Wednesday, December 23, 2009

Depression is Big Business

What is Depression ?

The term "depression" is descriptive and vague. I believe the whole concept of depression is flawed and needs to be revised. The term “depression” does not point to one discrete disorder but to a variety of unpleasant experiences common to all humans. When the term “depression” is used without qualification, it is usually misleading. Since antidepressant drugs have become a big business, the promotion of "depression" as a widespread illness, treatable with drugs has become a scandalous marketing enterprise with little or no merit. Although the term “depression” was an invention of psychiatry the use of the term is pervasive in medicine, the media and in folk psychology. Writers, TV journalist and MDs  have been talking about “clinical depression” as if “clinical” increased the credibility of this dubious term. The best use of the term “depression’ is to point to someone who is unusually and chronically sad, critical and angry; a person who withdraws from work, play and close relationships with other humans.

There are eight circumstances that cause sadness, anger and sustained dysphoria:

1. The inhalation, ingestion and injection of bad chemicals

2. Chronic illness

3. Oppression and abuse

4. Wrong food

5. Too little exercise

6. Noise, clutter and poor living conditions

7. Information noise and confusion

8. Loss of persons, property and prestige

All humans are involved in competition and negotiation with other humans. If you are losing a competitive struggle, you feel, sad and angry, sometimes with a terrible sense of loss; you want to withdraw, hide, cry and sometimes you want to die. If you habitually lose competitions or have an effective oppressor close by, you often feel dysphoric. We can call this social inhibition, oppression or suppression rather than depression.

Physicians have routinely prescribed drugs to patients who were sad, discouraged and thought of suicide. None of the drugs prescribed have reduced the overall suicide rates and new evidence suggests that some antidepressants increase the risk of suicide. For patients who died of an overdose, the prescriptions took on the ominous aspect of tools of self-destruction. The prescribing physician becomes an accomplice in the patient’s death.


Antidepressants were a hard sell until recently. Although many drugs in this class modified the behavior of patients, their slow action and many side effects were negative features. The introduction of a “new class” of antidepressants that increase serotonin activity, led by Prozac changed the market for psychotropic drugs. The effects of Prozac on “personality” were widely publicized and drug companies advertise indirectly and, more recently directly to the consumer, relegating physicians to the role of middleman. The patient now demands the prescription and the doctor complies. The consumer hopes that Prozac and related drugs can increase energy, confidence and assertiveness. “Shy” people were added to list of potential customers.

Although writers such as psychiatrist Peter Kramer (Listening to Prozac) suggested that the patient's interest in personality changing drugs was a new market force, nothing new really happened; it is the same old interest in psychotropic drugs but the names, the players and the prices changed. Cocaine outsells Prozac, but the profitability of prescription antidepressant drugs is outstanding.

Goodman, Chair of the US Food and Drug Administration (FDA) Psychopharmacologic Drugs Advisory Committee made a public statement in 2006 that claims in drug monographs and advertising that selective serotonin reuptake inhibitor (SSRI) antidepressants work by normalizing serotonin levels are not based on scientific evidence and should be prohibited. Moynihan and Cassels described the drug industry's marketing tactics. With obscene profits from drug sales; a drug company can afford to control the naming and perception of diseases by physicians, government, and consumers. They create drug demand by advertising to consumers and doctors at the same time. For example, Cohn & Wolfe Healthcare, SmithKline's PR firm created “social phobia disorder” treatable with Paxil, which became the world's best-selling antidepressant, earning US$3 billion annually.

Brain Drugs -- Benefit or Harm?

A review of data, just published, from the US Women's Health Initiative study (involving 136,293 postmenopausal women) revealed that , 5496 women taking drugs from the two major antidepressant groups, tricyclic antidepressants (TCI) and selective serotonin-reuptake inhibitors (SSRI), had increased all-cause mortality; SSRIs users had a 45% increased relative risk of incidence stroke and a 32% increased risk of death with a higher incidence of hemorrhagic strokes. The incidence of stroke per 1000 person-years with no antidepressant use was 2.99; the incidence for SSRI users was 4.16 for. Death rates for per 1000 person-years were 12.77 for SSRI users and 14.14 for TCI users, compared with 7.79 for non–antidepressant users. Studies of this nature cannot differentiate the negative effects of dugs from the underlying disease processes. In medical talk, depression has assumed a false reality, becoming a malevolent agent that acts upon its victim. While sad, tired and angry people are real, depression is not real and is not a cause of something else such as a stroke. My conclusion is that antidepressant drugs are potentially harmful and can add to the existing pathologies that they pretend to treat

Antidepressants are chemicals that are added to a dysfunctional chemical mix that caused dysfunction and dysphoria in the first place. Few patients make any effort to alter their disease-causing lifestyle and few physicians make any effort to investigate and improve the patient’s chemistry overall. Psychotropic drugs are added to the dysfunctional chemical mix and its effects merge with coffee, alcohol, the chemistry of food additives, and contaminants, sugars, food allergy and airborne neurotoxins that act on the brain.

New problems added by the prescription chemical may suddenly emerge such as unexpected bursts of anger and aggression or increased tendency to have violent suicidal thoughts. One young woman reported to me that after taking Prozac for two weeks, she had threatened her live-in boyfriend with hammer, chased him into the bathroom and attacked the closed door, smashing holes in the door until she more or less recovered composure. Her boyfriend fled the apartment and never returned. The boyfriend was domineering and verbally abusive, as boyfriends sometimes are, but the pre-Prozac young woman was usually compliant and never had a violent temper. Her Prozac rage is an example of chemically triggered behavior. Prozac may provoke agitated preoccupation with suicide or violence directed against others. The drug facilitates the rage response, as do most of the drugs that suppress appetite. Up to 73% of patients taking antidepressant report sexual dysfunction, such as diminished sexual desire, delayed sexual arousal, and muted or absent orgasm.

