Important Tuna Recall

This morning I was looking at the news and found an article about a tuna recall. As you know people, especially pregnant women, need to keep an eye on the news for public health and food issues. 

Today the FDA has recalled some frozen tuna because it has hepatitis A in it. The FDA recommends that people exposed to this fish get a Hepatitis A vaccine if they are between 1-40 years of age, or a immunoglobulin shot if they are outside of that range. 

Frozen Tuna is in sushi. And you can get it in restaurants. This tuna was shipped to restaurants in Texas, Oklahoma, and California. It was sent to New York State but not distributed there yet. 

This tuna comes from Philippines and Vietnam. It comes via a Hawaii based imported called Hilo Fish Company. 

Once again I wouldn't want to impugn the Hilo Fish company. They should be awarded for checking the fish and cooperating with the recall. It is the fish companies that don't test that we need to be alert for.  I have seen really giant tunas that caught by recreational fishers. These big tunas get distributed immediately to sushi shops. That kind of distribution is what we want to worry about. 

So for now, don't eat any frozen or uncooked tuna, and check the FDA's web site for further news and lot numbers, etc. This tuna was dated April and October apparently. 

I am not aware if cooking the tuna adequately will sterilize the Hepatitis A, but certainly it cannot be eaten raw or undercooked. Unfortunately I really like sushi. 

Thanks 

Dr John Marcus 

89 North Maple Ave 

Ridgewood NJ. 

Blog at doctorjohnmarcus.blogspot.com

Medical Science and Statistics

One thing that most people don't understand is that most medical science is very weak from a statistical and mathematical point of view. 

Another thing that doctors don't understand at all is the concept of Predictive Value of a test result. 

Lets go through both here. 

The medical journals are voluminous. There are many studies done. They are mostly done in a fairly uniform format. (such as Title, Abstract, Methods, Summary, Conclusion).  There is a ton of complicated language that is familiar only to the professors who read and write these studies.  

The biggest problem with medical studies is the issue of bias. There are a ton of problems with bias. Most studies have bias. If a scientist wishes to prove something, then they will attempt to make a study that proves their point. It is rare for a study to be done that doesn't have bias. Because a truly neutral scientist is not going to be motivated to produce a study and article at all. Pharmaceutical companies are biased because they want to make money. And meds are worth billions of dollars. 

Here is a publication that describes much of the bias in medical science: 

http://fhs.mcmaster.ca/surgery/documents/HandoutGrimesAssociationforResearch2of07Oct2009.pdf

The same article is here: 

http://thelancet.com/journals/lancet/article/PIIS0140-6736(02)07451-2/abstract

The best way to avoid bias is to gather a study group of people, and randomize them. This produces the least selection bias. Then the two or more groups of people are treated differently and someone analyzes if the outcomes are different. If the study is "Double Blinded and Randomized" then there is strong evidence that the different treatments created different outcomes, and the knowledge base of the human race has increased. 

But even the best randomized trials still have bias. One of the strongest biases is publication bias. You see, the studies are designed to create a "P Value" of 5 percent. This p value means that there is only a 5 percent chance that the outcome is due to chance variation. This kind of p value is easy to calculate for people who are trained in this kind of statistical work. There is software to calculate p values based on simple input numbers, such as study size, expected effect, etc. 

Here is a summary of how to calculate p value: 

http://www.wikihow.com/Calculate-P-Value

It looks really complicated and confusing. But it makes a ton of sense to people who know how to do it. I don't suggest you try to learn the details. Just know that the p value tells you how likely the research results are true, and not chance. P value of .05 is the standard and that means there is only a 5 percent chance the study results are just randomness. 

