drug after my would-have-been older brother was born a “blue baby” and died soon after, not really a miscarriage at all but a heart problem in the child.  DES is a good illustration of “The Twenty Year Rule.”  An apparently successful new technology appears; the medical profession gets excited and applies it to many patients.  Twenty years later (from the ‘50s to the ‘70s in the case of DES) unpleasant or dangerous side effects become evident and the medical profession backs off en masse.  You would think these experiences would lead all of us to be more cautious before trying out the latest thing on our irreplaceable bodies.

Update 1/10/2013:  Eli LIlly settled its case with the Melnick sisters for an undisclosed amount.  Lilly stated that, while it did not believe that its medication had caused the Melnicks' illnesses, the settlement was in its best interest.