Fisher suggested that these drugs blunt emotions and interfere with forming and maintaining meaningful relationships. When men and women take serotonin-enhancing drugs and fail to achieve orgasm, an important feature of pair bonding fails. You would not be surprised to learn that a woman taking Prozac decided to divorce her husband, stating that she no longer loved him. After she stopped taking the drug, she loved him again and stayed married.

Prozac can facilitate the rage response and may lead to acts of aggression and violence that otherwise would not occur. Prozac also inhibits appetite for food and sexual appetites; sometime useful effects, but not always. In Canada, three similar antidepressants were among the top-selling drugs; these are Prozac, Paxil, and Zoloft. Lauren Slater called Prozac the "Big Mac of Medicine" because of its popularity and the faddish consumer appeal based on the futile hope that a drug could resolve human suffering. She described the dramatic and brief benefits of taking Prozac: "those first few mornings were fairy tales, tall tales, replete with all the bent beauty of a New World." Her story is not simple, however and the long-term effects of taking the drug are mixture of benefits and negative effects. The initial recovery from depression is not sustained and a three or four phase sequence can often be discerned, beginning with an initial improvement that occurs in the first 2 to 4 weeks. The statement “the first time was the best time" applies to most, if not to all psychotropic drugs.

In Slater's experience, Prozac removed her sexual drive, blunted her creativity and reduced her appetite. The underlying problems are many and begin with the lack of specificity of the drug. Prozac blocks Serotonin re-uptake and in stage 1 of its activity, probably increases serotonin receptor activity in all areas of the brain. Serotonin synapses are not all conveniently arranged just to alleviate depression and a whole complex of unrelated functions are affected. The brain is not passive and changes to offset or accommodate the drug activity; the effects then shift to an adapted state, different from the initial drug-dependent state. The person taking the drug has also shifted in terms of behavior and learning and may be learning new skills and, at the same time, coping with new problems such increased anger, loss of libido and blunted feelings.

Martin Enserink reviewed the development of antidepressant drugs and stated: ‘Antidepressants have evolved through several generations since the 1950s, each a “huge improvement” over its predecessor--or so advocates have claimed. But a government-sponsored study published last month confirmed what other analyses had shown before: The fashionable antidepressants of the 1990s are no more effective than those of previous generations. The study, a meta-analysis commissioned by the Agency for Health Care Policy and Research (a part of the Department of Health and Human Services, USA) and carried out by the Evidence Based Practice Center in San Antonio, Texas, looked at 315 studies carried out since 1980. It focused primarily on the hottest pills that have hit the market since 1987, the "selective serotonin reuptake inhibitors" (SSRIs), a group that includes such brands as Prozac, Paxil, and Zoloft. The study found that on average, about 50% of patients in SSRI treatment groups improved, compared to 32% in placebo groups. But in the more than 200 trials that compared new drugs with older ones, the two classes proved equally efficacious. Because the newer drugs appear to have less severe side effects, however, patients may be able to stay on them longer. The failure to find evidence of progress is disappointing, scientists admit. And one of the biggest disappointments is that researchers still don't understand what causes--or relieves--depression. Most antidepressant drugs are based on the assumption that depression results from a shortage of serotonin or norepinephrine in the brain. Both are neurotransmitters, chemical messengers that cross the synapse, the cleft between two nerve cells. The first generation of antidepressants, discovered during the early 1950s, the MAO inhibitors, block monoamine oxidase, an enzyme that breaks down serotonin and norepinephrine. This allows the neurotransmitters to linger in the synapse, increasing their effect. Another type of drug discovered in the late 1950s, the tricyclics, prevents the nerve cells that excrete the neurotransmitters from mopping up these compounds shortly after they are released. Blocking "reuptake" also prolongs their effect. Because studies pointed to serotonin shortage as the main culprit in depression, industry developed the selective reuptake inhibitors, which now dominate the market.”

Data from United Kingdom's General Practice Research Database of 6.4 million patients were used to discover a relationship between antidepressant use and diabetes 2: 165,958 patients were identified who received at least 1 new prescription for an antidepressant between January 1, 1990 and June 30, 2005. The researchers conclded that taking moderate to high daily doses of antidepressants for more than 2 years is associated with an 84% increased risk for diabetes.The increased risk was particularly notable for the selective serotonin reuptake inhibitor (SSRI) paroxetine and the tricyclic antidepressant amitriptyline. Another study, the Diabetes Prevention Program (DPP) trial found that antidepressant use over an average of 3.2 years was associated with an increased risk for diabetes of 2.60 in the placebo group and 3.39 in the lifestyle-intervention group, but there was no increased risk in the metformin group. Paroxetine caused a 4-fold increased risk for diabetes above 20 mg/day. Related drugs, fluoxetine, citalopram, or sertraline did not increase the risk.

From the book: The Human Brain in Health and Disease by Stephen Gislason MD

Saturday, November 28, 2009

Impermanence & Plasticity

Everything changes. The largest chunk of uncertainly is impermanence. There are constant paradoxes and contradictions built into our brain function. We must be alert to notice and respond to changes but, at the same time, attempt to be stable and consistent. Our visual system is designed to notice minute changes but ignores most of the movement around us to create the illusion of a stable world in consciousness. Growth, development, and aging are the main expressions of predetermined impermanence that combines DNA programming with environmental opportunities and hazards.

You could argue that brain growth and development changes are most vigorous in the first 20 years of life; later, after a brief period of relative stability, degenerative changes take over, accelerating with advancing age.

A big problem we have is that while the world around us changes, we also change and the biggest changes occur in our brain. The idea of one personality remaining stable over many years is actually absurd, but we are tempted to believe in an enduring self. An astute observer will notice that each day brings forward a series of different personalities within one body. I call these personalities eigenstates. The self is not one entity but rather consists of a collection eigenstates that serve different needs, roles and capabilities. Some eigenstates are built it others are learned and remain open-ended, evolving with changing circumstances.