But here is the kicker, and it is a huge problem: 

Studies that prove nothing, with elevated p values, don't generally get published. Those "worthless results" might be considered a waste of time. But if you do the study 20 times, then one of them will give a false result. (one in 20 is 5 percent, or p value of 0.05); The result will appear excellent, but it is wrong, fake, biased, incorrect, garbage, dangerous. You might think that this is a stupid criticism of necessary science. But I can tell you that it is huge. There are studies that are done where the data is looked at hundreds of different ways. Not all of those ways are published. Only the significant results are published. So if a study looks at the same data one hundred different ways, and the p value is 0.05, then 5 results will show a fake but convincing effect. Worse yet, some studies do "early look" at the data. This should be condemned entirely. An early look at the data erodes the quality tremendously. Not only is there less data to look at, but it more than doubles the risk of a false p value. There will be a more than 10 percent chance of a false finding. And if one looks at the data 10 different ways, then it becomes very likely that there will be a false presentation of statistical effect. The study will show a false truth. This certainly happened with the "Woman's Health Initiative". There was an early look and there was a possible false finding of a cause of breast cancer. That study cost many millions of dollars. And it turned the previous data on its head. There was ultimately one table in that study that will show the possible truth, The "life table" analysis, which showed the incidence of breast cancer in the hormone group vs the nonhormone group, across time. If you look at that table, the incidence of cancer was higher in the early data in the estrogen group. But the incidence lines were about to cross, consistent with older data, at the 2 year early look. Despite the fact that the data was poor, the study was cancelled. The p value declared secure. And people believed that estrogen, a natural normal female hormone, is toxic. It might take another hundred years before someone does this study properly. The early look and the multiple analysis gigantically eroded the value of the data. And in any case, the effect of estrogen was a few cases in 10,000. It became easy to vilify estrogen to the point of wrecking woman's lives. 

Also, there is the effect of "study group". A study that is done in one setting will not apply in another setting. A study done by midwives can be perfect scientifically, but it will not apply to obstetricians. Because obstetricians treat their patients differently. A study done on men might not apply to women. A study done in a poor area of Chicago might not apply to Mormons in Utah. For instance, lets say you are doing a vitamin D study and your group is in far north Canada. They might not get sunshine for half the year. This will certainly not apply in Ecuador (which is named for being on the Equator), and has near vertical sunshine year round. (Vitamin D is created by sunshine on the skin). There are a lot of vitamin D studies. One should look carefully at the study population to see if the study applies to yourself or your population. 

One example of study population affecting results is C Section closures. In a university, C Section closure techniques were studied. Staples vs Subcu dissolvable. In this study the results were proven to be equivalent. Staples and sub cu had the same scar outcome. But, the kicker is, this university also published a very high surgical skin infection rate. If I remember correctly, it was as high as 15 percent. This study cannot apply to me, because my surgical infection rate might be 15 times lower than that. I practice at a hospital that has infection control procedures down pat, with highly experienced personnel, laminar flow operating room air, etc. So that study simply doesn't apply to me. I have to make my own decisions about C Section closures, unless I do my own study.  The bottom line is that I will close a C Section in a way that the patient finds best, In other words, the patient will help decide. Some don't like staples. Some have had very good results with staples. Some want dis-solvable stitches, even though those stitches takes weeks to months to fully dissolve, if ever. 

Now lets move from statistical medicine to the doctor patient interaction. 

Predictive Value:

Lets say that I ordered a pregnancy test. And it is positive. But, the test was done on a boy, or a virginal gay woman, or a virginal nun. What is the value of that test result? It will not be valid. It will of course lead to a lot of stress, maybe recriminations, and some terrible feelings. But the value of that test is nearly nil. The predictive value of a positive pregnancy test depends on the study population. Lets say for the sake of argument that this particular test is 99 percent accurate. That leaves a lot of room for error. Because there are women who cannot get pregnant. If we test them, all of the results are inaccurate. Or at least misleading. A test can be inaccurate for a number of reasons: tumors, ovulation, HCG injections for a number of indications. I've even had patients who were ALWAYS POSITIVE. They've never had a negative pregnancy test in their life. Sorting that out is a challenge. Lets hope a 14 year old is not disowned by her father while figuring that out. We might figure that there was a tiny bit of placenta left over from her own fetal days, stuck somewhere in her body. Wherever it was, it did not seem to harm her and she wasn't worried.

