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July 7th, 2010
WAKE up!
July 4th, 2010Much has been said about the Wakefield revelations, none more succinctly than here:
http://darryl-cunningham.blogspot.com/2010/05/facts-in-case-of-dr-andrew-wakefield.html
And, as the many comments have shown, some people STILL DON’T GET IT (such as this):
>Of course, if it isn’t MMR, where the hell are all these autistic kids coming from? I mean, I’ve got two.
That’s a very good question. Perhaps the poster should start with his own question: why does he have two, while the prevalence is (reportedly) 1 in 150? And why are both of them children of a man who can’t tell who is lying to him and who isn’t?
This:
http://darryl-cunningham.blogspot.com/2010/05/facts-in-case-of-dr-andrew-wakefield.html
is so going on my office wall…
Winter of Our Discontent II: The WNBC Interview
April 3rd, 2010The Winter of our Discontent: Sun and the Seasonal Affective Disorder
March 3rd, 2010http://www.healthradio.net/component/mtree/Health-Radio-Shows/Ask-Dr-2E-DeSilva/Winter-Blues-and-Its-Effect-on-Children-41737/details
I just did an interview with HealthRadio about the Winter Blues, also known as Seasonal Affective Disorder, and apparently there is great interest in this subject, so I’ll talk about it here in more detail.
SAD: Seasonal Affective Disorder. Kind of says it all: feeling sad in the winter. Think about SAD if your child starts acting like the Seven Dwarves:
Sleepy: a change in sleeping habits, inability to get out of bed, lack of interest, lack of exercise
Grumpy: Irritability, sadness, low self-esteem
Dopey: lack of concentration, difficulty in school
Bashful: lack of desire to be with other people, social isolation
Sneezy: unrelated to SAD, but it’s still flu season, isn’t it?
Happy is what you want them to be, and
Doc is who you take them to if you need help, right?
Oh, and craving for carbohydrates is a feature of SAD as well, but that’s more Sleeping Beauty, isn’t it, with the apple? And staying in bed and craving chocolates is what St Valentine’s day is all about.
And, just as in the summer, it’s not heat, it’s the humidity — with SAD, it’s not the cold, it’s the dark. When our eyes sense dim light or darkness, our brain makes more melatonin which acts like a sedative. In the winter, light may be dim all day. I’ve praised melatonin in the past as a natural replacement for sleeping pills, but in the winter the brain may be making it at a rate of a pill every hour between 4 PM and 11 AM, and that’s way too much sedation.
In addition, the light makes vitamin D in our skin; by winter’s end, almost everyone is Vitamin D deficient unless they are supplemented, especially children whose skin is dark.
The latest recommendations on Vitamin D are here:
http://www.medscape.com/viewarticle/707756
An extensive review on vitamin D deficiency in children, with new recommendations for supplementation, was published in the August 2008 issue of Pediatrics by Misra and colleagues on behalf of the Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society.[16] This paper provides an excellent resource for pediatric health care providers on topics ranging from biomarkers of vitamin D deficiency to dietary sources and dosing of vitamin D products.
Based on a review of the literature, the group recommended that serum 25 (OH)D levels be maintained at least above 20 ng/mL and that daily supplementation with 400 International Units (10 mcg) of vitamin D be initiated within days of birth for all breastfed infants and in formula-fed infants and children who do not ingest at least 1 L of vitamin D-fortified milk each day. Premature infants, dark-skinned children, and children who live at higher latitudes may require larger doses of vitamin D, up to 800 International Units (20 mcg) per day. Supplementation for vitamin D insufficient or deficient children should be dosed according to the chart below:
Patient Age Dose (International Units/day)
< 1 month 1,000
1–12 months 1,000 to 5,000
> 12 months > 5,000
In addition to their recommendations, the authors also highlighted the need for additional studies to determine if higher levels of 25 (OH)D (> 32 ng/mL) should be considered, as well as to determine the appropriate balance of the benefits and risks of sunlight exposure.[16]
And the light ionizes the air. Remember walking outside, breathing in, and saying, “Ahhh, spring!”? It’s negative oxygen ions you were smelling. And will again. More on that below.
The depression of SAD is made worse by a number of factors. Lack of exercise — too cold to play outside — is an important factor. There is ample evidence for the diet being a contributing factor (more on that below); and the many holidays in the winter bring our children in contact with their extended families, and no one does a greater job of making a child feel inadequate than a relative bragging about their own child, and why can’t you be like that?