Learning, in the best case, is adaptive impermanence that requires changes to brain structure and function. We will consider, for example, that learned movements are generated from dynamic cortical maps based on fields of activity that converge and diverge in complex patterns. Over time, the pieces of the map change with learning and practice, so that the construction of cortical connections is always in flux. This impermanence allows us to learn at all stages of life, to adjust to changing environments and, to some extent, to work around disabilities that arise from brain injury and disease.

Among affluent self-indulgent humans, there is conspicuous age denial and much promotion of anti-aging products and procedures. While, in the best case, humans can continue to learn into old age, the facts are not so encouraging. All brain functions decline with age and degenerative brain diseases appear with increasing frequency as the years advance. Slogans such as use it or lose it may contain some truth, but it is never obvious that high functioning elderly humans are doing well because of brain exercise with crossword puzzles rather than by luck, cleaner air, better DNA and superior diet. It is more obvious that sustained physical activity, reduced caloric intake and good nutrition are the keys to high functioning aging.

Too often, I am an unwilling victim of television news nonsense and plasticity is a current favorite topic. Brain damaged survivors are shown with plausible mental abilities, as if their example refuted neuroscience beliefs. The term plasticity has crept into neuroscience jargon and should be erased from the vocabulary. I am not aware of the source of plastic metaphor and can only assume that it refers to a material that can be coaxed into different shapes by heat and pressure using a variety of machines. I cannot see any connection between the malleability of plastic and the constant flux that characterize brain function.

Even smart, educated humans participate in these media delusions. For example, I was surprised to read a report by Allison Gandey from a meeting of the American Academy of Pain Medicine that revealed basic ignorance among a group of smart professionals. She stated: " Some suggest the discovery of neuroplasticity is the most important breakthrough in neuroscience since the revelation of the brain's basic anatomy. Proponents say the brain is pliable and can alter its structure and function. " One MD even admitted:" We used to think the brain was wired after about the first 3 years and what you had was what you got and you work within that because there was no chance of changing it. If on top of that the brain was damaged, you had to live with that damage. Neuroplasticity says that's not so — the brain is changing all the time."

It is true that the brain is changing all the time, but it is not true that this is a discovery or a breakthrough. It is also not true that lost function is easy to recover. While it might be true that limited recovery of function is possible after brain injury, it is more true that loss of function tends to be permanent after the initial recovery in the first few months. You might consider that some physicians are just like everyone else, entertaining erroneous assumptions and unrealistic fantasies, but then, I also read rather naive comments about plasticity in the neuroscience literature.

Let me restate what should be a basic premise of neuroscience: All learning is adaptive impermanence that requires changes to brain structure and function. Another premise is that if learned skills are not refreshed through practice, skilled performance deteriorates.

You can fantasize opportunities to intervene with new technologies in the future to compensate for lost brain function, but progress to date is minimal. While there are limited populations of stem cells in the brain, their proliferation presents a hazard (aka cancer)more than a solution for degenerative brain diseases.

There is a growing body of knowledge about the growth and development of the brain from conception through adolescence; one important feature of childhood and adolescence is the pruning of synaptic connections. To make real sense from the facts as we known them is that brain structure and function is in turbulent flux with abundant opportunities for things to go wrong for 20 years. In the best case, a confused, rebellious adolescent will become a responsible adult who is a little more stable for the next 20 years and then begins a descent into cognitive decline. To believe that the brain is a finished organ at any age is nonsense. At the same time, you need to know that neurons are long lived cells that can survive from their origins in the fetus through old age. The cell body of the neuron must endure for its synaptic connections to change. The most dynamic structures are spines on dendrites and the synapses themselves. Damaged axons can regenerate if the cell body is still alive.

One basic idea in neuroscience is that the old brain is preprogrammed with maximal automaticity and stability whereas the neocortex is built to be modified. Survival depends on the stability of neuronal circuits in the oldest part of the brain. The critical controllers of respiration and cardiac function must be reliable or you die. You might compare the neocortex with dynamic random access memory in a computer that is programmable, stores memory, and can be erased.

There are time critical episodes in early development that leave no opportunity for recovery if things go wrong. Knudsen stated:" during a critical period, a neuronal pathway awaits specific instructional information encoded by impulse activity to continue developing normally. This information causes the pathway to commit irreversibly to one of a number of possible patterns of connectivity. There are critical periods for the development of form vision and stereopsis and for the development of appropriate social responses to members of the same species. "

See Neuroscience Notes by Stephen Gislason MD

Wednesday, September 23, 2009

Naproxen Wins the Best NSAID Award.

I have followed the saga of nonsteroidal anti-inflammatory agents (NSAIDs) since Vioxx was withdrawn from the market in 2004. Rather intense reviews of NSAIDs followed with uncertainty about which drugs were the safest to use. As of Sept.2009, the winner is Naproxen, in doses less than 1000 mg per day.

A large retrospective study examined the medical records of 48,566 adults between the ages of 40 and 89 years who were admitted to hospital with coronary artery disease. The databases used came from Canada, the United States, and the United Kingdom. The study found that naproxen was not associated with a higher risk for coronary heart disease events or cardiac death in patients with a history of coronary heart disease. However, ibuprofen; high-dose celecoxib; high-dose rofecoxib; and, diclofenac, did increase this risk.

Relative to naproxen, current users of diclofenac had increased risk of serious coronary heart disease x 1.44 and serious cardiovascular disease/death x 1.52; ibuprofen had increased risk x 1.25; coronary heart disease risk increased for rofecoxib >25 mg x 2.29; celecoxib >200 mg x 1.61.

