I’ve lost count of the times I’ve asked someone whether they ate a healthy breakfast and the answer was “Sure. I had oatmeal.”

Is this true? Is oatmeal heart healthy because it reduces LDL cholesterol?

I don’t think so. Try this: Have a serving of slow-cooked (e.g., steel-cut, Irish, etc.) oatmeal. Most people will consume oatmeal with skim or 1% milk and some dried or fresh fruit. Wait an hour, then check your blood sugar.

If you are not diabetic and have a fasting blood sugar in the “normal” range (<100 mg/dl), you will typically have a 1-hour blood glucose of 150-180 mg/dl–very high. If you have mildly increased fasting blood sugars between 100 and 126  mg/dl, postprandial (after-eating) blood sugars will easily exceed 180 mg/dl. If you have diabetes, hold onto your hat because, even if you take medications, blood sugar one hour after oatmeal will usually be between 200 and 300 mg/dl.

This is because oatmeal is converted rapidly to sugar, and a lot of it. Even if you were to repeat the experiment with no dried or fresh fruit, you will still witness high blood sugars in these ranges. Do like some people and pile on the raisins, dried cranberries, or brown sugar, and you will see blood sugars go even higher.

Blood sugars this high, experienced repetitively, will damage the delicate insulin-producing beta cells of your pancreas (glucose toxicity). It also glycates proteins of the eyes and vascular walls. The blood glucose effects of oatmeal really don’t differ much from a large Snickers bar or bowl of jelly beans.  
If you are like most people, you too will show high blood sugars after oatmeal. It’s easy to find out . . . check your postprandial blood sugar.

In past, I recommended oat products, specifically oat bran, to reduce LDL, especially small LDL. I’ve changed my mind: I now no longer recommend any oat product due to its blood sugar-increasing effects.

Better choices: eggs, ground flaxseed as a hot cereal, cheese (the one dairy product that does not excessively trigger insulin), raw nuts, salads, leftovers from last evening’s dinner.

“We must all hang together,
Or assuredly, we shall hang separately.”

Benjamin Franklin, 1706-1790

For the solo doctor, who make up 30% of America’s practitioners, success often depends on teamwork with your staff. Simply stated, it is less “me” and more “we”.

In these days of declining reimbursements and rising practice expenses, it will help if you and you staff work from a common set of principles.

To identify these principles, I suggest the following.

1) Appoint a chief innovation officer – a nurse, practice manager, physician assistant, your spouse – someone you trust.

2) Meet once a month with your staff to elicit and discuss innovative ideas.

3) As an agenda for these meetings, go to amazon.com or similar website and order these books.

• Practice Enhancement: The Physician’s Guide to Success in Private Practice

• Managing Patient Expectations

• The Successful Physician: Productivity Handbook

• Marketing Your Clinical Practice: Ethically, Effectively, Economically

4) Make copies of a chapter from one of the books that is relevant to your practice and use it as a the agenda and basis for discussion for your money meeting.

5) Relax. This is commonsensical, human, non-technological way to unite you and your staff. It works well for solo and other small practices.

Review in the American Journal of Health-System Pharmacy.

In 1936 Charlie Chaplin produced a classic film “Modern Times ” at the height of the Great Depression. The film’s theme was – “A story of industry, of individual enterprise – humanity crusading in the pursuit of happiness.” The film featured a Time Machine, which fed worker automatically so they didn’t have to stop for lunch and to make sure the workers kept producing. A Big Brother foreman incessantly drove them, depriving them of their humanity and their health.

The modern version might go like this.

The hero is President Obama. The time is the Great Recession, featuring unemployment and hard economic times. Our hero, decked out in a cape and yielding a magic wand, flits from backroom to backroom, handing out money and favors, telling workers they are being deprived of health care by evil employers, imploring workers to accept him as their savior, promising to stamp out fraud, abuse, and waste, and blasting health plans and other profit-making health industries as the enemy of the People. And so the story goes: Profit is your enemy. Government largess is your friend.

It is a compelling narrative. Our hero is a magnificent speaker. He speaks loftily of social protest – of organizing the American community to throw off the forces of the health industry. He will restore the people’s humanity and their happiness by insuring their health and by extracting money through high taxes from their oppressors – the rich, profit making businesses , particularly those in health care – private health plans, drug companies, device manufacturers.

The message is: Government is your friend. I will set you free from the shackles of free enterprise, which is not free and which imposes upon you unaffordable health costs.

