Full Body Scans

Pet Scan Ct Xray MRI of Full Body

I was recently on vacation and my wife and I had a fascinating conversation with a couple from Texas. They were dot-com millionaires, owned three homes and were already retired at the age of 50. When they found out we are physicians they told us about an extensive physical they had gone through at a major university center on the east coast that will remain nameless. It included a nutritional assessment that was completely canned, scripted, uninformative rubbish but that is for another post. It also included a full history and physical with a physician and the kicker… a full body CT scan. Even before I said anything the couple already had the impression they had wasted a lot of money. I think they were hoping I would tell them they were wrong and they had gotten a great value… but if they were they were disappointed.

For profit clinics have been doing full body CT scans and MRI scans now for some time. They advertise that they offer piece of mind by catching cancers or other dangerous problems early so they can be fixed before they get beyond repair. However, these scans offer anything but piece of mind. For most people they will find what we in medicine call incidentalomas. That is a tumor, benign or malignant, that is found incidentally or by coincidence when you are looking for something else. Commonly this happens in medicine when for instance you do a CT scan of the lungs looking for a blood clot and instead find a small nodule that could be old scar tissue or could be a tumor. There is no way of knowing by looking at it on the scan so now you are pressed to either biopsy it or watch it by doing a follow up CT scan. But this nodule had nothing to do with why you did the CT scan in the first place and it was causing the patient no symptoms or problems.

When you do a full body CT scan you are basically guaranteeing anything you find will be an incidentaloma. Assuming you felt well when you went in for your body check up you now have found lesions or abnormalities that were causing you no symptoms. Best case scenario you find nothing. Then you really do get the piece of mind you were hoping for and you go on with your life.

What is not advertised is the 46% of patients where something is found and therefore needs follow-up studies. Usually these studies show the findings were nothing of significance. What much of the general public does not understand is there a large percentage of people carrying around benign tumors in their body that they do not know are there and are not causing them any problems and never will. Also, what even most physicians I know do not consider, is that your body forms cancerous cells hundreds if not thousands of times a day. However, your body has such wonderful defense mechanism to kill off cancerous cells that most of these will never make it past the microscopic phase. What has never been studied (and likely never will for obvious reasons) is if even small visible malignant tumors could also be killed off by the body if left alone sometimes. And this may be happening in the body often, we just don’t know about it because most of us do not get a CT scan unless we have symptoms.

There is no way for us as doctors to know if that mass we see on the scan is benign or malignant unless we biopsy or remove it and see what it is under a microscope. This sounds easy enough but it is not. Roughly 200,000 people die each year from medical mistakes. The more you submit yourself unnecessarily to procedures or medicines that are unneeded the more you increase your chance of being one of those 200,000. Biopsies carry a risk of bleeding, infection or even death depending on where they are. A biopsy of a lung mass can collapse the lung and require a chest tube to fix. Biopsies of adrenal gland masses have an extremely high risk of bleeding. Masses in the kidney are very risky to biopsy and often we cannot be satisfied that the biopsy ruled out cancer so often masses in the kidney lead to removal of that kidney.

More information is not always better. PSA blood test screening for prostate cancer is a prime example. Doctors and patients had assumed for years that by checking a PSA in the blood and possibly catching prostate cancer before it gets too big or metastasizes has to be a good idea. It was the standard of care for years but then studies showed it did not improve mortality or morbidity. It was of no benefit to patients at all.

Most are in agreement that yes, cancer is caught earlier with PSA screening but this benefit is offset by procedures and surgeries done on patients who had a cancer that would have never caused the patient any problems. In fact autopsy studies of men who died from other causes found prostate cancer in 30% of men in their 50s at autopsy and in 80% of men in their 80s. So this is why it is often said that prostate cancer is often a cancer someone dies with, not from. And the PSA screening that was supposed to be giving more information or piece of mind may actually just have been leading to unnecessary biopsies and surgeries for cancers that never would have caused any problems.