Recall that in September 2004, Merck & Co announced a voluntary withdrawal of Vioxx from the U.S. and worldwide market due to safety concerns of an increased risk of heart attacks and strokes, according to an alert from MedWatch, the U.S. Food and Drug Administration (FDA) safety information and adverse event reporting program. Vioxx was one of several selective COX-2 inhibitors that were marketed aggressively as the best drugs for pain relief. Because they were prescription drugs and more expensive, patients believed they were better than ASA, ibuprofen, diclofenac or naproxen but this was not true.

The claimed advantage of the COX-2 inhibitors, slightly lower incidence of gastrointestinal bleeding was supported by some but not all studies Cox-2 inhibitors that offered no advantage in terms of pain relief and anti-inflammatory effects. The fate of COX-2 inhibitors has been dismal. A growing controversy surrounded the use of Cox-2 inhibitors since their introduction in 1999. The drug companies involved were competing to secure a large share of the multi-billion-dollar-a-year market for pain-relieving anti-inflammatory drugs. A news report in 2002, for example, warned people that: "Elderly patients taking Vioxx, the most popular arthritis drug in Canada, were twice as likely to be hospitalized with major gastrointestinal bleeding than those taking its pharmaceutical competitor, Celebrex. In 2002, 3.4 million prescriptions for Vioxx were filled across Canada; 3.1 million for Celebrex.

The Therapeutics Initiative Newsletter in BC issued the following COX-2 inhibitors update in 2002: “Based on FDA data from the CLASS and VIGOR studies, COX-2 selective inhibitors are associated with an increased incidence of serious adverse events as compared to non-selective NSAIDs."

Reference: Ray WA, Varas-Lorenzo C, Chung CP, et al. Cardiovascular risks of nonsteroidal antiinflammatory drugs in patients after hospitalization for serious coronary heart disease. Circ Cardiovasc Qual Outcomes 2009; 2:155-163.

From the 2009 book, Heart and Arteries by Stephen Gislason MD

Wednesday, July 29, 2009

Mental Illness

When someone's brain is not working properly others describe them as "mentally ill." Mental health and mental illness are poorly chosen terms that obscure the medical and social issues that arise whenever human dysfunction is examined. The hospital in my community has a separate building described on a sign as “Mental Health and Addiction Services.” I suspect that the staff and the patients that use this building do not understand what “mental health” means. I am certain that the juxtaposition of the words “health” and “addiction” is a mistake.

Kurt Vonnegut described the cause of mental illness as “bad chemicals.” Humans are unrealistic about what substances they can safely ingest, inhale and inject into their bodies. Humans are most unrealistic about how easily and how profoundly small amounts of external chemicals can affect their mind. They believe that they are tougher than they are. Modern psychiatric theory imagines bad chemicals or good chemicals in the wrong amounts manufactured by mistake inside the brain of each victim. Physicians often view the brain as a black box with no chemical input except the drugs they prescribe. A neurobiologist will recognize that numerous chemicals arrive from the outside to interact with brain chemistry. Bad chemicals in the food supply can disturb brain function in entire populations with endemic brain dysfunction as the result.

The World Health Organization claimed that one-fourth of the world’s population is affected at any time by depression, other mental disorders or substance abuse problems. According to the WHO report: "Women are more often affected then men. The higher prevalence of mood disorders in women may include the frustration of relying on the role of housewife for identity and self-esteem; lack of personal income; and for those who do work lower pay and more labor-intensive jobs than men." In addition, violence against women has been recognized as a growing problem. Some studies show that as many as half of all women living on planet earth have been physically abused at some time in their lives. Their abusers are mostly men and most of those men are boy friends, spouses, family members or close “friends.”

Kessel et al suggested that half of all Americans will have a mental illness during their lifetime, with symptoms beginning in the teen years for many. They favored diagnoses such as mood disorders, anxiety, impulse control and substance disorders. Rather than using fuzzy terms such as “anxiety, mood disorders or depression,” we can recognize “mental illness” as a variety of interacting maladaptations caused by bad genes, bad chemicals, bad food, infections, malnutrition, poverty, oppression and abuse.

Mental disturbances are the first symptoms of bad environments that substitute disease-causing conditions for healthy conditions.

Mental illness is often self-inflicted by overeating the wrong foods, drinking alcohol to excess, using and abusing drugs obtained from both legal and illegal sources.

Social Chaos

Common effects of erratic brain function are conflict and chaos. Two people living together with erratic brain function increase chaos by more than a factor of two. More people interacting erratically increase chaos exponentially until family structures, community structures, and national structures become dysfunctional.

Bad chemicals entering human brains from polluted air and water, wrong foods, alcoholic beverages, legal and illegal drugs is a recipe for a society's dysphoric disintegration. We might better appreciate the folly of "fighting a drug war" when we realize that most chemical demons live at home. Unfortunately, in terms of substances that can impair brain function, “drug sellers" include every corner store, fast food outlet, pop vendor, pharmacy and supermarket. Local bars and liquor outlets generate a continuous stream of social and health problems at an enormous cost to society.

We must be smart enough to see the connections among food materials which influence brain function: alcoholic beverages, nicotine in tobacco, teas, coffee, chocolate, spices, food additives, sugar excess, wheat, milk, eggs, prescription drugs and street drugs. We should be very concerned about the prescription drug problem with drug addiction and dependency that is supported by all our institutions. Unfortunately, the practice of medicine has become a drug-pushing affair. An addicted society will better tolerate the social pathology and diseases caused by tobacco smoke, alcoholic beverages, air pollution, bad food, sedatives, antidepressants, tranquilizers, and sleeping pills but displaces its dysphoric energy in a "drug war" against cocaine, heroin and a few other "drugs of abuse".

