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Pesticide punch

Wading through the produce aisles

If you think apples don’t taste like they used to, you’re probably right. The Environmental Working Group (http://www.ewg.org/foodnews/) has just updated its list showing pesticide levels in 53 types of produce, and apples – formally No. 4 of their “Dirty Dozen” – now weigh in at No. 1!

Researchers at Purdue University in Lafayette, IN, analyzed 51,000 pesticide residue tests done over 10 years (2000-2009) by the U.S. Department of Agriculture and the Federal Food and Drug Administration. 98% of the apples tested contained pesticides out of over 700 samples. And most of the fruit and veggies under scrutiny had been washed and peeled, in order to represent more realistic eating conditions.

Others that made the Dirty Dozen were celery, strawberries and peaches – which contained 57 different chemicals – along with greens such as kale, lettuce and hot peppers – treated with as many as 97 pesticides.

If we stick to Canada’s Food Guide we’d consume a minimum of five servings of Mother Nature’s bounty every day. By choosing these from the least contaminated foods we’d ingest less than 2 pesticides. However, picking them from the Dirty Dozen would up our daily pesticide intake to 14 different chemicals – some of which are associated with nervous system disorders, chronic problems including cancer, endocrine system dysfunction, and lower intelligence levels in kids – who may (along with those in the fetal stage) be the most vulnerable to the synthetic residues.

There’s also evidence that the phosphorus-rich fertilizers used in fields have contributed to the toxic blue-green algae blooms in our freshwater lakes, reported to cause vision loss and difficulty walking in some people who’ve been in contact with it, but that’s another story.

When organic produce isn’t readily available -- at the market, or due to budgetary constraints – these lists could be your best shopping companions.
Milena Katz

UBC hospice gets rubber stamp

Hospice residents are the winners

It’s been five months since the UBC put their plan to build a hospice on the Point Grey Campus on hold. After checking out 15 locations, the Board of Governors agreed yesterday to stick with the plan, despite objections raised by the mostly new-immigrant Asian community living in the high-rise condo facing the sight. They say their opposition to the 15-bed facility has nothing to do with fears that property values might decrease or the "idea" of a hospice but rather deeply held cultural convictions based on their conceptions around death.

According to Professor of Chinese Religions Paul Crowe, Chinese believe “on the assumption the world as we understand it is a unified, single place that’s inhabited by both the living and the spirits of the deceased; and there’s this deeply held concern that we need to keep the spirits of the deceased separate from the living.”

Residents of the luxury tower say the prospect of having the hospice as neighbour has already triggered sickness and stress for them and their families.

UBC delved deeper into possible concerns and did further study on the potential impact on traffic and property values. They concluded that the hospice development be ratified with additional conditions. They recommended that UBC plant trees between the two facilities, maintain outreach programs for new immigrants, and “identify other housing opportunities on campus for residents of the adjacent building who wish to move.” Also, UBC’s VP Stephen Owen stated, “An open-air courtyard in the hospice will be open-air but screened so that it is not visible to the outside.”

The $15 million hospice would be used as a place for research and education, along with providing hospice care, a sorely lacking service for dying Canadians.
Milena Katz

End of the line for the gravy train?

Pharma giant AstraZeneca will no longer fund doctors' travel to medical congresses, becoming the first leading drugmaker to renounce this common perk.

Announcing the step at an industry conference in Istanbul, that pharma "is a force for good. But if we're honest with ourselves ... we’re often seen as the bad guys."

He cited a recent in the U.S., which found that only 11% of Americans rated big pharma as trustworthy, when even banks had scored 20%. The same poll also found, though he didn't mention it, that pharma, along with oil, was the industry Americans most wanted to regulate more strictly.

His company had resolved to address the problem by "never doing anything that could be misinterpreted," said Mr Brennan. "We have decided that we will no longer pay for doctors to attend international scientific and medical congresses but will instead focus our educational efforts on local educational opportunities for healthcare professionals."

He added an interesting take on the doctor/pharm rep relationship from the other side of the fence: "I know from my own experience as a sales representative, you will encounter people who will ask for gifts, or other inducements. And they will threaten to take their business elsewhere, if you don’t acquiesce ... we have made it clear that our sales force have to say no."

It's likely that other pharma companies will follow AstraZeneca's lead. The industry acted in a fairly coordinated manner in abandoning free gits like mugs and mousepads in recent years. And the announcement carries extra significance because Brennan, the only leading pharm CEO to come from a background in sales rather than medicine or chemistry, is also president of the the International Federation of Pharmaceutical Manufacturers and Associations.

