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More ER Questions and Answers

More ER Questions and Answers


Detoxifying the liver to reduce PMS symptoms?

Q:  I read a magazine article about detoxifying the liver to reduce PMS symptoms.  Is this legit?  They recommended a 4-day diet and some herbal supplements.  What is your opinion on this?  Carol

A:  Whenever I hear the term "detoxifying" it is almost always a red flag indicating quackery. I'm not one of those pill-pushing MDs who belittles natural approaches to health (in fact, it'd be difficult to find a doc who is more enthusiastic about that than I am), but just about everyone who advocates "detoxifying" is either a scammer, or a quack, or someone who knows very little biology and medicine.

While the liver is one of the primary organs involved in detoxification, it takes an awfully sick liver to not keep up with the demands. An average person has such a surplus amount of liver that there simply isn't a need to augment its detoxification functions. Even if improving detoxification were a worthwhile goal, going on a 4-day diet wouldn't improve things. In fact, such diets often starve the liver of the building blocks it needs to manufacture the chemicals it uses in detoxification. Certain foods (and not just some herbs per se) can accelerate estrogen inactivation. Since estrogen is one of the root causes of PMS, reducing it may help. However, if I were a woman my first step in reducing my estrogen level wouldn't be taking an herb, it'd be shedding fat. Why? Because estrogen is made in women's fat cells, not just her ovaries. In general, women with more fat make more estrogen.

Many drugs and some food substances (such as resveratrol) indirectly raise the estrogen level by inhibiting the body's P450 system of estrogen inactivation. Conversely, some drugs and foods (such as cruciferous vegetables like broccoli, Brussels sprouts, and cauliflower) stimulate the P450 system and accelerate estrogen degradation.

It is important to consider your intake and/or exposure to phytoestrogens (chemicals with estrogen activity that occur naturally in a variety of plants such as soybeans), xenoestrogens (man-made chemicals that mimic natural estrogens), and exogenous estrogens (estrogens unintentionally introduced into people from ingestion of food or water containing estrogens from animals, humans, or pharmaceuticals). On a milligram-for-milligram basis, these "other" estrogens are often much weaker than natural estrogens. However, they can still exert significant effects because they are sometimes consumed in large quantities, hundreds or thousands of times more than the endogenous production of estrogen. In general, exposure to small amounts of these substances can reduce the estrogen effect in the body, but higher levels can increase the estrogen effect. This apparent paradox is explained by the process of competitive inhibition.

Another way of reducing the estrogen level is by avoiding alcohol and eating more fiber. Fiber decreases the estrogen level by binding to estrogens in the gastrointestinal tract, thereby preventing them from being reabsorbed. In medical terms, fiber reduces the enterohepatic recirculation of estrogen.

Remember the ad slogan, "Milk does a body good"? In terms of helping with PMS, there may be some truth in that. Milk sugar, or lactose, is made of the sugars glucose and galactose. Galactose may be toxic to human eggs, thereby reducing estrogen production 

The next step I'd take is to ensure that I wasn't deficient in manganese, magnesium, calcium, or essential fatty acids (EFA) such as linoleic and linolenic acids. Women who take evening primrose oil or some other EFA supplement often experience a reduction in PMS symptoms a few months later (it takes time to replenish an EFA deficiency). Eating salmon (or some other source of omega-3 fats) at least twice weekly may help, too. Certain herbs (e.g., Angelica, peppermint, and rosemary) may relax the uterine smooth muscle and thereby produce symptomatic improvement.

Another way of combating the misery of PMS is by raising the body's endorphin production, since endorphins are the body's natural painkilling chemicals. Endorphin production can be increased by sex, vigorous exercise, certain foods (e.g., hot peppers, garlic, concentrated ginger, and to a much lesser extent, sugar and fat).

It is also helpful to raise the body's pain threshold. This isn't fixed, as is commonly believed. Instead, it changes in response to a number of factors. Deficiencies of tryptophan (an amino acid that is one of the building blocks of protein), vitamin B6, or copper can lower the pain threshold and therefore make any given pain stimulus seem that much more objectionable.

What underlies the placebo effect?
How can the placebo effect be augmented?
Using a heating pad to reduce abdominal pain

Q:  Dr. Dean Edell, the radio doctor, said that endorphins are the chemicals in the body that actually produce the placebo effect.  Do you agree?  Katie

A:  There is scientific evidence that endorphins underlie the placebo effect, but this does not necessarily mean that all placebo effects are attributable to endorphins.  I don't want to make this discussion needlessly complex, but I think what doctors call "the placebo effect" is not just one phenomenon, it's a group of phenomena that share the characteristic of disease or pain mitigation.  Some of these improvements (e.g., a reduction in pain) are clearly due to endorphins, while others (e.g., bald men growing more hair) can't be easily explained on the basis of endorphins.

Let's focus upon the placebo effects due to endorphins.  Logically, if the improvement is due to endorphins, then anything that boosts endorphin levels can augment the placebo effect.  Therefore, I believe that doctors who employ the placebo effect should not just give a sugar pill, injection of salt water, or similar placebo.  In addition, they should encourage the patient to do other things (discussed above) that also boosts endorphin release.

Q:  Dr. Edell also mentioned some study which showed that the pain of kidney stones is reduced if heat is applied to the overlying skin.  He expressed surprise that it took until the 21st century to discover this.  It seems difficult to believe that no one realized this until now.

A:  This is not a new discovery.  It was never mentioned in medical school as far as I know, but when I was in high school I used a heating pad on my abdomen to reduce the gnawing pain I felt from a peptic ulcer that bored a 10 mm (almost ½ inch) hole in my duodenum.  I don't know where I learned that tidbit about using a heating pad to reduce abdominal pain.  Perhaps my Mom told me (isn't every Mom to some extent a Dr. Mom?), or perhaps I stumbled upon it after trying every imaginable way to reduce that pain.  I certainly obtained no relief from my personal physician, Dr. Quack, but when I saw my Mom's doc, it took him less than a minute to realize that I had all the classic signs of an ulcer.

Coincidentally, I bumped into the wife of Dr. Quack years later in a pharmacy.  I was with my Mom when she was trying to fill a prescription, and I was speaking with the pharmacy tech.  She said, "It sounds like you're a doctor."  When I affirmed that, she continued and explained that she was the wife of the now-deceased Dr. Quack.  She began to tear up as she said what a great doctor he was.  She didn't know that I was one of his former patients, and that his failure to diagnose something that should be obvious to any medical student caused me two years of pain.  But why add to the anguish of a widow?  I just nodded in agreement.

Essential fatty acids and headaches

Q:  I've been bothered by headaches for years, and they don't seem to fit any of the classic headache patterns such as migraine or tension headaches.  I've seen my family doctor, an allergist, an ENT doctor, and a neurologist — all of whom haven't been able to figure out what's causing the headaches.  Can you help?  Mary

A:  Since you've been to several doctors I'm sure they covered all the usual causes, so there's no point in me mentioning those.  Have you tried keeping a log of what you eat?  In addition to the known headache triggers, one of the things that triggers headaches in some people that doctors rarely consider is the patient's intake of essential fatty acids (linoleic and linolenic acids).  The essential fatty acids, abbreviated EFAs, are present in various dietary oils (e.g., canola, olive oil, soybean oil), nuts, supplements (flaxseed, evening primrose oil), and other foods in lesser concentrations.  If you've had biochemistry, you may recall that the EFAs are precursors to prostaglandins and related substances.  What is important about this is that an excess of certain prostaglandins can trigger headaches in some people.  Hence, my advice is to keep this in mind, and try to correlate increased EFA intake with an increased likelihood of headaches developing soon after.

A caveat
:  it's OK to reduce EFA intake if they trigger headaches in you, but don't try to eliminate them from your diet.  As their name implies, they're essential to health.  A deficiency of EFAs can produce a wide range of abnormalities. This is not surprising, considering the fact that they are involved in critical biochemical pathways that affect every cell in the body either directly or indirectly, and they form part of the cell membrane for all body cells. EFA deficiency can produce or contribute to mental disturbances, poor wound healing, poor vision, muscle weakness, male sterility, breast pain, rheumatoid arthritis, poor growth, hair loss, dandruff, dry skin, eczema-like skin lesions, and phrynoderma. Given that most doctors have probably never even heard of phrynoderma, I think that a definition is indicated. Phrynoderma is the gooseflesh-like "pimples" present on upper arms, thighs, and buttocks. It is pronounced frin-o-der-mah, and it is caused by a deficiency of essential fatty acids or vitamin A.