Humans are seldom consistent in setting goals and priorities so that societal confusion about the use and abuse of food chemicals and drugs is more or less predictable. Smart policy makers will, however, understand that most citizens are under the influence of one mid-altering drug or another. The daily use and abuse of several brain chemicals produces mentally disabled people who are neither reasonable nor correct in their thinking and conduct. When physicians intervene and prescribe more chemicals, they add to the chaotic mix, not realizing there is there is little hope of benefit. To my way of thinking, this “drug psychotherapy” has become a perverse enterprise with no happy endings in sight.

Read the Human Brain in Health and Disease by Stephen Gislason MD

Tuesday, July 21, 2009

Pandemic Viral Illnesses Occur Every Year.

A Perspective

What interests me and other science philosophers is how nonsense routinely overwhelms reliable knowledge. Humans appear to have an endless capacity and need to generate nonsense. Nonsense is generated, in part, as nominal fog that obscures a simple truth - we do not know what will happen next. "Experts" are just as limited as the most ignorant and opinionated nonsense generator. You could, without any hesitation, award television news media with the Oscar for the best nonsense generators of the year. Their nonsense spreads worldwide with speed and penetration that would make any virulent virus envious.

There are a host of current examples of noumenal fog generators under titles such as Health Care, Economy, National Security, Terrorism and most recently, Pandemic. Whenever these key words appear, have a look, you will not be disappointed -- the ratio of nonsense to sense will be at least 9 to 1.

I have chosen today to do a brief review of the Swine Flu Scare of 2009 - a great pile of nonsense that seem to have overwhelmed even the most cautious of scientists. This is not to argue that H1A1 viruses are innocuous, but to develop a perspective on the relative threats of viruses in general and to reveal that the evidence for swine flu as a special threat is lacking.

In the Northern hemisphere, viral epidemics cause up to 80% of all respiratory illnesses. The most common infections are caused by six viral groups: rhinovirus (RVs), respiratory syncytial virus, influenza virus, parainfluenza virus, corona virus, and adenovirus. In one study of 285 children admitted to hospital with lung infection, viruses were identified in 125 - respiratory syncytial virus (107), influenza (9) and parainfluenza type 3 (9). Clinical and radiologic diagnoses included bronchiolitis (127), interstitial pneumonia (47) and lobar pneumonia (91).

Rhinoviruses often referred to as “cold viruses” cause the majority of respiratory illnesses. Other viruses contribute to waves of colds, coughs, bronchitis, asthma and pneumonia that pass through every human population in epidemic patterns. Colds are rhinovirus infections that are usually mild and self-limiting but are more serious in premature babies and children with chronic diseases or immunosuppression. The average child can expect to have four to eight rhinovirus infections per year, and adults have three to five infections.

Respiratory Syncytial Virus is spread by coughing and sneezing; by close contact with sick patients or by hand contamination. Infection develops in care -givers who touch their eyes or nose with contaminated fingers.

Adenoviruses While Influenza viruses are well-known and epidemics of more virulent influenza strains are feared, other less known viruses, especially adenoviruses, tend to be common and can produce severe illnesses. For example, adenoviruses are the second most prevalent cause of acute lower respiratory infection of viral origin in children under four years of age in Buenos Aires, Argentina. Pneumonia was observed in 71% and bronchiolitis in 29% of children admitted to hospital with adenovirus infection. Wheezing occurred in 58% of the children. Four children died (a fatality rate of 16.7%). Adenoviruses have emerged as important pathogens in immunocompromised patients, in whom disseminated disease occurs frequently and is associated with a high mortality rate. For over 25 years, the US military controlled adenoviral respiratory infections through immunization of its members. A group of Navy physicians reported a “large epidemic of respiratory illness due to adenovirus in healthy young adults” after adenovirus vaccine supplies were depleted.

The US military medical services are perhaps best equipped to diagnose and treat adenovirus infection which cause outbreaks of disease among military recruits. A National Surveillance for Emerging Adenovirus Infections system includes military and civilian laboratories at 15 sites in the USA. Fifty-one adenovirus serotypes have been identified. In 2007 the emergence of a virulent Ad14 variant spread through the United States with some deaths. Ad14 infection was described initially in 1955 and was responsible for an epidemic acute respiratory disease in military recruits in Europe in 1969. In 2001-2002, Ad14 was associated with approximately 8% of respiratory adenoviral infections in the pediatric ward of a Taiwan hospital, with approximately 40% of Ad14 cases in children aged 4-8 years manifesting as lower airway disease. During the years, 2004-2007, the US surveillance system detected 17 isolates of Ad14 from seven sites. During March-June 2007, a total of 140 additional cases of confirmed Ad14 respiratory illness were identified in Oregon, Washington, and Texas. Fifty-three (38%) of these patients were hospitalized, including 24 (17%) who were admitted to intensive care units (ICUs); nine (5%) patients died

Influenza viruses cause epidemic respiratory illness every winter in most countries on the planet. New virus strains spread globally and cause prolonged illness and some deaths. The routine death toll in the US and Canada every year has been estimated to be 32,000 people.
Since the exact cause of fatal pneumonia is seldom correctly diagnosed, the fatality rate for influenza ( and other viral infections) is not really known. Other viruses also cause illnesses that spread globally with substantial morbidity, cost and some deaths. Influenza often begins with cold symptoms and progresses to involve the lungs. Most patients develop a chronic cough that can last for weeks. Pneumonia can develop and is a common cause of death.

Much publicity has been given to the possibility of an especially virulent strain emerging that will increase the death toll from thousands per year in the US and Canada to millions. Some virologists were concerned that influenza virus epidemics in birds would produce a newly virulent human virus. The World Health Organization warned that the world was not prepared for the next pandemic ( true). As of January 2006, the strain of avian influenza, A (H5N1), has been identified in only 148 human, 79 of them fatal, from direct contact with infected birds. The strain was first detected in Hong Kong in 1997 and has spread through Southeast Asia and then in Russia and Turkey. So far, bird flu has not become a major threat to human survival.