The drug industry has come under pressure recently over dealings abroad, particularly with employees of foreign public health services, including doctors. AstraZeneca and other British companies have had to contend with a new bribery act in the UK, while in the United States has been investigating big pharma under the Foreign Corrupt Practices Act (FCPA). Johnson & Johnson last month to settle British and American charges that it paid kickbacks to win business overseas. AstraZeneca itself is being investigated under FCPA for its dealings in China.

Army of psychopaths to spring up in 2013

If you thought grim things were forecast for 2012, just wait till 2013. An army of psychopaths will spring up overnight. Many of our friends and neighbours will suddenly develop alcohol problems. In fact, eminent psychiatrists fear that millions of us will slip over that ephemeral frontier that separates the normal from (to use the proper medical term) the Crazy.

That's because 2013 will see the fifth coming of the brain-doctor's bible, the Book that tells us who is normal and who has a "disorder" - the Diagnostic and Statistical Manual of Mental Disorders. Is that weird neighbour just a jerk or does he have a syndrome? DSM-5 will decide.

Maybe he's a psychopath. Because, after 33 years' absence, the honest psychopath makes his comeback in DSM-5. In DSMs III and IV, psychopaths were hidden under the euphemistic category of Antisocial Personality Disorder. But the latest draft of DSM-5 will brand these undesirables as Antisocial/Psychopathic Type, which has a fine condemnatory ring. In fact it sounds more like a judgement than a diagnosis. You can presumably cure a disorder, but can you cure a "type"?

If anyone thinks this is all just semantics, consider the impact in recent years of three disorders that were redefined by DSM-IV in 1994: attention deficit disorder, autism, and child bipolar disorder. The Chairman of the DSM-IV task force, psychiatrist Allen Frances, his panel "inadvertently contributed to three false 'epidemics'."

"I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences," wrote Dr Frances. "Clearly, our net was cast too wide and captured many 'patients' who might have been far better off never entering the mental health system."

DSM-5 offers the opportunity to undo some mistakes in DSM-IV. The autistic spectrum was a bit of a dog's breakfast, and the next iteration will try to bring it some order, doing away in the process with Asperger's Syndrome and the unpopular diagnosis Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). It seems a little harsh on Dr Asperger, whose name is being de-immortalized, but fair enough.

But many more new diagnoses are trying to creep in, some pushed by eager researchers, others befriended by lawyers, all surely welcomed by big pharma. Each seeks to push the boundary between Normal and Crazy so that more people will fall into the second category. The draft includes a Hoarding Disorder. The proposed Mixed Anxiety Depression will capture millions who don't qualify for Major Depression but who constitute what we call 'the worrying type'. Irritable people who throw tantrums will have Disruptive Mood Dysregulation Disorder. There's Minor Neurocognitive Disorder for those with expected cognitive decline of ageing that's too mild to justify a diagnosis of Mild Neurocognitive Disorder .

There's also constant pressure to ease the criteria for existing conditions. A finds that the prevalence of alcohol use disorders is 62% higher under DSM-5 criteria than under DSM-IV. Adult ADD is also getting more broadly defined. It's the medicalization of normal, if bad, behaviour that scares Dr Frances and many other critics.

Book needs appendectomy
To be fair, most of the worst ideas come from outside the American Psychiatric Association committees responsible for the drafts. Some of the silliest have already been rejected. Divorce lawyers will not get their "parental alienation syndrome", which would have allowed them to counter child abuse allegations by alleging that Mommy had turned Johnny against Daddy.

Disorders that have made it this far in the process, however, are so far advanced that to ignore them would apparently be rude, so those that don't get a disease code are likely to end up in the Appendix on Axes for Further Study, which is beginning to sound like a smorgasbord of half-baked ideas, about as useful as a human appendix. One pseudo-condition that's already definitely heading there is Hypersexual Disorder, which has been derided as a philanderer's charter.

The behavioural "addictions" - shopping addiction, computer game addiction, internet addiction, will also be relegated to the appendix, except for compulsive gambling, which became officially crazy in 1994 with DSM-IV. It makes the leap from humble Impulse Disorder to become the first recognized Behavioural Addiction. Can the others be far behind?