Somehow the message needs to get out that more medicine is not always better. Medical tests, procedures and medications all have benefit but come at a cost. Not only financial but risk wise as well. However, as long as our medical system is based on financial profit for each test done or medication sold the incentive will always be to play up the benefits and brush off the risks. This has to change.

 

* UPDATE- I spoke to the case manager mentioned above and got the OK to use her true name. Her name is Denise Wells and she can be found at her website Om Sweet Om Yoga. There you will find some of her story and her current yoga classes and teaching. Thank you again Denise for opening my eyes to this.

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Yoga for Small Bowel Obstruction- Un-kink that Garden Hose

yoga

For anyone who has had surgery on their abdomen before, there is an increased risk for bowel obstructions. A bowel obstruction can be imagined by thinking of your intestines like a long garden hose. If they get twisted they can pinch off like a garden hose only instead of water not going through it is your food. It gets backed up and can cause pain, nausea and vomiting and inability to have bowel movements. Sometimes this will correct on its own but sometimes it requires surgery to re-straighten the bowel. This can happen in people who have never had surgery before but it is much more common in those that have because surgery can cause bands of scar tissue that we call adhesions. These bands of scar tissues give the intestines something to wrap around and get kinked.

For some this can be a recurrent problem. I have had a number of patients that this has led to a debilitating spiral of recurrent surgeries to un-kink the bowel and then further scar tissue causing more obstructions. These patients’ lives are changed forever and they often lose weight and become quite ill. And there is not much we in the medical community can do for them. It is a mechanical problem so medications are of no help. Some University hospitals will try extensive “lysis of adhesion” surgeries to go in an break up these bands of scar tissue but this more often then not just leads to more scar tissue.

Here at the hospital where I work there is a nurse who went through this personally and after years and multiple surgeries she met a doctor from India who seemed shocked that she had not tried Yoga yet. He stated that Yoga would fix her with such conviction and she was so desperate that she gave it a try. And it worked! Ten years later she has not had another bowel obstruction and she is now a Yoga instructor.

I was elated when I heard this story as these cases are so hard for me as I see the patient spiraling downward and I feel powerless to help. Finally I had something safe and possibly effective to offer. And I can tell you from personally experience that the patients that have tried it so far all to the best of my knowledge and follow up have been bowel obstruction free.

One may think this is all tree hugging, hippy, new age crap (no pun intended) but actually it makes perfect sense. Yoga entails a lot stretching and is one of the few exercises that really stretches the core area. This may very well be the key to Yoga’s success. Bending and stretching the core area may likely pull and lengthen those scar tissue bands until they are long and floppy, no longer giving the intestines anything to wrap around. And as for the side effects of Yoga. Well from what we know it’s mostly improved cardiovascular healthy, balance, mood… well you get the idea.

As for the data… none. I can not find one study looking at this approach. Not for yoga, stretching or any other form of exercise.

So yet again we have a risk free, effective treatment for a debilitating medical condition that also happens to cost medicare billions of dollars in hospitalizations and surgeries that do nothing to fix the underlying issue. And yet it has not been studied in any way and other than that Indian doctor and myself I know of no other doctor recommending it to their patients with recurrent bowel obstructions.

It is time we do a study to look at Yoga for bowel obstructions and see if we can finally stop the endless nonsense cycle of surgery making scar tissue that is broken up with surgery that creates more scar tissue. And I highly doubt this will be the only thing Yoga is found to treat.

The FDA Wants to Regulate Your Poop

Poop

Awaiting FDA approval.

Yep, that’s right, the FDA has claimed jurisdiction over poop. There is some background to this story first that I have covered in my previous post on probiotics and C diff. Clostridium difficile (C diff) is an infection of the colon that happens to people after they have taken antibiotics and killed off their normal healthy gut flora. This leaves no competition for C diff to grow and cause a bad infectious diarrhea that can range from annoying to deadly. And treatment can range from a 10 day course of antibiotics to an emergent colectomy (surgery to remove the entire colon). Recurrences of the infection after a course of antibiotics is very common.