If you are a doctor, here is the "doctor's definition," so to speak:  phrynoderma is a chronic, papular dry skin eruption (follicular hyperkeratosis), often accompanied by neuritis and eye symptoms. It is also called toadskin. Since few of your patients would appreciate being told that they have toadskin, it's probably better that you use the correct term.

Do I need the tetanus immune globulin or just the tetanus vaccine?

Q: A bicyclist ran into me full-force, and I mostly smashed my head and hands onto the pavement and I got a big deep wound on the side of my leg—I think it might have been the bike pedal. That wound was open a few hours before it got stitched together (15 stitches). Should I take the tetanus immunoglobulin? I am a very healthy "all-natural" person, and never been ill for the last 14 years!  And if I should do it, when should this be done?  If symptoms appear, is there time to get a shot?  What are the symptoms? Thanks a lot! Tina

A: Tetanus usually presents with jaw stiffness, difficulty swallowing, stiff neck (or arms or legs), fever, chills, sore throat, headache, muscle spasms, difficulty voiding, constipation, and respiratory paralysis (that, of course, is fatal if not treated).  The worldwide mortality rate is around 50%.  In other words, it's nothing to sneeze at.

As for whether or not you need just a Td booster or TIG (the tetanus immune globulin), that depends upon whether or not you've been fully immunized, how long it's been since your last booster, and the severity of your wound (which, from a tetanus standpoint, sounds as if it's at least a moderate risk wound).

Any risk from swallowing a tongue barbell?

Q: I swallowed a tongue barbell on accident. What should I do? Will it hurt me? Jaime

A: There are two factors to be considered:  (1) the physical characteristics of the "barbell" and (2) the metal(s) from which it is made. Taking the latter point first:  when exposed to the acid in the stomach, many metals dissolve, and some of them can be toxic, either to the body as a whole, or focally (that is, the metal may damage the lining of the GI tract).  If you don't know the composition of the barbell, it would be a good idea for your doctor to contact the manufacturer or supplier.

In regard to the physical characteristics of the barbell:  if there are no sharp points on it, it will likely pass on through.  However, it is possible for stomach acid to etch away enough metal to create sharp corners where there were none before.  That can be very dangerous, since it could poke a hole in your intestines and cause bacterial peritonitis (bacterial infection of the space surrounding the intestines).  That condition can be fatal if not treated.

When you see your doctor or an ER doctor, he will obtain an x-ray of your abdomen to determine the barbell's location.  By now, it is most likely past the point where it could be retrieved by endoscopy.  Hence, the doc will likely obtain serial x-rays to keep track of how the barbell is progressing (or if it isn't, since that would mean it's snagged on something), and the doc will likely tell you to examine your stool to know when it's out.  He will also tell you the warning signs that would warrant an immediate return to the ER (for example, fever, abdominal pain).  The doc may also give you a cathartic to hasten the expulsion of the barbell. Finally, if the metal was itself toxic, the doc might give you something to counteract, neutralize, or minimize the toxicity of the metal. It would probably be a good idea to print this and give it to the doc you see. Good luck and let me know how you're doing.

Friend blurting out odd sounds; is Accutane the culprit?

Q:  I have a friend on Accutane [an oral acne drug].  Recently he has been blurting out odd sounds such as blubublblbububhbb .....  When I question him about it, he completely ignores the questions.  Could this possibly be a side effect of Accutane?

A:  Accutane can increase intracerebral pressure (ICP), which could conceivably cause unusual behavior.  However, unless your friend has a headache or nausea (other symptoms of increased ICP), his "blubublblbububhbb" utterances are not likely attributable to Accutane.  In any case, I think he should be seen by a doctor since his behavior may be the tip of the iceberg, so to speak, as a sign of some serious disease.  The reason why this concerns me is because if he says something so unusual and then has no recollection of it, his perception of reality is somehow distorted.  What if his perception were distorted while he was driving a car, for example?  The consequences could be tragic.  Obviously, I cannot make a diagnosis over the Internet, so that's why I recommend an evaluation by a doctor.

One thing to bear in mind is that his behavior seems to be episodic (if I've read your question correctly), and therefore he may appear completely normal to the examining physician.  Therefore, it is important that you accompany him and fully explain all of the unusual behavior you've witnessed.  Also, don't let the doctor "blow you off."  Your friend's problem is the kind of complaint that a diligent physician would take seriously, while a typical doctor would trivialize and brush off his behavior as being inconsequential.  Clearly his behavior is abnormal and worrisome, so don't let an ignorant doctor who doesn't like to think deeply tell you and your friend that it's nothing to worry about.  If that were my brother saying "blubublblbububhbb" I'd have him seen by a neurologist.  If he is examined by a family practitioner you're probably wasting your time.

Good luck and let me know what you find out.

Can chocolate and other foods worsen acne?

Q:  My dermatologist says that chocolate won't make acne any worse, but I'd swear that it does.  What is your opinion, Dr. Pezzi?

A:  The traditional "party line" from dermatologists is that foods do not exacerbate acne.  This is utter nonsense.  I've noticed an association, and so have countless other acne patients.  I often hear dermatologists substantiate their opinion by citing a study of chocolate and acne that was — are you ready for this? — funded by the Hershey chocolate company.  I wonder if there was any bias?  :-)  One need only look at the ingredients in chocolate to realize that some of the chemicals in them can indeed worsen acne in susceptible people.

Many authors opine that coffee and soft drinks also do not exacerbate acne.  That's true only if they do not contain caffeine.  Stress increases acne by elevating certain stress hormones in your body.  By a similar mechanism, caffeine worsens acne by artificially increasing the production of these same hormones.  Essentially, almost any drug with some degree of a stimulant or "upper" effect can do the same thing.  Researchers have recently clarified another link between stress and flare-ups of acne and other inflammatory skin diseases:  during periods of anxiety, nerve fibers secrete a protein called substance P, which contributes to white blood cell aggregation.  White blood cells are components of the immune system which can be likened to bouncers in bars:  when they spot potential trouble, their job is to clear it out.  In the process of removing the offender, they often create a ruckus.  In this analogy, the biological "ruckus" is the development of redness, swelling, tenderness, and sometimes pus, that forms a pimple; the "potential trouble" is a clogged pore.

Iodine can trigger acne because it is secreted by the skin's oil glands into the pores, which it can irritate.  Kelp, iodized table salt, asparagus, certain food colors, and liver are a few things to avoid if acne is a problem for you.  You should also avoid fast food, as such meals often contain amazingly high levels of iodine.  An often overlooked source of iodine is Betadine® and other brands of povidone-iodine.  Significant absorption of iodine from Betadine® is most likely to occur when it is used as a vaginal douche*, or when it is applied to large, open wounds**.  To a lesser extent, iodine can also be absorbed through small skin lesions, especially when it is frequently used (as by health care workers and surgeons; the latter might spend an hour per day scrubbing their hands — and you thought they had exciting jobs!).

* Betadine® Vaginal Gel can be used in treating certain forms of vaginitis (trichomoniasis and vaginitis due to Gardnerella vaginalis), when the preferred oral antibiotics cannot be administered for some reason.  However, iodine absorption from the vagina is so extensive that Betadine® Vaginal Gel should not be used during pregnancy, because the absorbed iodine can cause goiter and hypothyroidism in the fetus and infant.

** Betadine
® Solution is an OTC antiseptic.  Its manufacturer states that it can be applied undiluted to wounds.  However, if you apply it to an open wound, it should be diluted at least 10-to-1 with sterile "normal saline" (that's what it is called) solution.  Undiluted Betadine® Solution may injure cells, thus delaying wound healing, and increasing — not decreasing — the risk of infection.  Properly used, it is great stuff.

Another food that may exacerbate acne is dairy products, because of their hormone and iodine content.  D
airy products often contain high levels of iodine because some dairy farmers use an iodine-based antiseptic to swab the cow udders before milking.  Some of this gets into the milk.  I noticed that my skin improves remarkably when I avoid cheese, which of course is a very concentrated dairy product.

Several observational studies have shown that acne flares when a group of people change their diet from one that is primitive to one that incorporates modern, processed foods.  For example, when Zulus move from the countryside into the city, they develop acne.  Similar results have been demonstrated when Eskimos said good-bye to their igloos and hello to city life.  While some people might attempt to explain the emergence of the acne as a result of the stress of modern living, this assumes that life in the wild is an idyllic existence that is devoid of stress.  Until you've come within feet of a hungry bear — and I have — you don't know the meaning of the word "fear."