What we know about SAD comes from many sources. SAD is 7 times more common in New Hampshire than in Florida. It occurs in 10% of Scandinavians and 20% of people in Ireland. Oddly, it is rare in Iceland despite a longer, darker winter (which suggested one of the effective treatments for SAD). And we know what works.
Why are we “dreaming of a white Christmas?” It fights SAD in two ways. First, you see the snow. Lots of it, all over the place, reflects light into your eyes. It is exactly the kind of bright, diffuse light that works best against SAD. Then, you get to shovel that snow. That’s exercise, and it is also very effective. No snow? Any exercise will do, and other sources of bright white (or green) light such as light boxes or bright fluorescents work, too.
Why are the Icelanders spared the worst of SAD? The only difference between them and other Northern Europeans is in the amount of fish they consume — many times more than Swedes or Danes or people in the British Isles. Fish is the only common food that is rich in Vitamin D and omega-3 fatty acids. And fish oil and Vitamin D supplementation do appear to be effective against SAD.
And ionized air? No need to wait for spring (not that far off now, but still…): there are commercially available air ionizers that have been shown to benefit people with SAD.
And, finally, brighten up their day. Say something nice to them. Praise them for something they did right — show them that you understand how hard it was to accomplish it. Maybe even throw caution to the wind and take them to Florida, or skiing. I said before, ‘don’t let your school interfere with your child’s health’; if you think a vacation will benefit your child’s health, school schedule should not stop you. The school should be happy when your child returns in better shape to study. We hope they should be happy.
With all this, what can you “Doc” do for you?”
First of all, is is really SAD? Major depression needs to be taken much more seriously. In major depression, feelings of hopelessness and worthlessness predominate, and “rumination” — obsessive thinking about the negative — occurs much of the time. If this is a concern, see your doctor right away.
It is also possible for the SAD feeling to be due to a real medical condition. Thyroid disease, hypoglycemia, anemia and mono can commonly present with depression-like symptoms; your doctor should be able to check for them, and begin treatment if they are found.
And, finally, you and your child should leave your doctor with the knowledge that, in the cold and dark in the dead of winter, you are not alone.
Swine Flu 4.994: Guidelines
January 10th, 2010
A few pieces of information are coming together now:
There was a rise in the number of severe swine flu cases during the holiday season, and
CDC recently broadened its recommendations for use of antiviral medications in suspected H1N1 influenza.
First of all, how does CDC come up with recommendations?
CDC collects data from local health departments who collect it from doctors and hospitals; it analyzes it and looks for factors that predict best outcomes. Which is excellent. But it takes a while.
Our office saw its 100th patient with H1N1 flu when the epidemic was less than a month old. We were quite aggressive with early diagnosis and early antiviral treatment from the beginning, and to us the flu appeared mild. Flu appeared more severe to physicians who followed more traditional approach — wait and treat only those who appear to be getting worse after a few days. In essence, we were reformulating our own guidelines with each piece of incoming data — with each patient we saw and with each update we read from CDC, NYC Health Department, and the media. And each update to our own, ongoing summary of experience confirmed the validity of our approach. Which is as it should be in the early stages of an epidemic that has not yet been properly analyzed by the appropriate agencies.
And, sadly, there is only one explanation for the uptick in flu severity without a corresponding uptick in its incidence during the holiday season: a significant reduction in patient access to medical care, whether patients are away from home, or because their physicians are on vacation. Which brings up to the one lamentable limitation in our services over the holidays: Yes, we were open on Christmas and New Year Day, as well as Saturdays and Sundays, in our main office; but, no, we could not follow our patients to their vacation destinations. Sigh. I am told Mexico was lovely this time of the year…
Swine Flu 4.993: It Ain't Over Till It's Over
December 13th, 2009Most of the swine flu stories are about the epidemic winding down, and not being as bad as feared. Maybe. If you ask the numbers (or better yet, the graphs) –
Still pretty impressive. In the rightmost pediatric mortality spike, purple is confirmed H1N1 deaths, and green is untyped. Deaths from flu strains other than H1N1 are at 1 to 2 per week.
Several troubling developments lately. I went to my home town, Lvov, in Ukraine, a few months ago, for the first time after 34 years,
and shortly after I left, the Polish-Ukrainian border was closed because of a then-unknown epidemic of a deadly infection in Western Ukraine. Shortly thereafter, the epidemic was identified as a somewhat mutated H1N1 swine flu, the mutations making it somewhat less sensitive to Tamiflu, more likely to produce “cytokine storm” leading to rapidly progressive hemorrhagic pneumonia, and an antigen drift making H1N1 flu vaccine somewhat less effective for that strain.