In 2009 a H1N1 variant ("swine flu") emerged and caused another media frenzy; the WHO declared a "pandemic" and despite reports of a relatively mild illness with a low mortality rate, news anchors began to refer to a "deadly virus" (false). The positive aspect of the scare tactics was increased international cooperation in monitoring the spread of the virus and increased funding of vaccine development.

Some of the fear was generated by comparison with the 1917 flu pandemic caused by another H1A1 virus. The truth is that speculations adn predictions based on very limited knowledge of that pandemic are likely to be wrong. While you can argue that every year, influenza and many other types of viruses create pandemics and every year more virulent strains could emerge, there is no reliable knowledge that allows experts to predict what will happen next.

Airborne causes of illness are discussed in the 2009 book,
Air and Breathing by Stephen Gislason MD

Monday, May 11, 2009

Who knows how to treat high blood pressure

We might wish that all the effort in hypertension research over several decades had determined an optimal approach for the treatment of hypertension. Instead, the proliferation of often-conflicting study results creates confusion and less certainly about an optimal approach. A public health approach would change the nation's diet, encourage exercise and launch a vigorous assault against obesity. Diet changes require less sodium, less sugar, less fat, more fruits and vegetables. Taking drugs is more popular since it requires no effort and no change in habits.

MDs are willing to prescribe several drugs to achieve “normal” blood pressure. In contrast, the US, the National Heart, Lung and Blood Institute the sponsor of the ALLHAT study, launched a High Blood Pressure Education Program in 2006. They hoped to encourage patients to adopt healthier lifestyles and to influence physicians’ drug prescribing habits. They stated that the basis for the program is the ALLHAT conclusion that " diuretics are more beneficial than calcium channel blockers (CCBs), angiotensin converting enzyme (ACE) inhibitors, or alpha-blockers as initial treatment to lower blood pressure and to protect against adverse effects of high blood pressure."

American Society of Hypertension issued Diabetes Guidelines 2008

ASH called for patient-centered management and early, aggressive treatment of hypertension in diabetics. Their advice might apply to everyone. The ASH urged physicians to adopt a more integrated, individualized approach to treating hypertension by treating the intricacies of each patient rather than focusing on the disease in isolation. Goal blood pressure in hypertensive diabetic patients remained 130/80 mm Hg. All patients should reduce weight reduction, improve diet, increase physical activity, limit alcohol consumption, never smoke and limit salt intake to less than 2.4 g/day. The report stressed a reduction to glycated hemoglobin [HbA1c] to less than 7% mantaining finger test fasting glucose levels in the range of 70-130 mg/d. Low-dose ASA (aspirin) 80 mg/day was recommended. Lipid leves in the blood should be: low-density lipoprotein cholesterol <> 40 mg/dL in men and > 45 mg/dL in women. Potassium levels should be kept to < 5 mEq/L.

2009 Update

In a best evidence review Vega stated:”Angiotensin-converting enzyme (ACE) inhibitors are some of the most commonly prescribed medications for hypertension. This enthusiasm for ACE inhibitors is somewhat inconsistent with current recommendations, which prefer thiazide diuretics as first-line medication for uncomplicated cases of hypertension. With the popularity of ACE inhibitors in mind, investigators conducted a systematic review of published studies to determine how effective the drugs actually are in reducing blood pressure.”

The conclusions: ACE inhibitors (benazepril, moexipril, ramipril captopril) were associated with an average reduction in systolic blood pressure between 6 mm Hg and 9 mm Hg and in diastolic blood pressure of 4-5 mm Hg; all drugs in this class are similar and achieved most of their power in reducing blood pressure at half of the maximum recommended dose, or less. Related drugs, angiotensin receptor blockers (ARB), provide similar modest reductions in blood pressure; 46 randomized controlled trials examining 9 ARBs, and found that average reductions in systolic and diastolic blood pressure were 8 mm Hg and-5 mm Hg, similar to ACE inhibitors. ARBs were effective at one eighth to one half of the manufacturers' recommended doses.There is no strong evidence that ACE inhibitors can prevent diabetes or heart failure.

An analysis of the Treating to New Targets (TNT) study was presented at the American Society of Hypertension 2009 Scientific Meeting. Messerli et al published did an analysis of the INVEST study, a trial comparing two antihypertensive regimens in 22 576 patients with hypertension and coronary artery disease, and found that excessively lowering diastolic blood pressure was harmful. Messerli stated: "It stands to reason that when you lower blood pressure too much, you can do harm. After all, if blood pressure is zero, mortality is 100%. So somewhere there must be a nadir, below which the lowering of blood pressure becomes counterproductive."

Compared with the reference blood pressures -- systolic >130 to 140 mm Hg and diastolic >70 to 80 mm Hg -- patients with systolic blood pressure <110 mm Hg had a threefold increased risk of cardiovascular events, whereas those with diastolic blood pressure <60 mm Hg had a 3.3-fold increased risk of events. Messerli suggested that lowest point of inflection on the morbidity and mortality curves was 140.6 mm Hg for systolic blood pressure and 79.8 mm Hg for diastolic blood pressure.


Bakris GL, Sowers JR; on behalf of the American Society of Hypertension Writing Group. ASH Position Paper: Treatment of hypertension in patients with diabetes -- an update. J Clin Hypertens (Greenwich). 2008;10:707-713.

Charles P. Vega .How Effective Are ACE Inhibitors for Hypertension? A Best Evidence Review. Posted Medscape Online 03/13/2009

Heran BS, Wong MM, Heran IK, Wright JM. Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database Syst Rev. 2008;(4):CD003823.

Bangalore S, Messerli FH, Wun CC, et al. J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) trial. American Society of Hypertension; May 7, 2009; San Francisco, CA.