I discuss acne in much more detail in Fascinating Health Secrets.

Can you die from following the advice in a Bayer ad?

Q:  I recently saw a Bayer commercial that said it's a good idea to take a Bayer aspirin if you're having a heart attack (more properly, a myocardial infarction or MI).  What is your opinion on this, doc?  Gary  (PS:  By the way, I loved your book -- I've never seen anything else like it!)

A:  I think it's a dangerous suggestion, and I'm stunned that a company such as Bayer would open themselves up to zillions of dollars in lawsuits by offering such advice.  To the best of my knowledge, Bayer aspirin is usually laced with caffeine.  To verify this, I recently went to a Wal-Mart store and, sure enough, every variety of Bayer available had both aspirin and caffeine in it.  Taking aspirin with an MI is generally very beneficial, but taking caffeine can be suicidal.  Caffeine can increase the stress on an already over-stressed heart, and caffeine can heighten the chance of developing a potentially fatal arrhythmia (abnormal heart beat).  People with MI's are already predisposed to fatal arrhythmias, so taking caffeine makes about as much sense to me as putting a plastic bag over your head if you're short of breath.

I don't claim to be an expert on all of the million and one nonprescription drugs available, so perhaps there is a type of Bayer that contains aspirin but no caffeine.  If so, that would be fine to take in most circumstances if you're having an MI, but you'd better be 100% sure that it doesn't contain caffeine, or you may pay the ultimate price.  However, since many people with MI's are scared out of their wits and aren't thinking clearly, that is not the time to be reading the fine print on Bayer bottles to see if the pills in it are safe.  Since there are so many other forms of pure aspirin available, I think the public as a whole would be better off remembering to take an aspirin that is NOT Bayer.

I'm not anti-Bayer.  As I pointed out in Fascinating Health Secrets, caffeine is itself a mild analgesic (pain reliever) and it can enhance the efficacy of aspirin.  Therefore, Bayer is a more potent pain reliever than plain aspirin.  However, there is nothing magical about the caffeine in Bayer aspirin; you can achieve the same effect by washing down a plain aspirin with coffee, Pepsi®, or Coke®.

Now that I'm on the subject of aspirin, I should mention a couple of other general pointers.  First, if you're having an MI, do not take a slow-release form of aspirin because you want the aspirin to work NOW, not a few hours from now.  Second, with the exception noted in the above paragraph, plain, generic, el-cheapo aspirin is just as effective as brand name aspirin.  You'll pay a lot more for the brand name stuff, and if it's Bayer aspirin it might kill you if you take it during an MI, so I think everyone should buy generic aspirin.  As I said before, you can always add caffeine when it's appropriate.

My opinion of allergists:  not much

Q:  A friend recommended that I see an allergist.  Do you think this would be worthwhile?  Thanks, Suzanne

A:  Perhaps.  Allergists have a few tricks up their sleeves that family doctors don't know, but for most routine allergies, family doctors are just as helpful.  One beef I have with allergists is that they're often too myopic and inclined to attribute every problem to an allergy.  Remember that old saw that goes when all you have is a hammer, everything looks like a nail?  That seems to be the motto for too many allergists.  I could regale you with tale after tale of how they've missed the true diagnosis because they were overly eager to find an allergy — and hence something within their purview, and hence something they could profit from.  But rather than writing that book, I'll present one case that was particularly egregious.  Cliff, a friend of my Mom, saw an allergist for his chronic cough.  Not surprisingly, the allergist attributed the cough to an allergy, and treated him for that.  It took me about a tenth of a second after I saw Cliff to realize that he had CHF (congestive heart failure) — something any physician should be able to readily spot.  How on Earth could anyone with an MD after his name not make such an obvious diagnosis?  It seems to me that too many physicians, and allergists are at the top of this list, forget everything they know about general internal medicine the second they specialize.  Some specialists are honest enough to admit their shortcomings, and some admit they're really technicians, not doctors.  You'd do well to think of allergists as technicians, not doctors, because no one would knowingly put their health solely into the hands of a technician.

The second beef I have with allergists is that their training seems to have more to do with learning ways to maximize reimbursements rather than giving the best, most economical care to their patients.  Another egregious example to illustrate this.  During my residency, I noticed that every patient seen by the allergy service was treated the same way:  fiberoptic rhinoscopy, followed by a prescription for Seldane.  Rhinoscopy, in which a long, illuminated tube is passed far further up the sinuses than you'd ever think was possible, is not especially pleasant for patients, nor is it inexpensive.  But if a patient had insurance, dang, it'd be done!  Can you guess why?  Apart from that pecuniary motive, I thought it was pointless to do the rhinoscopy on every patient that came down the pike — if they were all going to end up on Seldane, why bother with the rhinoscopy?  A basic tenet of medicine is that it is not advisable to do a test unless the results of that test will possibly influence the chosen therapy.  Here is the algorithm then in vogue (Seldane is no longer on the market, but its cousins Claritin and Allegra are the latest darlings of allergists):

Does the patient ever sneeze, cough, itch, wheeze, have watery eyes, or anything that I can ascribe to "sinus problems"?

YES:  Prescribe Seldane.
NO:  Come to think of it, who doesn't occasionally have a symptom that could be tied to an allergy?  Ergo, whip out the ol' prescription pad, and prescribe Seldane . . . what else?

Are hot-air hand dryers more sanitary?

Q:  Restrooms in businesses often have hot-air hand dryers, and those dryers typically are labeled with a claim that they're more sanitary than paper towels.  What's the medical scoop on this?  Is that claim true, or is it just marketing hype?  George

A:  It's hype.  In fact, there is evidence that the converse is true:  namely, that those hot-air dryers contribute to the spread of disease.  First, there is nothing about hot air that is inherently dangerous in this context, but the problem is two-fold.  First, people who use hot-air dyers typically don't dry their hands as thoroughly as people who use paper towels.  It takes much longer to use a hot-air dryer than it does to use towels, and people usually don't have the patience to wait for a hot-air dryer to completely dry the hands.  Moist hands are more apt to spread germs than dry hands.  Second, people are more likely to wash their hands if they are provided with paper toweling instead of a hot-air dryer.  People are often rushed, and hot-air dryers provide a disincentive for hand washing.

As a doctor, I'm incensed by that specious claim that hot-air dryers are more sanitary.  The real reason why restaurants and other businesses install them is because it saves them money.  Not much, but some people will do anything to pinch a penny.

Hot-air dryers could be redesigned so they could effectively dry hands in a jiffy, and still save money for business owners.  I know how to do this, but I've been too busy working on other, more pressing projects.  However, the engineers who design those things cannot use that as an excuse, since they're paid to design the best possible product.  Why they come up with such antiquated, uninspired designs is beyond me.  Gee whiz, the technology they use is a century old!  One of my pet peeves is poorly engineered products, whether it is buggy software, or a "takes forever and a day" hand dryer that has the audacity to claim superiority.

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Can arsenic poisoning cause renal failure? Should ER docs pick up on this?

Q: I came across an article in the American Journal of Kidney Disease, Vol. 26 #2 (August), 1995:pp 373-6. In this article the doctor states that "Arsenic poisoning is an often unrecognized cause of renal insufficiency. This case emphasizes the importance of heavy metal screening in patients with multi-system complaints and tubulointerstitial nephritis." My question is:  do all emergency room doctors test patients for renal failure when they have multi-system complaints? Do they test the blood for metals or poisons of any kind? And if not why? I'm concerned that people are dying because of this lack of testing, because my mother died of acute renal failure (ARF).  I later found out that the emergency physician plays a critical role in recognizing early ARF, preventing iatrogenic injury and reversing the course of ARF. Could it be that like my mother, people are coming into the ER with symptoms suggestive of  influenza, and complaining of multi-system problems, yet are not being tested for heavy metals? Then they're admitted into ICCU where they are treated for influenza, and by the time the symptoms of ARF develop, it's too late to reverse and they can do nothing but die. Please write back. Stan

A: It's true that arsenic poisoning is an often unrecognized cause of renal insufficiency. In addition to the common sources of arsenic listed in the standard texts, another possible source is pressure-treated lumber (e.g., Wolmanized®) used in decks, retaining walls, and in other ground-contact and near-ground-contact applications.  Occasionally, people will use such lumber to build "flower pots" in which they grow edible vegetables.  Carpenters who work with pressure-treated lumber rarely do two things that would otherwise control exposure of the arsenic salts in that lumber for themselves and their customers:

1. For the carpenters' sake, wear masks while sawing the lumber.  They should also avoid skin contact, and wash thoroughly after any prolonged and/or significant exposure.  Pressure-treated lumber should never be burned, since this releases arsenic into the air which could poison people in the vicinity.