But alas, our hero has distractions – a unified opposing political party, a skeptical public that supports individualism, a Tea Party movement that keeps citing Constitutional rights, and a political Time Machine, which feeds his supporters and keeps his administration ticking.

Unfortunately, the hands of the Time Machine indicate – in September, December, and now March – that our hero is not meeting his deadlines for getting the job done. The Machine says he must get it done before November, or else, he may never get it done.

P.S. I welcome comments – good, bad, and neutral. I will comment on your comments.

This review from the Journal of Emergency Medicine (full text via Medscape) may be the best evidence synthesis available on the topic. It deals with all the studies and focuses both on the use of tPA in general as well as the new extended window. Concerning the latter question here’s the author’s bottom line:

The publication of the ECASS III trial has produced much excitement and discussion in the Stroke community. The Heart and Stroke Foundation of Canada and the European Stroke Organisation have both recommended treatment with IV tPA up to 4.5 h from symptom onset for appropriate patients. At this time, treatment with IV tPA for acute stroke beyond 3 h from symptom onset remains without FDA approval, but it has been endorsed by a Scientific Advisory from the American Heart Association Stroke Council.

The paper notes that many tPA associated head bleeds may be of little clinical importance, partly because those who suffer them tend to have large infarcts already destined for bad outcome. This was illustrated in a 2007 paper cited by the author:

Background and Purpose—A clinically relevant number needed to harm for tissue plasminogen activator (tPA)-related symptomatic intracerebral hemorrhage (SICH) would greatly assist therapeuticdecision-making.

Methods—A 15-variable prognostic model was derived from a placebo group enrolled in National Institute of Neurological Disorders and Stroke tPA Trials 1 and 2 and used to predict final global disability outcome for patients with tPA-related SICH had they been treated with placebo, rather than tPA, and not experienced SICH.

Conclusions—Most patients who experience SICH have severe baseline infarcts and already are destined for poor outcomes. For every 100 patients treated with tPA, approximately 1 will experience a severely disabled or fatal final outcome as a result of tPA-related SICH.

In other words the clinically relevant number need to harm is higher than one might expect.

But there’s more than one way to interpret the NINDS data as illustrated by this recent analysis:

Methods
We used the original data from the NINDS trials to create graphs showing the effect of treatment on neurologic function in all 624 individual patients in the trial. Our goal was to show detailed graphics of the 90-day outcomes, stratified on relevant confounders and effect modifiers.

Results
Final outcomes were highly dependent on stroke severity. In many graphs, the small difference between groups favored tissue plasminogen activator, particularly when baseline NIHSS score was between roughly 5 and 22. These differences diminish or disappear when 90-day change in NIHSS is graphed. Our graphs fail to support the time-is-brain hypothesis.

I welcome comments – good, bad, hostile, complimentary, controversial, informative, practical, theoretical. I will comment on the comments.

Richard L. Reece, MD

I never really understood why IBD was such a high risk condition. Apparently it was known to be so because the Chest guidelines gave it special mention in their recommendations for VTE prophylaxis in medical patients.

Now a new Lancet paper reports this:

13756 patients with inflammatory bowel disease and 71672 matched controls were included in the analysis, and of these 139 patients and 165 controls developed venous thromboembolism. Overall, patients with inflammatory bowel disease had a higher risk of venous thromboembolism than did controls (hazard ratio 3·4, 95% CI 2·7–4·3; p less than 0·0001; absolute risk 2·6 per 1000 per person-years). At the time of a flare, however, this increase in risk was much more prominent (8·4, 5·5–12·8; p less than 0·0001; 9·0 per 1000 person-years). This relative risk at the time of a flare was higher during non-hospitalised periods (15·8, 9·8–25·5; p less than 0·0001; 6·4 per 1000 person-years) than during hospitalised periods (3·2, 1·7–6·3; p=0·0006; 37·5 per 1000 person-years).

So let’s see if I understand this. IBD in general carries an increased risk of VTE. That risk is even higher during an active flare. But why was the difference between patients with and without a flare less in hospitalized patients? Perhaps because other VTE risk factors inherent in just being hospitalized may dilute out the difference.

IBD must be an under-appreciated VTE risk because it isn’t talked about all that much. It deserves inclusion on the list of usual suspects such as hereditary thrombophilia, cancer, severe acute respiratory disease, etc. I also have to wonder how many patients are deprived of chemical prophylaxis because of a perceived risk of GI bleeding.

H/T to Clinical Cases and Images.