One new condition that teeters between recognition and the obscurity of the appendix is Attenuated Psychosis Syndrome, a diagnosis intended to catch mostly young people who might be at risk of developing a real psychotic episode later in life, but who have never met any criteria for one. Those diagnosed, including the many false positives, would be treated with atypical antipsychotics, costly drugs with a heavy burden of side effects. The creators of DSM-5 declare themselves torn on this one, and welcome outside comment. In fact the whole process is in an open comment period until June 15. You can have your say .
OD

Not out of the woods yet

Last year, Canada saw the biggest increase in new physicians in 20 years. About 2,700 extra practitioners brought the national total to around 68,000, according to figures released by CIHI, the Canadian Institute for Health Information.

Most of the new physicians, about 2,300, were graduates of Canadian medical schools. A few more doctors returned to Canada than went abroad in 2009, perhaps partly due to the weakening of the US dollar. And about 300 new doctors were international medical graduates.

Until about 2004, the number of physicians was barely keeping pace with the rising population. From 2004 to 2008, the rate of increase in physicians was double that of the general population. The 2009 increase was three times faster than the rate of increase of the population.

Clearly, steps are being taken to address Canada’s chronic physician shortage. But a crunch is still coming, and this may not be enough to divert it.

For the first time in decades, the average age of physicians didn’t increase in 2009. But it didn’t decrease either, hovering at 49.7 years. Is there any other job on earth where the average age is 50? Maybe being a nun. Meanwhile, the population ages apace. Older patients mean greater need, older doctors mean less provision.

This is not to suggest that older doctors work less. On the contrary, many do longer hours than their younger colleagues. And many are delaying retirement. Quite a few may have been burned in the stock market collapse, and the 2009 figures may partly reflect their decision to work a few more years to replenish the retirement fund. Others aren’t retiring simply because they can’t find a replacement to take on their patients. Of physicians aged 70-79 in 2004, most were still working in 2008, a feat of endurance surely unmatched in any other profession.

But retirement must come eventually. And with an average professional age of 50, the numbers leaving are going to be significant.

At the same time, their young replacements appear to be working shorter hours. Doctors today want a life as well as a career. And the dramatic increase in female doctors means more family responsibilities – women doctors average about 8 hours less work per week. They have also proved more likely, in the past, to drop the profession altogether. Of the new class of 2009, 52% of general practitioners and 45% of specialists were women.

(Ratios of women to men, strangely, vary quite sharply from one province to another. In Quebec, for example, the numbers are almost even, while in Manitoba male doctors outnumber female by 2-to-1.)

Family practice continues to get short-changed, though the picture is improving. In 2004, just 23% of medical students said they wanted to go into family practice. In 2009, that had jumped to 33%. But it needs to be 40% to meet the actual need.

And why is the need growing faster than the population? Because, of course, of the ageing of Canada. In 1921, one Canadian in 20 was aged over 65. Today, it’s one in eight. In 2026, it will hit one in five. And the “oldest old”, the 85-plus, is the fastest-growing group of all. Consumption of healthcare is astronomically higher in these age brackets. We’re not out of the woods yet.
Owen Dyer

Avandia gets its death certificate

For three years now, the once-promising diabetes medication rosiglitazone (Avandia) has been waiting for the axe to fall. Sales plummeted after a linked the drug to a sharply increased risk of heart attack.

Since then, re have only confirmed that rosiglitazone increases heart attack risk in diabetic patients by 30 to 80%. Equally damning was data showing that this is not a class effect common to the thiazolidinediones – in fact rosiglitazone’s direct competitor pioglitazone has a fairly good cardiovascular risk profile.

Many diabetologists have suggested that rosiglitazone remains a useful option in reducing glycemia, so long as it’s used with care, and only in patients without heart problems. But pioglitazone’s better showing really kicks the last leg out from under this argument. Rosiglitazone delivers nothing that pioglitazone doesn’t, except for extra cardiovascular risk.

Rosiglitazone has had a Health Canada warning in its monongraph since 2007, issued a few weeks after the FDA gave it one of their notorious “black box” warnings. Its indications for use were also tightened considerably. Since then, sales have fallen by about two-thirds. The end has been drawing near, and this time, Health Canada beat the FDA to the punch.

From now on, the drug will only be prescribed in Canada if patients sign a consent form acknowledging that they’re aware of added dangers of heart attack, angina and heart failure, plus unspecified “other risks”. The patient must also certify their awareness that “there are other options to treat my diabetes.”

The physician, meanwhile, is enjoined not to use rosiglitazone-containing products except in cases when “all other oral antidiabetic agents, in monotherapy or in combination, do not result in adequate glycemic control or are inappropriate due to contraindications or intolerance.”

So farewell, then, Avandia. Neither patient nor physician is likely to go along with that, especially when there’s a boatload of promising new diabetes drugs hitting the market. Drugs whose hidden pitfalls, if any, have yet to be revealed.