2. For the homeowner's sake, carpenters should take steps to minimize dissemination of the sawdust (usually several pounds for a typical deck) onto the surrounding area.  Because of the surprisingly large surface area of the sawdust, it leaches a lot of arsenic into the soil.

Do emergency room doctors test patients for renal failure when patients have multi-system complaints? Yes, assuming that the multi-system complaints were consistent with a possibly serious disease process.  In reality, ER docs order screening tests (BUN, creatinine, urinalysis) very commonly for a myriad of presentations (oftentimes even trivial ones).  Hence, unless your mother's presentation was clearly benign, those tests should have been ordered.  If for no other reason, they're great tests to evaluate a patient for dehydration.

Do ER docs order tests for metals or poisons? These are not common tests ordered in the ER.  Generally (unless suggested by the history, physical, or clues evident upon other labs tests), it's difficult to possess what's termed "a reasonable index of suspicion" that might warrant the test.  However, if clues pointed to a possible toxic exposure, then of course such a test should be ordered.

Does the emergency physician play a critical role in recognizing early ARF, preventing iatrogenic injury and reversing the course of ARF? Yes. Regardless of whether or not the ER doc picked up on the etiology (causation) of the ARF, he could have—and should have—taken steps to prevent a patient dying from that condition.  No one should die from ARF in this country.

Are patients with symptoms suggestive of  influenza, and complaining of multi-system problems, not tested for heavy metals? That is certainly possible.  I'd have to see your mother's chart to determine if her complaints were sufficiently unusual to make her doc suspect something other than a run-of-the-mill case of "influenza" (by the way, that disease is often over-diagnosed and is a "catchall" for many things that are clearly not true influenza).

Finally, as to whether or not people should die from a delayed diagnosis of ARF:  again, people should not die from ARF.

Q: Dr. Kevin, can you tell by someone's medical records if they were being treated for ARF? 

A: Yes.

Q: Does ARF cause the heart to stop and lungs to pop? Is ARF associated with adult respiratory distress syndrome (ARDS), and do people with influenza have ARF?

A: Not directly, but renal failure can precipitate failure of other organs.

Q: Also, you said that "no one in America should die of ARF." What do you mean, why should no one die?

A: If nothing else, renal failure is treatable by dialysis.

Cocaine overdose

Q: I would like to know what the signs and symptoms are for cocaine overdose for a research paper that I have to turn in. Thank you. Kathy

A: Cocaine OD can present with anxiety, hallucinations, nausea & vomiting, sweating, difficulty breathing, tachycardia (rapid heart rate), arrhythmias (abnormal heart rhythms), circulatory failure, & seizures.

Causes of pancreatitis

Q: My child's father died of pancreatitis.  For the sake of my son's future health, I'd like to determine the cause of it so he might minimize his risk of acquiring it.  Do you know how I could determine which type his father had?  Chronic, acute, or hereditary?

The best way would be to review his medical records.  In general, some of the most frequent causes of pancreatitis are alcohol, gallstones, certain medications, hyperlipidemia (elevated triglycerides), hypercalcemia (elevated calcium in the blood), genetic mutations (cystic fibrosis), some infections (mumps, CMV), trauma, and HIV.

Pancreatitis may also result from pancreas divisum.  This is a congenital abnormality of the pancreas caused by the failure of the pancreatic ducts to fuse during embryologic development.  The pancreatic secretions of people with this disorder drain through a very small opening (the accessory ampulla), and this partial blockage is likely why they may develop relapsing pancreatitis and eventually chronic pancreatitis.

Timeliness of being treated after arriving in an ER

Q: Last night my son and I visited an ER.  It was the worst experience of my life! My son gashed his head open off a round glass table.  He didn't lose consciousness but it was a deep cut and openly bleeding.  One could see right into it. We waited there for 2½ hours and a doctor hadn't even looked at it yet, and they told me he still had two more patients ahead of him which meant another 45 minutes or more, so I made a call to the ER down the street. The nurse there confirmed they were at a slow pace for the moment so I made the decision to take him there.  He was treated so much prompter; he was stitched up in 1½ hours.  Was his trauma a low trauma that he shouldn't have been seen stat?  I'm a first-year nursing student and I don't know the class of my son's accident. I feel he was totally neglected, no one was available to sign him in, and the nurses were so nonchalant attending to us. Any response would be greatly appreciated. Daidra

A: It's very difficult to generalize about the promptness of ER staff in responding to a specific injury.  For example, I've worked night shifts in which I was the only doctor on duty, and I was so swamped by taking care of multiple patients who were critically ill and literally on the verge of death that any cut, short of a wound to a vital organ, would need to have been put off until the critical patients were stabilized.  On the other hand, I can certainly sympathize with your frustration in waiting for such a long time in such a circumstance.

Refusing medical tests

Q: Dr. Pezzi, my question to you is this. If someone goes into the emergency room for treatment and denies requests from a doctor for certain tests, is there a procedure or a form that the patient must sign stating that they have denied these tests? Thank You. Tammie

A: Yes.  Generally, the doctor or nurse will ask the person to sign a form specifying that he was offered a particular test for a certain reason, but the patient, having been made aware of this, declined to have the test performed.  Of course, the patient doesn't have to sign the form, but if the patient refuses to sign it the doc will very carefully document this in the chart, with the result that it doesn't make much of a difference from a legal standpoint. Plus, it makes the patient seem obstinate, if the case were to ever go to trial.

Understanding why you wait in an ER

Q:  My question is:  why is it when you go to the emergency room in your car, you are treated about 4 to 8 hours after you get there?  Even if you are cut to the bone of your ankle!   PLEASE E-MAIL ME BACK AS SOON AS YOU CAN!!!  Thanks! 

A:  Hi LilLover,

The order in which patients are treated in the ER is determined through a process called triage in which the most serious problems are seen first.  Therefore, you may be seen quickly, or you may wait for hours, depending upon the number of patients you're "competing with" and the severity of their complaints.

If you want an analogy (sorry, but your e-mail "handle" [LilLover] made me think of this), here it is.  Let's say that you're a moderately pretty woman looking for a date, and you go into a room full of men.  If you're the only woman in that room, you'll get lots of attention right away.  If there are many other women in the room but they're not attractive, you'll still get lots of attention immediately.  However, if some stunningly beautiful women enter the room, the men will divert their attention to them.  See the analogy?  Think of the attention given by the men, and the rapidity of it, as being analogous to the attention a patient would receive by the ER staff who must first attend to more serious problems (represented in the analogy as more attractive women).

In reality, this analogy is very apt.  In the real world people compete for more desirable people to date, and if someone better comes along the first person is soon forgotten.  When more serious patients come into the ER, ER doctors and nurses must focus their attention away from the less serious patients and onto the more serious patients.  We don't forget about the less serious ones, of course, but I'm sure it seems that way to them.  Remember that you're competing for the attention of the doctors and nurses on the basis of how bad off you are, so look on the bright side:  if you're waiting a long time, think of those poor souls going before you who are worse off than you are.

PS:  What did you think of my analogy?  Was it clear?

From LilLover:  Thank you.  It was perfectly clear and will help me with my paper for English.

What is a triage note?

Q:  On television last night, I heard the term "triage note."  What is that?  Thanks! Tiffany

A:  This is the note written by the triage nurse, who is generally the first professional you encounter after walking into the ER.  The note summarizes your complaints, and sometimes includes relevant positive and negative responses elicited by the nurse in the pursuit of their primary job:  to figure out which patients need to be seen immediately, and which can wait.  In general, nurses do an excellent job in separating the wheat from the chaff.

Why is there a latency period for wrinkles after sun exposure?