Tuesday, April 28, 2009

Swine Flu and Infection Risk

The emergence of a new influenza virus has created a frenzy of misinformation and panic. TV news shows people wearing paper face mask, the latest signal that the world is a dangerous place. While I have broadcast my concern for many years that infection surveillance is inadequate and promoted a new ethic of social responsibility, I find the frantic media reports this week to be offensive if not absurd. Social responsibility means -- don't spread infections you have acquired; if you are sick, stay at home.

There are real dangers in the world. Infectious agents evolve continuously. Increasing populations and increasing urban density are ideal for infection transmission. Transportation of people and goods all over the world means that infections become worldwide in a matter of days, not localized. I continue to meet physicians who think they are living in the nineteeth century and refer to localized, "endemic" infection.

Solutions can only be found by well-informed, calm methodical people. Turn off CNN and let us proceed with caution and appropriate concern. In my business, we have looked at air quality issues for several decades. Here is a response to a typical question we addressed:

Question: I do a lot of international flying, from North American to Asia, several times a month. I have gotten, many times, upper respiratory infections, bronchitis, bad coughs that my physicians, as well as my common sense, tells me comes a great deal from the poor air quality on airplanes. In addition, just the past week, with the outburst of some kind of Asian virus with serious symptoms, I want to protect myself as much as possible, while at least on the airplanes. What masks do you suggest, and any other comments or suggestions you might have?

Answer: We have looked at this problem repeatedly over 2 decades and not arrived at a satisfactory method of personal protection except for canceling the flight. You have to accept that traveling involves exposure to thousands of strangers who may infect you with microbes most of which, you have not encountered before and you will lack protective immunity. This increased exposure begins when you leave home and continues even after you arrive back.

You have to disinfect everything, including yourself, before you are free of foreign microbes. It’s easy to focus on the in-flight conditions, but exposure in the aircraft is only a small component of the overall risk of infection when you travel. Biological agents infect through the respiratory mucosa; ingestion; contact with the mucous membranes of the eyes, or nasal tissues; by penetration of the skin through scratches, small cuts and abrasions Organic airborne particles share the same characteristics in air or on surfaces as inorganic particles from hazardous dusts.

Here is a quick summary of the basic strategies you can use:

Disposable paper face masks provide minimal protection against dusts, fungal spores and bacteria, but not viruses. These are obviously the cheapest, most available and probably most acceptable to wear in public including in airports and perhaps on a flight. The protection rating is hard to assess, but is probably very low in the range of 5-10. Paper masks with a NIOSH protection rating of 100 offer better protection against viruses, if you wear them properly.

The mask has to be changed often and you must wash your hands after handling the mask. For more serious protection you can use half-mask or full-face air-purifying respirators with particulate filter efficiencies ranging from N95 (for hazards such as pulmonary tuberculosis) to P100 (for hazards such as viruses). The protection rating is somewhere between 50-200, depending on the filter chosen and degree of proper utilization.

The best protection against airborne infectious agents (as well as all airborne toxins) is provided by self-contained breathing apparatus (SCBA) respirators with a full facepiece operated in a positive pressure mode. This reduces the hazard from most sources -- airborne particles, microbes, chemical vapors and gases. The National Institute for Occupational Safety and Health (NIOSH) suggests that the proper use of SCBA reduces the user’s exposure by at least 10,000.

Decontamination of clothing is a precaution against particles that have settled on the outside. Use detergent, hot water, and 0.5% hypochlorite solution (one part household bleach to 10 parts water) to wash clothes and baggage. You should wash your hands frequently and shower ASAP after a flight using generous quantities of detergent and water. Shampoos contain detergents that tend to be better cleansers than regular soap. Use a basic shampoo as a whole body wash.

Until more people wear APRs and everyone is used to them, we can assume that if you strap one on to go to work, travel in an airplane or walk the dog, most people will think " you look weird!" We are not sure how new security regulations will treat the use of APRs on airplanes… it will controversial.

See the book, Air and Breathing by Stephen Gislason MD

Sunday, April 26, 2009

Unsafe? Avandia for Diabetics

There have been a succession of disappointments about drug therapy in recent years. One drug, Avandia, became a popular diabetes medication. It took several years and a brave MD to uncover evidence that it is not such a good drug, after all.

Avandia is rosiglitazone, a popular diabetes 2 drug. Doubts were raised about the safety of this drug and there are arguments for and against it. The arguments and concerns will not be resolved quickly. Avandia is marketed by Glaxo, which, like all drug companies, vigorously defends its big money drugs. Sales of Avandia reached $3.2billion per year in the US.

Our perspective for 2 decades is that the drug treatment of diabetes lacked convincing long-term efficacy and there were important concerns about side effects and long-term adverse effects. Oral medications should not be considered as primary treatment. However, MDs tend to be drug prescribers, drug companies are interested in making money and patients are obedient consumers who like to believe there are simple solutions for complex problems.

Dr. Steven Nissen and colleagues from the Cleveland Clinic reviewed more than 40 studies and concluded that Avandia increased the risk of heart attacks by 43 percent. Psaty and Furberg recalculated Nissen’s analysis using interim results of the Record study in addition to the studies that Nissen used. They found that Avandia increased a patient’s risk of having a heart attack 33 percent. Nissen is an experienced but independent FDA advisor who has become an ombudsman for the American people.

In the US where Avandia was developed and concerns were announced, questions about the safety of Avandia and how regulators have dealt with its risks were asked at Congressional hearing in June 2007. Glaxo had an ongoing study, REPORT, and rushed to submit favorable interim results for publication in advance of the government hearing.

In his New England Journal editorial, Dr. David M. Nathan, a Harvard diabetes expert, doubted the value of the REPORT study because of the high number of patients who dropped out and the study design which compared Avandia to a combination of metformin and sulfonylurea. While this combination is popular, doubts about its safety were raised and never resolved in another study that showed a 96 percent increase in diabetes-related mortality. Metformin alone appears to be relatively free of cardiovascular risk. Nathan concluded that the interim results of the Record trial do not provide any assurance of the safety of treatment with rosiglitazone and suggested that doctors should use medications other than Avandia.