Going back more than 10 years some physicians have tried in desperation in very sick patients who failed antibiotics to repopulate the normal healthy gut flora by injecting the stool from a healthy person into the colon of the infected patient (a process now commonly known as a stool transplant or  fecal microbiota transplantation). And amazingly it works, very well actually. Cure rates in the studies that have been done suggest a cure rate above 90 percent. And that is is in a population that has been tried usually on multiple courses of antibiotics and is quite sick.

Ten years later in steps the FDA. They now state that stool transplants are under their jurisdiction and have required people to file an “investigational new drug application” form before performing a stool transplant. This requires paperwork and a long delay before a response and authorization which may not be granted.

So now the FDA has labeled poop as a drug and is trying to restrict its use. I have so many problems with this. First, it is clearly an overreach of their authority to call poop a drug. Secondly, to call it “investigational” is also misleading. Like so many of the other things I speak of in my posts there is lots of data on stool transplants already. Stool transplants are not only safe, they actually outperform antibiotics by a landslide and that is even with only being used in the sickest patients who have failed antibiotics.

I also can’t help but think that the makers of Dificid (fidaxomicin) have something to do with this. Dificid is a relatively new antibioitic for C diff. The data that led to its approval was not impressive. For treating C diff it was no better than the standard antibiotic flagyl. The advantage it touted was a decreased recurrence of C diff after treatment. But that advantage was very small to almost insignificant. And for this very minor advantage it comes at a price of about $2000 for a 10 day course. That is compared to $10 for the standard treatment with Flagyl. And poop of course is free.

Lastly, and what disturbs me the most, is that despite the extensive press on this issue no one seems to be asking the more obvious question. Why don’t we just research probiotics which do the same thing? Probiotics are designed to repopulate the normal healthy gut flora just like a stool transplant does and it doesn’t have the ick factor like stool transplant. The studies of probiotics that have been done so far are very promising. I can tell you from personal experience that they work. I use probioitics to prevent C diff in my patients taking antibioitics and I have not had a case in over 3 years, which is when I started doing this as standard practice. And when I get a patient who was not been cared for by me and got C diff I given them probiotics along with flagyl to treat their C diff and I have not had one treatment failure or recurrence after treatment while doing this. Prior to starting these practices of use of probiotics I cannot count how many cases of C diff I caused using antibiotics, and patients I cared for frequently failed a single course of flagyl and I had to go on to try vancomycin or both. I still remember one case I cared for that failed all treatments we tried and she had to go for an emergent colectomy (removal of her colon), but even that did not save her and she passed away. That case was 6 years ago and it still haunts me to this day. Could I have saved her with probiotics? Who knows? We have to do the studies to find out. A stool transplant almost certainly would have helped given the data that already exists. Unfortunately the FDA has just taken away that effective tool from us and it is my personal opinion that there will be emergent colectomies and deaths because of this policy. Fortunately, for now, we still have access to probiotics. For now.

Tryptophan and Depression

Spirulina sp. (scanning electron micrograph)

Spirulina

Tryptophan is one the 22 amino acids and is an essential amino acid, meaning we must eat it in our diet, we cannot make it ourselves. Tryptophan is also known to be a precursor used by the body to make serotonin. Serotonin is the chemical in the brain that almost all antidepressants act on to increase its activity in the brain. So it is logical that increasing tryptophan in the diet may increase serotonin and possibly help treat depression. And indeed, this has been looked at going at least as far back as 1976.

Since that time multiple small studies have been done showing that tryptophan levels are lower in depressed patients and tryptophan supplementation does help alleviate symptoms of depression. In 1976 there was a study by Dr. Farkas of 16 patients. After that there were multiple studies in the 1990s and early 2000s showing that depressed patients have lower levels of tryptophan in the blood. Shaw K et. al. from Australia in 2002 did a good review of all clinical trials that had been done to that date and found of the studies that were done almost all pointed to tryptophan being better than placebo for depression. However, it was noted that these studies were mostly small and of poor quality making it difficult to draw conclusions.