Q:  My dermatologist tried to convince me not to sunbathe by saying that, among other things, it would eventually lead to skin wrinkling.  My question is, why do wrinkles take so long to appear?  I've read that most people obtain over 90% of their lifetime sun exposure in the first 18 years of life, but wrinkles usually don't appear until a person is in their 30's or 40's.  So, Dr. Pezzi, can you please explain why wrinkles have a delayed appearance?  Thank you.  Megan

A:  To understand why there is a latency period for developing wrinkles after sun exposure, think of the straw that broke the camel's back.  To some degree the dermal (skin) degradation induced by sunlight is camouflaged by the fact that it takes a fairly substantial accumulative injury for it to be readily detected visually.  Once the collagen and elastin content of the skin has been sufficiently reduced and the skin thins, when additional sun exposure triggers a minor further reduction in collagen and elastin, this incremental weakening of the skin may be sufficient to produce wrinkles.

To further simplify this explanation, let's say that skin wrinkles are apparent when the skin loses 40% of its collagen and elastin content.  If a person has lost 39%, their skin is sufficiently thick that wrinkling is generally camouflaged.  Add that extra 1% of damage (the figurative straw that broke the camel's back), and the wrinkling starts to become apparent.  Thus, while most people obtain most of their sun exposure early in life, further sun exposure later in life can cause enough additional skin deterioration to cause wrinkles.

Here is another reason why there is a latency period for wrinkles.  As you age, your body is less able to deal with damaging free radicals, which are produced by sunlight (and many other factors).  Thus, while older folks generally get less sun exposure than younger people, people who are older take more of a hit, so to speak, from any given sun exposure.

Because wrinkling is somewhat of a threshold effect, the good news is that once wrinkling begins it's very easy to repair the skin enough so that the wrinkles disappear or are greatly diminished.  Besides the obvious therapies such as laser treatments, dermabrasion, and isotretinoin (Renova and Retin-A), it's very important to obtain excellent nutrition.  Collagen and elastin are proteins whose production is dependent upon adequate dietary protein and the presence of other dietary constituents that are important in helping to form collagen and elastin.  Therefore, if your diet is poor, your skin will suffer.

I know that most people think they eat fairly well, but when I shop for groceries I look at what other people buy, and most people purchase a lot of processed foods that are crap (please pardon my unprofessional language, but I cannot think of another word that adequately characterizes how I feel about the junk that's eaten in this country).  Just about every processed food contain trans-fats, as evidenced by an ingredient label that says "hydrogenated" or "partially hydrogenated."  Can you guess why food manufacturers put hydrogenated fats in their products?  Because they prolong their shelf lives.  That sounds laudable until you understand the ultimate reason why the shelf life is prolonged:  because they can't support the life of bacteria.  Nor can they support your life.  In fact, they're not just a big zero from a nutritional standpoint, they're a real danger.  Trans fats will raise your cholesterol level and interfere with the normal body functioning in other ways.  Simply put, evolution or God (however you wish to look at it) never taught the body how to deal with trans fats that are, quite literally, a foreign invader that the body cannot safely process.

Because trans fats are so ubiquitous in the American diet, we're inundated with them.  At the same time the food manufacturers are stuffing us full of these harmful fats, they're shortchanging us on the beneficial fats such as the essential fatty acids (linoleic and linolenic acids), or EFA's.  EFA's are important to many processes in the body, including skin maintenance.  I have a lot more to say about EFA's in Fascinating Health Secrets and The Science of Sex (yes, EFA's are essential to optimal sexual health, too).  EFA's and related compounds also help the brain function normally, so if you're studying for the MCAT, LSAT, or other important test you might benefit from learning a few rudiments of nutrition.  Remember that whatever you put in your mouth fuels your brain, not just your body.  And here's something else to think about:  how many mothers give their children Ritalin for years without spending one second thinking about their child's EFA intake?  And how many people take Prozac or another antidepressant to correct a "chemical imbalance" without thinking of why their brain chemistry is skewed?

Panicked?  Don't run to your doctor.  I attended Wayne State University School of Medicine which had a more intensive course in nutrition than any other medical school.  After obtaining the highest score in the class in the unit that contained nutrition, I can confidently say that what doctors learn about nutrition in medical school is very rudimentary and wholly inadequate.  Worse yet, it's covered in the first year and rarely mentioned after that.  Consequently, most doctors soon forget about nutrition.  I've read hundreds of books on that subject, and if you value your health—and the appearance of your skin—you should read a few, too.

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You know that writer's block you get when you sit down to write the essay portion of your personal profile for online dating? And you know the difficulty you have trying to think of a catchy headline? Well, MyProfileWriter allows you to create a profile essay and headline without typing, just by clicking!

Preventing heart disease:  drugs are not the first step

Q:  I'm afraid of having a heart attack.  My doctor just measures my cholesterol and monitors my blood pressure, but I'm wondering if there are any alternative medicine approaches that may help?  Thanks, Jason

A:  I am not a strong proponent of alternative medicine per se since I think that so much quackery is perpetrated in the name of alternative medicine, but I do believe that most physicians give short shrift to the benefits of healthy eating and a healthy lifestyle.  Of course, most docs give lip service to those basic tenets, but when was the last time you heard about a doctor counseling a patient on ways to modify a diet so as to optimize their ratios of inflammatory versus antiinflammatory prostaglandins?  When most doctors read about Ridker's research about the nexus between C-reactive protein and the risk of heart disease, they probably think about what drugs they can give to modify inflammation.  However, since diet (specifically, essential fatty acid content) influences prostaglandin production and prostaglandins are one of the prime mediators of inflammation, I think it makes more sense to first look at what we are eating.  Sorry for the medical discourse, but I just wanted to illustrate my viewpoint on medicine — it's not quite the mainstream "give them a drug for everything" approach but it is certainly not unfounded like some of the wacko alternative approaches.  My health book (Fascinating Health Secrets) is sort of an amalgam between traditional medicine and alternative medicine.  In it, I discuss a number of things that people can do to minimize their risk of heart disease and other cardiovascular diseases (e.g., stroke, impotence, etc.).

Long after our current crop of "wonder drugs" are out of vogue and are wholly antiquated, healthy eating will remain one of the primary tools to stave off disease.  If your primary care doctor hasn't discussed your diet in detail or referred you to a nutritionist, your doctor isn't sufficiently knowledgeable to guard your most precious asset:  your life.  My advice?  Get a better doctor.

Lesch-Nyhan syndrome

Q:  Hey, I am a lowly RN student, trying to graduate next Friday.  I have an ER doc driving me nuts asking about a weird disease called "Leech-Nyhaw Syndrome."  He wants to know what enzyme is deficient in this disease.  My friend Cathy (who referred me to you) says you are the most wonderful, smart, SWEET individual and you would love to help me prove this doctor that nurses know something.  Please reply ASAP!  Thank you.   Maribeth

A:  I think you're referring to the Lesch-Nyhan syndrome, a.k.a. hereditary hyperuricemia, a condition in which males (usually) are severely disabled, both mentally and physically, and they have pronounced hyperuricemia (which causes gout and kidney stones) and a tendency to mutilate themselves by chewing their fingertips and lips.  Choreoathetosis and spasticity may also be seen.  The deficient enzyme is hypoxanthine-guanine phosphoribosyltransferase.  I'd like to see that question on Jeopardy!  "I'll take hereditary metabolic defects for $500, Alex."

Intractable de Quervain's tenosynovitis

Q:  I have de Quervain's tenosynovitis and had surgery for it, but I still have bothersome wrist pain.  Why?  Thanks, Mandy

A:  Have you done anything to precipitate your de Quervain's tenosynovitis?  Any repetitive or excessive movements such as hand twisting or forceful gripping?  Hammering?  Skiing?  Racquet sports?  Lifting a baby?  Any direct trauma to that area?  Do you experience any "snapping" with thumb motion?  Any crepitation (a crackling sound)?  Do you have any visible swelling?  Have you had x-rays to exclude osteoarthritis at the thumb CMC joint?  Do you have a positive Finkelstein test (i.e., flex the thumb across the palm, wrap your other fingers over it, then ulnar deviate the wrist — that is, bend it medially with the palm facing forward)?  Do you have any numbness on the back of the thumb and index finger?

Are you diabetic or pregnant?  Any thyroid disease?  Any rheumatoid arthritis?  (Those conditions are sometimes associated with de Quervain's disease.)