What lesson may be gleaned from all of this? One reason rosiglitazone’s dangers went unnoticed for so long is that, while the drug brought much more cardiovascular risk than placebo, the effect was less noticeable when compared to other antihyperglycemic drugs like sulfonylureas and even the reliable standby metformin – because all of these drugs also increase the risk of lethal heart problems.

It may seem odd that, when cardiovascular disease is the thing most likely to kill diabetic patients, we routinely treat diabetes with drugs that increase the risk of cardiovascular disease. It seems even odder when we consider that there’s a safe, cost-free way to reduce blood sugar that actually improves cardiovascular health … that is, exercising and eating a healthy diet of low glycemic index foods.

Oddest of all, surely, is the fact that so many patients are apparently more comfortable with the idea of popping multiple pills with potentially grim side effects than they are with the idea of eating a few more vegetables and a bit less ice cream.
Owen Dyer

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A little bit of poison?

Expert witnesses fail to acquit BPA in the court of public opinion

Last month, Canada became the first – and still the only – country to formally declare bisphenol A (BPA) a toxin, listing the organic compound as hazardous both to human health and to the environment.

BPA is an endocrine disruptor that can mimic the effects of estrogen. In vivo studies have linked even very low concentrations with permanent changes to the brains and reproductive systems of laboratory animals.

Two years ago, Canada announced its intention to ban BPA from baby bottles, as did several US states. In the event, they were largely pre-empted by the industry, as the shower of negative publicity surrounding BPA made it commercially nonviable.

But BPA hardly went away. In fact, it’s ubiquitous. It may be found in cellphone casings, cash register receipts, and all sorts of packaging, including and especially canned food. It’s an extremely common ingredient in the epoxy linings that cover the metal on the can’s inside.

This, most experts agree, is the number one source of human exposure. In Canada, the age group with the highest detected levels of BPA is teenagers, followed by younger kids. These are also the age groups most likely to eat canned foods.

This month, a panel of international experts sat down in Ottawa to get to the bottom of the issue of BPA in food. The meeting was sponsored by the World Health Organization, with support from the FDA, Health Canada and the European Food Safety Authority.

Their conclusion? That canned food is indeed the main avenue by which we absorb BPA … and it’s not a problem. Their modeling shows that BPA coming in through food consumption matches the quantity going out through urine. BPA does not significantly accumulate in the body, says WHO, and therefore action to remove it from food packaging would be “premature”.

Why premature? Because, as WHO acknowledges, there are still several studies suggesting adverse health effects even at very low levels, and finding worse overall health in people who work around BPA, for instance in canneries. Some of the best quality studies have still to report their findings, so the WHO wants to keep its options open.

But WHO also didn’t want to hurt industry by causing a public health scare before it knew the facts, so it held the meeting behind closed doors and made participants sign confidentiality agreements.

This approach may have backfired. Several manufacturers, apparently unable to stand the strain of not knowing, pre-empted the conference’s findings by announcing plans to remove BPA from their products while the experts were still deliberating. Among these was the world’s largest, Nestlé.

But Nestlé only said it would remove BPA from its US products – though many such products will undoubtedly find their way onto Canadian shelves. Different solutions might apply in different parts of the world, said the company, depending partly on local “cultural sensitivities” and consumer preferences. In other words, where the public shows no sign of caring about potential toxicity, manufacturers are unlikely to worry about it either.

Kryptonite to the rescue?

A superglue that can slash heart surgery recovery time shows super promise

We’ve all been warned of dire consequences if we accidentally get Krazy Glue on our fingers when we’re fixing the lamp the dog knocked over. Many glues are so strong savvy people use them to help close wounds. In fact, they are used in medicine during hip replacements and other procedures.

Dr. Paul Fedak, at Calgary’s Foothills Hospital Medical Centre has recently shown that a new superglue can be applied to the sternum after open-heart surgery, with superior results compared to conventional treatment.

Last Sunday, over 3,000 health professionals were treated to information on this super adhesive, called Kryptonite, at the Canadian Cardiovascular Conference in Montreal. The results from a trial on 55 patients who had undergone open-chest surgery – during which the breastbone must be cut open – received either standard treatment with steel wire closures (25 patients), or wires along with the superglue (30 patients).

The glue, made by Doctors Research Group in the U.S., bonded the bones together within 24 hours, without sticking to any other tissue, while the wires alone took up to eight weeks.