The news isn’t all bad. Our experience in previous years showed that (a) even a slightly mismatched injectable vaccine is better than nothing, (b) a slightly mismatched live nasal vaccine is nearly as effective as a full-match vaccine, (c) clinically, even patients who became ill during epidemics with Tamiflu-resistant strains responded to Tamiflu reasonably well, (d) most of the cases are still caused by the “old” strain, Tamiflu-sensitive and matching the vaccine, (e) there is still plenty of vaccine available, EXCEPT for the under-2 year olds (we ran out of that, at this point), (f) there do not seem to be repeat cases of H1N1 infection in people who already had it, making it yet more likely that the vaccines will work against the mutated strain.
I did a count of H1N1 doses already given out this year. It’s over 1400 since October 14 2009, with no serious adverse effects, and so far I know of 2 cases of confirmed flu in H1N1 vaccine recipients, neither infection causing complications. That’s pretty good, as we are seeing between 1 and 5 confirmed cases of flu a day for the last month.  Too early for a statistical inference (odds ratio in vaccinated vs unvaccinated individuals), but looks good so far.
Way back when (late April 2009), in the Fox News interview, I mentioned that many infections are more severe in Native Americans, possibly accounting for higher flu mortality in Mexico. This has now been confirmed. The CDC also now recommends more widespread use of Tamiflu in H1N1 patients, which is something we had been practicing all along.
We still recommend Vitamins A and D supplementation; elderberry extracts have been tested in test tubes and appear to slow down flu virus replication (though no human studies have confirmed this), but it’s worth a try. And, of course, handwashing, “Dracula Cough”, and staying out of crowds.
And get your flu vaccine — H1N1 now, seasonal flu later.
Swine Flu 4.992: The Winter of our Discontent
November 17th, 2009Â
Â
Yes, the picture that is worth 1000 words: H1N1 mortality in children has overtaken seasonal flu mortality. Considering how prevalent this infection has been (we were busier during late spring than during any seasonal epidemic I can recall), swine flu is clearly more contagious than seasonal, but not necessarily more virulent — an individual’s risk of contracting it is high; once contracted, the risk of complications is in the same ballpark as for regular flu, except for highest-risk groups such as pregnant women. Our original impression of this as mild flu is based on our model of care — rapid access to care, rapid diagnosis, prompt treatment. Children treated 24 hours after onset of fever in our office have been recovering literally overnight!Â
 We have also dispensed close to 1000 doses of H1N1 vaccines (injectable and nasal), and are running out. As always, shortages create demand, and people who were declining the vaccine a month ago are clamoring for it now. As of last night, we were out of injectable, and down to 30 doses of nasal. Additional doses are expected from the Department of Health, which so far has done an amazing job handling this epidemic.Â
Safety of the vaccine has been reviewed elsewhere; we have seen no serious reactions to any of these vaccines. The number of people who turn up sick after immunization with “normal” illnesses is no higher than the number of unimmunized people who get sick just from being around other sick people. There have been too few (a couple a day) positive flu tests to say anything about how effective the vaccine is; that is the subject for another post.
Swine Flu 4.991: The Quality of Mercy
October 10th, 2009
This is the picture that is worth 1000 words, and it is what informs the rest of this post.
The fall outbreak, nationally, is now officially worse than the spring outbreak. We are not seeing any cases here in Brighton yet, but we will soon — the outbreak map:
now shows New York in widespread brown, along with the rest of the country.
First of all, even though the H1N1 vaccine is not available to us yet, the risk of the wild flu is now high enough for the potential vaccine risks to be acceptable. I now recommend it highly, especially for the high-risk populations: pregnant, obese, young, health care workers, parents on newborns, and those and with preexisting conditions.
Secondly, there are not very many plausible explanation for the summer vacation that the flu takes. The incidence curve and the mortality curve correlate well with seasonal variations in Vitamin D levels, due to differing sunlight-to-skin exposures:
The science behind this connection is not conclusive, but it is a whole lot better than that purported for the so-called vaccine-autism connection, and the downside of “just-in-case” Vitamin D supplementation is negligible, which cannot be said for “just-in-case” vaccine refusal. So vaccine, Vitamin D, hygiene, avoiding crowds, “Dracula cough” –
and liberal school attendance policy remain my recommendation; taking Tamiflu prophylactically is not, except for the very high risk individuals.