Was the surgery beneficial to any extent?  Did your surgeon discover any adhesions between the tendons and their sheaths?  De Quervain's disease rarely recurs after proper surgical intervention, which leads me to wonder if you received the best possible care.  Both the abductor pollicis longus and the extensor pollicis brevis tendons need to be released.  A septum may be present that separates the two motor units.  This can be deceiving, leading the surgeon to miss attending to the extensor pollicis brevis tendon.  The tendons can be differentiated by moving the patient's thumb during surgery.  If a tendon glides with metacarpophalangeal (MCP) joint motion, it is the extensor pollicis brevis.  If a septum between the abductor pollicis longus and the extensor pollicis brevis is identified, it also is released.

I imagine that you've already tried rest, splinting, and oral anti-inflammatory drugs in conjunction with splinting.  Ever had cortisone injections?  One injection permanently relieves symptoms in roughly 50% of patients, and a second injection given at least a month later permanently relieves symptoms in another 40-45% of patients.

If you had cortisone injections, were they definitely injected in the tendon sheaths?  If given subcutaneously, they could lead to fat and dermal atrophy, causing a hollowing out of the skin and loss of normal pigmentation.  These atrophic changes generally resolve over six months, but their prior presence could be a tip-off that the injection site was inadvertent.

Have you tried reducing your intake of trans-fatty acids?  (Any food containing "partially hydrogenated" or "hydrogenated" fats will contain trans fats.)  Have you tried increasing your intake of fish or fish oil?  Those are good sources of essential fatty acids (EFAs) that tend to inhibit inflammation.

Staying healthy during and after travel

Q:  I frequently get sick during or shortly after I travel.  Do you have any idea why?  Thanks, Tara

A:  There are a number of possibilities.  You didn't say how you travel, but if you travel by air one possible culprit is the notoriously contaminated air on airliners.  Not only may you be seated next to Typhoid Mary, but in an attempt to avoid her breath you may direct the airliner's air nozzle toward your face.  Result?  You're just inoculating yourself with the stale, over-recirculated and under-filtered air that's been exhaled by the other passengers.  Judging by the frequency with which they cough, I often wonder if the plaque is making a comeback.  Even if you travel by train or bus, you're packed like a sardine much closer to sick people than you'd like.  Bottom line?  Mass transportation is a great way for spreading disease.

Can your immune system go to sleep once you're off the jet, train, or bus?  Not quite.  Your next stop is often at a hotel or motel — and if you have a weak stomach, you might want to skip this paragraph since it's going to be very graphic.  Detectives investigating a murder at a Holiday Inn (hardly a flophouse) analyzed a bedspread for evidence.  In addition to what they were looking for, they found 106 stains, 38 of which were semen.  So what can you realistically expect to find on a motel bedspread?  Besides semen, you're likely to find vaginal juices, fecal matter, nasal effluence (snot), menstrual fluid, smegma, blood, urine, saliva, tears, skin oil, countless varieties of bacteria, fungi, and other infectious organisms — and do I really need to continue?  You get the message:  bedspreads are rarely washed between customers, so you should treat them (and the equally unwashed blankets) as contaminated objects.  State laws generally mandate that bed sheets and pillow covers be washed, but hotel/motel housekeeping staff often think that it's a waste of time to change a sheet that's not visibly soiled.  So what do they do?  Just make the bed so it looks spiffy and fresh.  Given that I harbor a healthy and not unwarranted fear of germs and much skepticism about the thoroughness of some housekeepers, I carefully inspect the bed as soon as I check into a room.  In doing this, I've found visible pubic hairs and crusty stains — sure signs of unwashed sheets — at least 5% of the time.

If you think the bed is the only thing you need to worry about in a motel room, you're wrong.  Have you ever watched a maid clean a motel bathroom?  I have, and here's what I noticed.  Generally they use gloves — great for them, but utterly inconsequential to you.  What's important is what they touch, and in particular the order in which they touch things.  For example, using a rag to wipe off a toilet seat and then using it to wipe off a bathroom sink faucet is something you and I would never do at home, yet some maids (based upon my observations) either don't know about germs or don't care if you get sick.

After you've settled into your motel room, you'll soon leave it to go out to eat.  Are you safe yet?  No way.  It's simply human nature: compared to you, restaurant workers are less likely to be meticulous with food hygiene. Working in the ER of a tourist town (and therefore seeing many patients who have eaten restaurant food) has convinced me that the incidence of gastroenteritis or food poisoning is remarkably greater in people who eat out than in people who eat at home. Contracting such a problem can stress your immune system, lessening its ability to deal with other infections. If you're lucky, you'll witness the hygienic faux pas and thus be able to avoid the contaminated food, but most likely you will savor every germ as you unwittingly infect yourself. I once ate at a popular fast-food Mexican restaurant in which most food preparation is done at a counter directly in front of the customer. The teenie bopper who was preparing my burrito had what was obviously a whopper of a cold (pun intended). She blocked a couple of wet, slimy sneezes with one of her hands, and then resumed working on my burrito, pawing the tortilla with her well-lubricated hand. Even if nasal effluence (a.k.a., snot) were devoid of germs, I'd be less than enthused about wrapping my lips around such slime. Common sense should dictate the advisability of washing her hands after the sneeze, but when I suggested that she do that after discarding the burrito, she looked at me as if she were truly mystified and offended by such a request. Her countenance said it all. Such temerity! Such insolence! How dare you suggest such a thing? Well, I wouldn't eat food peppered with the nasal discharge of someone as delectable as Ashley Judd, and I certainly wouldn't bite into the effluvium of a burrito bimbo. I never ate there again.

Having treated innumerable injured restaurant workers in the ER, and having noticed that many of them have obvious infectious diseases, I've come to the conclusion that most restaurant managers don't care if your food is inoculated with a germ-laden "Special Sauce" contributed by an infected employee. Most of the resultant infections will cause no more than a few days of misery (as if that weren't bad enough), but there are some truly nasty germs lurking inside a disproportionately high number of food-service workers. Consider cooks and chefs. One of their occupational hazards is sustaining a hand cut. Do you think the contaminated work surfaces and utensils are completely disinfected before your next burger is made? Do you think that any contaminated food is discarded? Dream on. A former employee at a popular restaurant in my childhood hometown revealed that it was common practice for their cooks to spit on a steak that had been sent back for additional cooking. With such an attitude, it is difficult to believe that they would be more careful with food that was otherwise tainted. Professionals, they're not. And now for my politically incorrect observation of the day. Most likely, you will not see the person who cooks your food in a restaurant. When they're injured, I see them in the ER—and I see that a noticeably higher percentage of them are sickly, scrawny people who look as if they're in the latter stages of hepatitis or AIDS. I'll bet that their emaciated appearance does not result from a lack of food, either, which leaves chronic disease as the next-most-likely condition to cause such a problem. Many of them have told me that they're intravenous drug abusers (which, of course, is a major risk factor in the acquisition of the germs which cause hepatitis or AIDS). Are you appetized yet? Furthermore, some restaurants (and, disgustingly, most hospitals) seem constitutionally unable to provide truly clean dinnerware and utensils. The telltale adherent food particles says it all:  if bits of the last meal are clinging to your fork, how clean is it? Not very, I'd wager. If you have the runs a few days later, my mouth will not be hanging open in disbelief.

If you are going to eat in a restaurant anyway, your best defense is to dine in an expensive, classy establishment. Odds are, their chef and workers will be less likely to be infested, and less apt to engage in behaviors that might transmit germs to you. And if you're pleasant and a decent tipper, they'll likely return the favor by being careful with your food. Hold the pickles, hold the lettuce, special orders might upset us . . . .

OK, what's the next threat to your health while you're traveling?  In addition to the specific threats discussed above, the stress of jet lag or even the stress of sleeping in an unfamiliar bed can be enough to depress your immunity enough to bring on a cold or other infection.  In Fascinating Health Secrets I discuss many ways to avoid contracting infections and I present many tips for keeping your immune system in prime condition.  Some people may think that it's a pain to take a few seconds to employ my tips, but what is preferable:  taking that time to stay healthy, or spending a week blowing your nose and coughing?

No time for exercise?

Q:  My wife is always bugging me to exercise, but I just don't have the time.  You seem to be the man with an answer for every imaginable question, so I thought I'd write to you.  Do you have any magical solution, Doc?  Thanks, Jim.