And now, 37 years after the original studies, we are still without compelling evidence to prove or disprove the effectiveness of tryptophan. So we have a totally benign substance that has good pharmacological reasons why it would work for depression and multiple studies pointing in the direction that it does work, and still we have no studies sufficiently large enough to recommend for or against its use.

Currently it is estimated that 11 percent of all American adults are taking medications for depression. All those antidepressants cost Americans $11 BILLION (that is billion with a B) in 2010 alone.

If tryptophan was found to work as well or better than these drugs we could instead be using tryptophan which costs about 15 dollars a bottle or better yet we could just get more tryptophan in our diet.

Tryptophan can be found in all kinds of foods, especially protein based foods. Soybeans, cheese, sesame or sunflower seeds, meats, milk, and many other foods are all good sources. One great source is Spirulina which is a microscopic cyanobacterium found in tropical lakes. It was eaten in the past by many ancient American civilizations such as the Aztecs. It is a complete protein containing all of the essential amino acids which includes tryptophan. Diets replacing 60% of all protein intake with Spirulina showed no adverse side effects. It does however contain large amounts of vitamin K which has to be avoided by patients on blood thinning (anticoagulant) medications.

Nearly 40 years is far too long to wait for such a potentially beneficial and safe treatment for depression to be evaluated.

Vitamin D and Psoriasis- Yet another expensive drug instead of a cheap vitamin

Vitamin Packaging

I posted previously that studies have been done using a chemotherapy drug (bexarotene) that stimulates vitamin A receptors for dementia rather than using vitamin A itself. The argument for this is usually that the analog may be safer than using the vitamin itself. Of course this claim is never investigated The only rationale I can come up for this is the analog is able to be patented and then sold at MUCH higher prices rather than the vitamin which cannot be patented. Well this same thing has happened before with psoriasis and vitamin D.

Going back as far as the 1980s it has been known that vitamin D can help with psoriasis. However, regular old vitamin D has been discouraged due to the risk of hypercalcemia (high calcium levels in the blood). However, studies never put patients on doses sufficient to do this. In fact most studies looked at doses of vitamin D far below what is known to be safe (a dose of 5000 to 10000 units per day of vitamin D3 is generally accepted to be safe in review of the literature and especially if levels and calcium are monitored). Then, after skipping over oral vitamin D without adequate testing they went straight for topical vitamin D analogs.

There are two main problems with this. First and foremost is cost. A bottle of vitamin D3 can cost as little as 10 dollars. One tube of the most commonly used vitamin D3 analog Calcipotriol (calcipotriene) can cost as much as 300 to 400 dollars.

The second problem is that psoriasis and other skin problems are often a symptom of a full body problem. The skin is just the most visible and noticeable area. Therefore the vitamin D deficiency in these patients must be treated otherwise by lathering a vitamin D analog on the skin you may merely be masking the most obvious symptom of a full body disease.

And this is a common problem with relying solely on the pharmaceutical industry. They are doing their job trying to find effective drugs. However, if they cannot patent the drugs they study they will go broke. So no one can blame them for not studying Vitamin D3. That is not their role. And they do the same with herbal supplements. They do not study turmeric, or ginger, or ginkgo because they cannot patent them. Instead they try to find synthesized chemicals that can mimic their action and patent those.

This is where the government or some type of insurance supported research organization needs to step up. We MUST have research looking at vitamins and herbs and seeing how effective they are and proving if they are safe or not. Then if, for example, vitamin D3 is shown to be effective for psoriasis with few side effects the challenge goes to the pharmaceutical industry is to find a drug that is more effective and with equally few side effects to justify their high prices. Right now they have no competition from vitamins or herbs so they can charge what they want no matter how ineffective or toxic their drug may be.