Because Kryptonite’s ingredients are derived from components in castor bean oil – fatty acids and calcium carbonate – Dr. Fedak says the stuff is “bio-compatible,” i.e. the polymer forms a porous, very strong bonelike substance, and it doesn’t contain the toxins found in most other bone cements.

Recovery time was cut in half and the pain encountered during healing was greatly diminished. Normally, just the thought of coughing, sneezing or even breathing deeply brings on dread to recuperating chest surgery patients. Those treated with the superglue needed far less medication for their pain.

Of course, the innovation comes with a price – in the arena of $700. Dr. Fedak, however, believes that the shortened hospital stays and reduced medication needed after operations using Kryptonite would help compensate for this cost.

Of the approximate 29,000 chest surgeries performed in Canada annually, it’s highly possible that if the next trial – of 2,000 people – on Kryptonite confirms this study’s results, only high-risk patients (those with internal bleeding or other complications) will not receive this breakthrough treatment in the future. I can’t wait for the results!
Milena Katz

Getting drug addiction treatment on track

Implants may trump liquid and pills

Methadone has helped countless people hooked on heroin and prescription pain relievers wean themselves off for over 40 years. A methadone alternative may soon outshine the well-known withdrawal aid in some important ways.

Buprenorphine hydrochloride, a semi-synthetic opioid compound used for pain control and detoxification, has been available in pill form for two years. But its downside includes diverting the tablets for sale on the streets and crushing and liquefying them into an injectable – and therefore more potent -- form.

A recent study published in the Journal of the American Medical Association (http://jama.ama-assn.org/cgi/content/short/304/14/1576) shows promise for a buprenorphine implant, called Probuphine by its California makers, Titan Pharmaceuticals.

One hundred and sixty-three opioid-dependent adults (18-65 years of age) received either four 3-cm long (a centimeter shy of the width of a ping-pong ball), ethylene vinyl acetate and buprenorphine implants, or 4 dummy rods for 6 months. The 108 participants with the real deal received 80 mg per implant. All the subjects were given drug counselling, and urine samples were taken to detect illicit drug use.

If anyone felt the slow-release dose from the implants did not combat their cravings sufficiently, they could request sublingual tablets. Over the first 16 weeks, about 60% of the buprenorphine group requested extra doses, while over 90% of the placebo-implanted group did. Urine samples tested negative for illicit opioids more often in the buprenorphine implant group than the placebo group (approximately 40% vs 28%) over the same timeframe. And more of the buprenorphine group opted to stay in the study for the full 24 weeks (66% vs 31%).

Cravings and other withdrawal symptoms were generally reduced in the treatment group, although there were minor adverse reactions reported, i.e. discomfort at the implant site, in both groups.

Considering that Canada ranks almost as high as Germany and the U.S. for prescription opioid use, a six-month implant may be well worth the trouble – as long as it doesn’t dissuade regular visits to the clinic for counselling.
Milena Katz

Doctor, heal thyself

Post-grads ignore their own signs and symptoms of sickness

We all know the definition of absenteeism: you fall ill, you call in sick, you stay home and nurse your cold. If you think you know the meaning of presenteeism, then, you’d be right: you feel ill, you go to work anyway. Presenteeism has remained a going concern for many medical residents, despite reforms made over the last decade, according to a recent study conducted by the Accreditation Council for Graduate Medical Education.

It seems junior docs in specialties as diverse as internal medicine, pediatrics, general surgery and obstetrics/gynecology will risk infecting their patients and co-workers, and risk affecting the quality of their performance more often than what might be prudent, because of the extreme dedication to their jobs. Or, might it as likely be a protection of their image? Often, they don’t want to appear to be shirking their responsibilities in the competitive hospital environments in which they must practice. Some don’t relish finding a replacement, when he or she may also be doing a gruelling 80-hour sleep-deprived week. Plus, add to the mix sincere devotion and empathy for the patients, who would not be familiar or comfortable with the substitute doc.

Study co-author Dr. Anupam Jena, a Massachusetts General Hospital medical resident who did not take part in the JAMA-published study (http://jama.ama-assn.org/cgi/content/short/304/11/1166-a?rss=1), admitted to once working overnight, despite developing food-poisoning symptoms. He has company. Of the 537 medical residents anonymously surveyed, almost 58% said they’d worked at least once while sick the previous year, 31% said they’d done so more than once, and at one hospital, a full 100% reported working when sick. Many said they also could not find time to visit a doctor for their symptoms.

Despite the unique pressures on these groups of young physicians, isn’t it time that program directors heighten the emphasis on the benefits of being a healthy hospital practitioner – especially during flu season?
Milena Katz