A:  I'm not sure if I'd term this magical or not, but I do have a reasonable solution to your problem.  First, if you have a limited amount of time to exercise you should lift weights (and this should be the cornerstone of an exercise regimen for just about everyone, even those without time constraints).  While people who lift weights typically spend 30 to 60 minutes two or three times per week exercising, most of that time is spent resting between sets.  The actual time spent lifting the barbell is usually just five or ten minutes.  Therefore, here is what I do when I'm really pressed for time:  instead of doing what I usually do while resting between sets (watching TV or reading), I do some productive task that I need to do such as washing dishes, doing laundry, vacuuming, picking up around the house, paying bills, etc.  Integrated into my day like that, the few minutes spent in actual exercise is negligible.  Furthermore, even that time isn't wasted because exercise improves your sleep and daytime energy level to the point that it more than makes up for the time spent in actual exercise.

Beautiful drug reps:  a symptom of a diseased pharmaceutical industry

Q:  I just read in a magazine that a pharmaceutical manufacturer published misleading data on one of their drugs, and I've heard of several similar reports.  With such alarming findings as this, how can you trust the drug companies and the drugs they produce?

A:  I don't.  In the criminal justice system, if a person is found to have given false testimony, everything that person said (even if some of it were true) is automatically suspect.  I think that people with common sense naturally doubt anything a liar says, especially when that liar has a vested interest for lying — and drug companies, eager to make billions in profits, have a strong incentive to lie.

For healthcare consumers — and that's all of us — the bad news is that this problem of lying about drugs is more widespread than what you might suspect based upon the number of times drug companies or their lackeys, the researchers, have been caught lying.  Does anyone seriously believe that we've caught pharmaceutical companies every time they lie?  I don't.  In fact, I think we're aware of only a small percentage of the cases.

To compound the problem, the whole system is suspect.  The relationship between drug companies and researchers who are purportedly independent, objective, and unbiased scientists is one that is just too cozy.  Because of the way pharmaceutical companies dole out money, there is an incentive for researchers to either lie outright or twist the facts to favor the drug companies.  A number of prestigious researchers have built their careers by giving drug manufacturers the data and interpretations they desire; thus, those brown-nosing sycophants are essentially academic prostitutes.  More principled researchers who refuse to kowtow to the drug companies are often punished either by being sued, or by being denied future research grants.  If you're a drug company executive looking to maximize profits (as all of them are), who do you want doing your research:  a puppet who will bend over backwards to please you and give you the info you want, or an unbiased researcher who might say that the drug you've spent $250,000,000 developing has problems with efficacy or safety?  All too often, the dollars are channeled to the puppets.

Clearly, there are a number of drugs that do work without possessing undue safety hazards.  Unfortunately, the drugs which fall into that category are usually the time-tested drugs for which patent protection has expired.  Consequently, drug companies don't actively push those drugs.  Of all the drug ads and pharmaceutical reps I've seen, not one extolled the merits of an old drug from which the company had little profit to be made.  Naturally, drug companies promote their latest expensive drugs that are protected by patents.  History has taught us that the latest, greatest drugs often aren't nearly as effective or safe as the drug companies would like us to believe.  To combat this reality, they spend billions of dollars convincing doctors and the public that their new drugs are better.

One of the tools in this deception are gorgeous female drug reps, who are hired for their ability to transfix doctors.  If the drugs were really as good as the drug companies make them out to be, there wouldn't be a need for such exceedingly beautiful reps.  I don't know where they find such perfect physical specimens, but many of them are so attractive that many docs would follow them through a minefield.  Not surprisingly, it is easy to get docs to listen to a 10-minute drug spiel, after which the doc is rewarded with free pens, notepads, magnets, stickers, flashlights, tickets to sporting events, and whatnot.  The really lucky docs are sometimes given a date with the goddess — I mean, drug rep.  As a physician, the only thing I can say about that is, "Been there, done that."  So do you want to put your faith in such a system?

I don't.  I used to be an ardent believer in that system, after receiving the usual brainwashing afforded any American and after being indoctrinated by four years of medical school.  I'm now justifiably cynical about the supposed successes of modern medicine.  Except for vaccines and a handful of antibiotics (most of them old, by the way), what do we really have to show for our supposedly miraculous wonder drugs and exorbitantly expensive medical gizmos?  Not much.  People sometimes point to our increased average lifespan, but the reality is that that increase primarily resulted from a diminution of child mortality, obstetric complications, a sharp reduction in the rate of accidental deaths (especially those at work), and conquering a few infectious diseases such as tuberculosis, smallpox, diphtheria, and influenza.  The truth is that the physical health of people is often worse than what it was many years ago.  Some of this decrement is due to our poor diet and sedentary lifestyle, but the point is that modern drugs are often not the saviors we think they are.  Add up all the supposed plusses of our zillion wonder drugs and you'd probably think you could beat any disease and live forever.  I don't claim that those "wonder drugs" aren't helpful, but I think their benefits are overblown and the negative aspects of using them are given short shrift.

By the way, if you think you're better off by swinging your pendulum the other way and opting for alternative medical approaches, you're in for a rude awakening.  I used to be a strong advocate of some alternative approaches, some of which are helpful.  The problem with alternative medicine is twofold:  some of the therapies which fall into the rubric of alternative medicine are therapies that are pure hogwash, such as homeopathy.  The other problem is that some of the possibly meritorious therapies are tainted; a good example is herbs, many of which are contaminated by heavy metals such as lead, and other toxic chemicals.  Incidentally, many of these herbs originate in China.  In one of my books I made a comment that if the Chinese can't nuke us, they'll poison us.  Unfortunately, that was only partially tongue-in-cheek.

Increasing lifespan

Q:  What can I do to increase my lifespan (besides the obvious things like don't smoke, over-eat, abuse drugs or alcohol, or sleep with women whose prior boyfriends were bisexual)?  Andy

A:  I put a number of such tips in Fascinating Health Secrets, but here is one tip that isn't in my book:  if you don't have it already, cultivate a fervent raison d'être (reason for existing).  In other words, find something in which you're passionately interested — something that makes you excitedly say to yourself, "I just can't wait for __________." (Fill in the blank with whatever it is that floats your boat.)  For example, I'm avidly interested in inventing, and I just can't wait to see how some of my inventions will turn out.  I have hundreds of things that make me say "I just can't wait!" and collectively these things make me crave to be around tomorrow and for as long in the future as possible.  The more scientists learn about the body, the more we realize that the mind-body connection is very real.  People who possess a thirst for the future are the folks most likely to see it.

Common errors people make in choosing what they eat

Q:  I'd like to eat better, but I don't know how.  Can you help me?  Anna

A:  You didn't give me any indication of your diet, so I'll just pass along a few general tips by mentioning some of the most common errors people make in choosing what they eat:

-- Assuming that fortified foods are good for you.  A few are healthy, but in general most fortified foods are just junk food with a few vitamins and minerals added.  Junk food that is fortified is still junk food.  For example, many mothers think they're doing their kids a favor by giving them some fake juice that supplies 100% of the daily vitamin C requirement per serving.  If those mothers gave orange juice instead, their children would receive vitamin C and many other nutrients, too.  I object even to foods that are fortified with a wider spectrum of nutrients because manufacturers rarely fortify with all nutrients; instead, they fortify with popular, well-known nutrients.  Does your body care whether or not a nutrient is popular?  Obviously not.  Furthermore, I wouldn't count on the fact that scientists know all of the nutrients that affect health.  In the years that I've studied nutrition, scientists discovered many previously unknown or previously underappreciated substances in foods that are conducive to health, and in the future many more are sure to be found.  There are hundreds and hundreds of these salubrious substances, so when your "fortified" food contains a smattering of six or so nutrients, you know you're being shortchanged.  This trend in fortifying with popular nutrients created another problem; namely, that some people are now receiving too much of some nutrients, such as calcium, which is ubiquitously added to scads of foods these days.

-- Eating far too much sugar.  I've had many patients who obtained over 50% of the calories in their diet just from the sugar in soft drinks!  Add in the sugar from other sources in their diets, and it is clear that a staggering percentage of their calories came from refined sugar, thus displacing other more healthy foods from their diets.  Even if you don't drink sugared soft drinks, it is almost impossible to avoid loads of sugar in other products — even ones that don't seem likely to be laced with sugar, such as ketchup.  To compound this problem, food manufacturers often attempt to disguise the fact that their products are primarily sugar by adding different sources of sugar.  Here's an excerpt from Fascinating Health Secrets that clarifies this duplicity:

Food manufacturers are required to list ingredients according to their proportion in the food. If the food has more water than anything else, it is listed first on the label. This seems straightforward enough, but there is a loophole which allows manufacturers to engage in chicanery. For example, consider the following label: "Flour, sugar, corn syrup, butter, baking powder, and salt." You might conclude that there is more flour than sugar in this product, but this may not be the case. Corn syrup is essentially liquid sugar, so if the product was 30% flour, 29% sugar, and 28% corn syrup, it would actually be 51% sugar (it's not the 57% that you might expect, because corn syrup is about 77% sugar and 23% water). Nutritionally, honey and maple syrup are essentially liquid sugar, too.