It is possible to distinguish even Identical Twins. Identical (monozygotic) twins Raymon and Richard Miller had better watch out. The two were embroiled in a paternity suit that alleged both had slept with the same woman on the same day and nobody knew which brother had impregnated her. In May 2007, the judge decided that Raymon is the legal father of the child who was subsequently born although child support was split between the two brothers. Standard paternity testing examines 16 DNA markers which is enough to make them over 99.99% accurate. In the case of the State of Missouri and Holly Marie Adams vs. Raymon and Richard Miller, the paternity test showed that the two brothers both had a 99.999% probability of being the father. There is currently no commercially available test that can determine which of the twin brothers passed his DNA to the child even though there are ways in which the genomes of identical twins differ. Epigenomic chemical modifications. Researchers at Ohio State University found epigenetic changes in twins’ genomes that increased as pairs of twins aged. One of the main epigenetic processes that occurs to our DNA is methylation which can be caused by environmental exposures, such as diet and physical activity. Methylation can lead to differences in gene expression and as we age, the amount of DNA methylation increases. So, it’s expected that identical twins will grow less and less similar in their patterns of DNA methylation and gene expression as their lives progress especially if their lifestyle habits and surroundings differ greatly. DNA copy-number-variation profiles. Another way in which the genomes of identical twins may differ is in copy number variation (CNV) that appears as segments of DNA that are missing, occur in multiple copies, or have flipped orientation in the genome. Identical (monozygotic) twins have been found to have different CNVs which could explain why even identical twins are not truly identical in appearance or other physical characteristics despite similar environmental exposures. For example, one twin sometimes develops a disease while the other does not. The DNA Identity Testing Center of Bio-Synthesis Inc., headquartered in Lewisville, Texas, is the global leader in DNA testing including, Paternity, Maternity, Siblingship, Avuncularity, Grandparentage, and Forensic Samples, in both Private and Legal Cases since 1995. Our staff of highly experienced and qualified DNA experts and Paternity Consultants has reliably and consistently provided products and services to customers across the country and the world that meet the most demanding requirements for quality, turnaround, and expert technical support. For more information, please call 1-800-227-0627

Would someone out there among my readership help me understand?

President Obama keeps saying a big problem behind the nation’s troubled economy and our dire unemployment picture is rising health costs.

I have a problem.

I understand Obama’s point of view to a limited extent. Employers, particularly small businesses and start-ups, can’t afford to hire new workers because of health benefit expenses, so they do not hire new people, let go the old, or end health benefits all together.

What I do not understand is this: the latest Labor Department report indicates the U.S. lost “only” 36,000 jobs last month while the health sector gained 12,000 jobs. For February, the subsector for ambulatory health-care services posted the largest runup, adding 6,700 jobs. During this deep recession, the U.S. has lost 7 million jobs while health care has added 700,000 jobs.

Are job gains in health care bad? Are gains in health employment, and added taxes for local and state budgets, bad for the economy?

In many communities, health care is the dominant employer – the only place to go for a job, even a new career.

Is this bad? Please explain.

Signed,

A Dismal Economist

Two basic technologies, “intrauterine insemination,” and “cyropreserved embryos” are leading to potentially massive impact on peoples’ lives and the legal community. “Intrauterine insemination” is what many people have always referred to as “artificial insemination.” Although the technique has been around for centuries in animal husbandry, it has also been in use with humans since the late 18th Century. In this method, sperm is “artificially” placed in the female for fertilization. In “cyropreserved embryos,” eggs are removed from the female and fertilized outside of the uterus. The combinations of uses of these procedures and the people these procedures can help are many. The legal implications are also complicated and relatively unchartered at this time.

Interesting opportunities and legal scenarios come from the taking of many eggs from a woman. Couples who go through in vitro fertilization often remove many eggs from the woman and use the embryos to create pregnancy and then “freeze” or “cyropreserve” the rest for future use. Several options present themselves for unused embryos, such as storing them, donating them for research or thawing them and discarding them. If a couple has stored embryos and then divorce, issues have arisen as to what should happen to the embryos that have been stored. It is thought that there are literally hundreds of thousands of stored embryos.

There is some case law out there regarding these issues but there appears to be little uniformity. Three states have passed laws touching on some of these issues. The National Conference of Commissioners on Uniform Laws proposes a model act called, “ART,” for “assisted reproductive technology.” Lawyers should educate themselves on these matters in order to assist people and open up these magnificent technologies for more use.

(All material taken from the seminal publication on this topic authored by my friend Professor Charles Kindregan, Jr., and Maureen McBrien, Assisted Reproductive Technology, (ABA, 2206) which may be obtained at ababooks.org.)