The role for Tamiflu is in early, aggressive treatment of identified high-risk individuals who actually have flu, which means that rapid availability of urgent care is the key to minimizing complications. Looking at the so-called “Quality Indicators” by which practices are judged in New York, we find that the state is interested in many factors such as up-to-date immunizations, lead testing, weight and activity counseling — all laudable goals — but not availability. So the practice that dumps urgent care on emergency rooms to concentrate on crossing the T’s and dotting the I’s in preventive care will actually look like a higher-quality practice than one that actually takes care of sick children. I hope I am not the only one who finds this ironic.
Swine Flu 4.99: Sound Bites
October 7th, 2009I spoke at some length to Mr Juan Gonzalez at Daily News yesterday, with this result:
Some of the points that came up in the conversation but did not make it into the article are worth reiterating:
Mr Gonzales told me that most authorities now consider H1N1 to be more likely to produce complications such as pneumonia than seasonal flu, especially in Black and Hispanic patients. That was, on one hand, to be expected, based on the difference between the original high mortality in Mexico during the early phase of the pandemic, and the much lower mortality in the US; on the other hand, we just did not see this pattern in our practice. Some of the previous seasons, 2000/01 and 2004/05 if I remember correctly, had much higher rates of complications. I attributed the difference to our practice being much more aggressive with early detection and early treatment with Tamiflu, preventing many of the complications that could have been expected with more conservative care. On the other hand, we hardly used any Tamiflu at all for prophylaxis, expecting (correctly) that such use may produce resistant strains with more likelihood than short-course treatment of sick individuals:
http://www.who.int/csr/disease/swineflu/notes/h1n1_antiviral_use_20090925/en/index.html
I will also refer (again) to my Fox interview, back in April, in which I went over the reasons the flu may have been more severe for Mexican victims:
http://www.foxnews.com/search-results/m/22200273/swine-flu-reality.htm
I would certainly concur with Mr Gonzalez’s call for more studies to determine the common risk factors that militate toward poor outcomes in Black and Latino children: not only would it help these children, but the results of such studies are always useful in protecting other populations where risk factors may be present at lower prevalences. Vitamin D deficiency and obesity are in no way limited by race or ethnicity. Diseases are not “racist”, as some commentators to Mr Gonzalez’s article suggested, but there are always genetic, cultural and socioeconomic factors that influence outcomes. The more we know about that, the better for everyone.
Swine Flu 4.98: I guess that's why they call it the news
October 6th, 2009Swine Flu is still on hiatus, and few mourn its exile (except the folks where it’s exiled to, South and Southwest, right now) — according to:
Something finally went right: it finally seems to penetrate the collective consciousness that, though swine flu is not significantly worse than seasonal flu, it is not so much a dismissal of swine flu as a threat as it is a renewed realization of seasonal flu as a significant perennial problem. This is from a CDC report from 2004:
During the 2003-04 season, CDC requested that states report deaths in children < 18 years of age who tested positive for influenza. As of May 31, 2004, 152 influenza-associated deaths in U.S. residents aged < 18 years were reported by 40 states. All patients had influenza virus infection detected by rapid antigen testing, viral culture, or other laboratory methods. The pediatric data are preliminary and subject to change as more information becomes available.
That’s 152 pediatric deaths in one season from seasonal flu alone, confirmed cases only. Cumulative total for 2008-2009 so far, including the seasonal spike and BOTH the spring and the fall H1N1 spikes, is 128. That’s not to belittle H1N1; that’s to put it in perspective — and I think the perspective is becoming clearer and clearer, and I say this because demand for seasonal flu vaccine this year is far above last year’s.
The WCBS interview with which I start this blog post is only about 5 minutes, and I hope I made my points clearly: I support the vaccine, both seasonal and swine, both injectable and nasal. I mentioned the 1976 (misspoke; said 1975 in the interview) vaccine as the worst-case scenario — even if current vaccine were as bad as that one had been, it would still be worth taking; and I think we as healthcare workers should take the vaccines both for our own sakes and for our patients and our families — and I can’t think of a better way for the state to discourage people from getting the vaccine than by making it mandatory. This is still America. You know, the land of the free and the home of the brave –
– and you have to be really brave to pass up the flu vaccine. So go get yours. In spite of it being mandatory. Save your protests for something important. I don’t think the government will keep you waiting long for some really bad initiatives worth demonstrating against.