While there is sometimes a legitimate reason to include more than one type of sugar, manufacturers often include different types for the sole purpose of misleading the consumer. This trick can be done with fats, too. Be on the lookout for it. You will be surprised how common it is.

If you think it was tricky to list the sugar as two separate items (sugar and corn syrup), it can get even worse when you learn that manufacturers sometimes use other synonyms for sugar such as dextrose, glucose, sucrose, and natural sweeteners.  This trick is often used to camouflage how much sugar is in "health bars."

-- Eating too much bad fats (saturated fat and trans fats) and not enough good fats (monounsaturated fats and essential fatty acids or EFAs).

-- Thinking that fat-free foods are good for you.  Some naturally fat-free foods are obviously healthy, but many fat-free manufactured foods are actually worse for you than their fat-containing counterparts.  For example, many fat-free cookies contain more sugar and calories than the same brand of cookies in the regular (fat-containing) version.  Thus, people who eat these fat-free foods in an attempt to lose weight are misled.

-- Not eating a wide variety of vegetables and fruits.

-- Thinking that pasta is good for you.  If you believe that fallacy, I have some swamp land I want to sell to you.  Pasta may be better for you than eating a few tablespoons of sugar, but that doesn't make it healthy.  The pasta that most people eat is over-refined, but I won't object if you eat whole-wheat pasta.

-- Thinking that natural sweeteners such as honey and maple syrup are much healthier than plain old sugar.

-- Eating too many processed foods.

-- Failing to modify nutrient intakes during times of special needs, like pregnancy.  Everyone knows pregnant women need more nutrients, right?  Well, did you also know that they should carefully limit their intakes of some nutrients, too?  The risk of birth defects is doubled when women consume more than twice the RDA of vitamin A in early pregnancy. Women can easily exceed this amount when they take multi-vitamin tablets, fortified cereals, or other foods.  Think about that:  a mother who goes out of her way to take vitamins and "eat right" may actually harm her baby.  I hate to be a health nag, but if you're a woman and this one fact alone doesn't convince you of the need to learn more about nutrition, what will?

Can being chilled cause a cold?

Q:  Can being chilled cause a cold?  I've heard a lot of conflicting opinions on this matter.  Thanks, Eric

A:  Being chilled cannot directly cause a cold (that requires infection by a virus), but it can indirectly cause one by reducing immunity.  Stress of any sort — from running a marathon to taking final exams to working outside during cold, rainy weather — can impair immunity and thereby predispose someone to a cold or other infection.  People are constantly exposed to a myriad number of germs, so one of the essential conditions for infection is generally present.  Your immune system is usually able to fend off these incessant attacks, but if your immunity is suppressed by stress, poor nutrition, lack of sleep, or other factors, then an infection can develop.

One of the reasons why I think people shouldn't be so blasé about infections is because some of them are not nearly as benign as they may seem.  I've seen many pregnant mothers express a nonchalant attitude about exposure to germs that may cause a cold or similar infection.  What those mothers don't know is that some germs which cause minor infections in pregnant women can trigger horrendous birth defects in their unborn children.  Also, in recent years scientists discovered links between certain infections (even seemingly minor ones) in adults and the subsequent development of serious and often lifelong diseases such as schizophrenia, depression, bipolar illness (manic depression), and anorexia nervosa.  We also know that germs are at the root of certain diseases, such as peptic ulcers, that once seemed to be totally unrelated to germs.  Research also suggests that germs play a role in heart disease, and some germs can induce cancer.  Sorry for the pun, but germs are nothing to sneeze at.

With such potentially serious consequences, you might think that people would try to minimize their exposure to germs.  Let's say you're in the checkout line in a grocery store, and you notice that the cashier is coughing and sneezing.  Would you move to another line?  I always do, but I've never seen anyone follow my lead even when I explained to the people behind me why I was exiting that line — they just seemed happy to have one less person ahead of them!

In Fascinating Health Secrets I gave numerous tips for minimizing your exposure to germs and enhancing immunity.  The tips on enhancing immunity are also excerpted on my web site.

Chance of catching something from the ER?

Q:  I am very nervous about the hospital and going in there.  I was recently in an ER after a dog bite and all went well, but still I wonder:  what is the chance of contracting some infection or disease from visiting the ER?  Has this ever happened?  I know this may sound psychotic, but what do you think?  Thank you for your time!  Lonnie

A:  The chance of acquiring an infection in the ER is relatively small for an adult. However, I've seen young children play on the floor with toys and, as they so often do, put those toys into their mouth. I'd warn the parents that the floor was not sterile — who knows, the last person in that room may have been a patient with AIDS or hepatitis, and their blood sometimes drops on the floor.

Medical pros and cons of heated floors?

Q:  My wife and I are building a home, and we're considering heated floors in the kitchen and bath, both of which will have ceramic tile.  We are curious as to whether or not there are any pros or cons about this from a health standpoint.  Thanks, Dan and Barbara

A:  Yes, there are.  First, the good news.  Compared to walking on unheated floors (especially ceramic tile floors, which can feel very cold), walking on heated floors is a pleasant experience that helps to mitigate stress.  When a person is subjected to any type of stress — mental, emotional, or physical — the body responds by releasing stress hormones such as cortisol and epinephrine (adrenaline).  These hormones have a number of adverse effects, from increasing cardiovascular risk to depressing immunity to changing the distribution of body fat — in a not very appealing way, incidentally.  Obviously, walking on cold tile floors isn't torture, and walking on heated floors isn't ecstasy, so the switch to heated floors isn't going to dramatically affect your health.  However, that doesn't mean that heated floors are worthless.  Let's consider cardiovascular risk, for example.  There are a number of things you can do to reduce that risk:  not smoking; avoiding saturated fats, trans fats, and sugar; eating oatmeal; exercising; avoiding obesity, getting enough good-quality sleep; drinking alcohol in moderation; controlling your blood pressure and blood sugar levels; ensuring that you're not deficient in vitamins involved in homocysteine metabolism (B6, B12, and folic acid); reducing stress; and on and on.  Individually, any one of these interventions will not safeguard you from a heart attack.  However, if all or most of those steps are taken, your cardiovascular risk will fall.

Now for the bad news.  Heated floors get warm enough to foster bacterial growth, but not hot enough to kill them.  Couple this heat with moisture, such as what you'd find in a bathroom, and you essentially have a large bacterial incubator.  However, this problem can be controlled by frequent washing and disinfection.  Keep in mind that unglazed tiles are more porous and difficult to sanitize, but even they are better than heated wood floors, whose porosity and cracks make complete cleaning virtually impossible.

Docs who are anti-nutrition

Q:  Why do you suppose doctors in this country are so anti-nutrition?

A:  Most know very little about nutrition, and they're indoctrinated (or brainwashed) into thinking that drugs are the answer. The pharmaceutical industry has too much influence over doctors. Also, part of it is the fault of Americans. We're so used to easy and immediate things, from entertainment, to travel, to food, to shopping . . . the list goes on and on. When I was in the ER, some patients who didn't need a prescription would scream at me if I wouldn't give one to them. In their minds, a pill is the answer. Lifestyle changes are too hard. Just waiting it out — such as waiting for a cold to pass — is too much to ask, even if the prescription drug would not hasten the disease resolution. So, they want a quick fix, even if it is just a voodoo treatment.

Links to other pages in the More Q&A section:

Questions about becoming an ER doctor

Questions about other ER personnel

Miscellaneous questions

Very miscellaneous questions

Questions about love and sexual attraction, libido, pleasure, and performance

Copyright © 2000 - 2001 by Kevin Pezzi, M.D.  All rights reserved.  No liability is assumed with respect to the use of the information herein.  You should consult with, and obtain the approval of, your personal physician before instituting any of the measures presented.  No material intended for the general population can attempt to treat specific individuals, and no material in this web site should be construed as offering individual medical advice.  Given the innate variability of people, it is critical that your physician approves the adoption of any information herein contained as being safe and effective for you.  A physician's circumspection is his—and your—greatest asset.

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