A series of drug adverse effect withdrawals in recently years have generated criticism, that the US Food and Drug Administration fails to protect the public. In the Avandia case, critics say that the US FDA should have warned about the potential heart risks years ago. A supervisor in the drug safety office at the agency said in an interview that she was rebuked after calling for a stronger warning label on Avandia and a competing drug, Actos.

November 20, 2007: A US Senate Committee on Finance released a report describing what it terms the "intimidation" of Dr John Buse by GlaxoSmithKline (GSK) over his concerns about the cardiovascular risks associated with the company's antidiabetes drug rosiglitazone (Avandia). The committee stated: "According to documents provided to the committee by, among others, GSK and the University of North Carolina, it is apparent that the original allegations regarding Dr Buse and GSK’s attempts at silencing him are true. According to relevant emails, GSK executives labeled Dr Buse a 'renegade' and silenced his concerns about Avandia by complaining to his superiors and threatening a lawsuit."

The main problem for a growing number of patients is the false belief that a drug or combination of drugs can rescue an individual from a disease-causing lifestyle. While there may be benefits to be had with medications, a person with diabetes 2 should learn expert self-management skills and exercise all the therapeutic and preventative options available before taking drugs.

From the Book Managing Diabetes 2 by Stephen Gislason MD

See further discussions of medical biases and limitations

Also See Diabetes Drugs

Monday, April 20, 2009


While the term “healthcare” is popular, it misrepresents health in every possible way. Health is supposed to refer to being “healthy” – free of disease, physically fit, productive and happy. Healthy people do not need to spend money on doctor visits, drugs, hospitals and surgery.
So what is a more accurate term than healthcare? Medicalcare is the proper term. Medicalcare is a heterogeneous collection of products and services provided by MDs, drug suppliers and hospitals that deal with people who are not healthy. Sometimes medical intervention is merciful, humane and lifesaving. Most of the time, medical care is wasteful, inefficient and potentially dangerous. Healthy people do not seek medical care.

Lundberg, Editor of MedGenMed stated that: “The US medicalcare system is immensely complicated, almost inexplicable, costly beyond belief, seriously discriminatory, and often unsafe. The money expended from all sources in American medicalcare is extraordinarily large, some $1.7 trillion in 2004, one seventh of the total US economy, and larger than the total economies of most countries of the world.” Lundberg suggests that the marketplace" determines how much money is spent on what and how many people of what types work in medicalcare but it is not a free market. “

People in the US and Canada are less than healthy because they eat too much of the wrong food and exercise too little. The mechanisms of bad-food diseases are numerous and complex. Profit can be made by attempting to manage the consequences of eating too much and exercising too little. Marketing chemicals to reduce the negative effects of eating too much of the wrong food is unbelievably profitable, even though none of the drugs are really required. Canada is the third-highest-per-capita spender on drugs among industrial countries after the United States and France. Canada spent $3,003 US per person in 2003 lower than the U.S. at $5,635. Norway and Switzerland were next in line at $3,800 per capita. All affluent countries are spending more on drugs, increasing 32 per cent between 1998 and 2003 to more than $450 billion annually. Growth in spending on pharmaceuticals outpaced the rise in total health-care expenditures in most countries, including Canada. In the U.S. and Australia, spending on drugs grew more than twice as fast as total health expenditures.

The real solution is not taking drugs, but removing the causes of disease, by, for example, eating less, choosing the right foods and exercising more.

Download free eBooks from Persona Digital

Wednesday, April 15, 2009


For many years, I collected reports from patients disappointed in the medical care they received. For several years patients would come into my office and complain that they had seen several doctors, had many investigations and tried many drugs without benefit. I noted that patients routinely left the care of their physicians and shopped around the “alternative” community and bought curious, bizarre and often expensive tests, treatments and products with little hope of benefit.

I am aware of the limitations of physicians, however, and want my well-educated, well-motivated reader to recognize these limitations and assume responsibility for their own management. When you look critically at modern medicine you see expensive techniques deployed to rescue individuals from calamities which were often avoidable. Although many talk about the "health-care system", they are really talking about a high-cost medical intervention system, directed at treating diseases that are fully developed, but not preventing disease. While “high tech” medicine promises miraculous cures, there only is a short list of problems which can be fixed by medical or surgical methods but a much longer list of problems which cannot be fixed.

One problem is that MDs seldom learn how to manage food-related diseases. In the physician’s mind, food is someone else’s responsibility. Physicians, like everyone else, have prejudices and preconceptions that limit their understanding of the complex issues that determine food selection, metabolism and the consequences of bad diets. Both physicians and patients have an overwhelming bias in favor of drug and surgical treatments. Medical practice is based on a routine of ordering tests and writing prescriptions for drugs.

While diet and “life-style” modifications are mentioned in medical texts, few MDs pursue this approach to patient management. Many MDs have argued that the task of changing patients’ habits is beyond their mandate, is too time-consuming, and is often futile. Even if MDs are interested in solving food-related problems, they are usually too rushed to spend the time necessary teach patients the knowledge and skills they require to self-manage effectively.

There is a fundamental misunderstanding between doctors who know something about their limitations and patients who often have unrealistic expectations for fast solutions. Both sides of the relationship become frustrated and tend to act irrationally when quick and easy solutions do not work. The more passive and dependent a patient is, the deeper this misunderstanding grows and the more expensive it becomes. Patients demand more investigations, referrals, and support services. Physicians tend to order more tests and prescribe more drugs and that are increasingly potent and more risky. When neither strategy works, many illnesses remain unsolved, suffering is not relieved and expensive problems continue to drain the resource of individuals and their communities. Stephen Gislason MD

Download Free PDF eBook SelfCare for the 21st Century