So to calculate the predictive value of a positive result, the most important factor to consider is the pre-existing chance of the problem studied for. A good test has a 80 percent "Sensitivity". This means that, in the presence of the condition tested, there is an 80 percent chance of the test showing it.

Take a look at the Wikipedia page as of today:

https://en.wikipedia.org/wiki/Sensitivity_and_specificity

There is a lot of math there. We don't need to know the math, but we have to know the idea. And if we don't, we mess up.

For instance, I might order a "Comprehensive Metabolic Panel" from the lab. This test has about 20 different natural chemicals on a person. For instance glucose and sodium (salt) are usually at the top. It is really tempting to order this test as it gives a ton of good info about a patients chemical status. The lab can print this out in minutes to hours. The problem, and it is not a big problem, is that the normal ranges are set at 95 percent normal ranges. That means that if we do the test 20 times, there will be on average one that falls outside the normal range, in an otherwise completely normal person. For instance, they ate a jelly donut and their glucose is high. That is a bad example because most people won't eat a jelly donut prior to a lab test, but in an emergency, the ER doc might not be able to ask the patient when they ate. So, on average there are 20 measurements, with a 95 percent "confidence interval", that means that a normal person has about one test outside the normal range. This is a completely false positive. And it is normal.

Notice the similarity here to the 95 percent confidence interval, or 5 percent false positive rate. This is identical to the 5 percent false positive rate assigned to medical studies. It seems that medical scientists are somewhat favorable to the 5 percent/95 percent confidence interval.

Where this gets really complicated is when we have tests that are 80 percent confident, or less. This is high for a screening test. A pap smear in the old days prior to HPV testing has a confidence of about 5-10 percent. A glucose screening test in pregnancy has about a 10 percent positive predictive value. In other words, 90 percent of positives are false. So we deal with low predictive values all the time. The tests still have a lot of value but alone mean nothing.

Low Predictive Value:

What is the chance of an 18 year old getting cervical cancer? It is very low. If we do a pap smear, the chance of a positive pap smear meaning cancer is next to nothing. That is because pap smears have a high false positive rate, in a population that is very low risk. Back when I used to do paps in 18 year old women, I only intervened when the biopsies showed severe risk. This did happen, and I kept my interventions very light, like a gentle laser surgery to remove only the surface of the worst areas. But it turns out that even that is unnecessary. The incidence of cancer is so low as to make the positive pap smear nearly worthless. The positive predictive value was near zero. So, as per the new protocols published by the ASCCP, I have stopped doing paps in women under 21 years of age. The paps simply don't help. The predictive value is low. It is like doing pregnancy tests on a boy. Or doing a vaginal sonogram on normal woman, which has been proven again and again to be worthless to dangerous. The predictive value is most likely below zero. In other words, it harms women.

18 year old women can still get checkups, or checked for problems, of course. It is just that the pap is not part of the checkup, unless there is a specific reason. (the reason might be the woman or her mother really wanted it).

But please, don't assume that sonograms themselves are worthless. In fact, woman should have more of them. They should present early and often for pelvic pains, pressures, bloating, or any other symptom. An indicated sonogram can save a life. And we all need to do better detecting ovarian cancer.

I haven't given up on medical science. But there is still a lot of room for what is called the Art of Medicine. That is keeping people healthy, preventing disease, eliminating risk and  pain. And doing it while keeping people feeling safe, comfortable, and happy. And I do that to the best of my abilities.


Comments are appreciated. And let me know if there are any errors.

Thanks
Blog at doctorjohnmarcus.blogspot.com.

LOONEY MONTHS

I came home from work today just after sundown and I saw a full moon rising.  A family friend was over. I mentioned it offhandedly and said full moons were fun. She looked at me straight faced and asked why?  so I started thinking.  Why indeed? As an OB I of course think of the busy obstetrical unit. Full moons are busy nights right?  The ancient lore is that full moons make for very busy labor units. This has been suspected since the beginning of time. The reality is that there may be a small increase of maybe a percent or two, but the lore is very strong. Is there something to the ancient lore? May there be a reason to think that Ob units are busy on full moon nights? Is there some ancient anthropological principle involved? So I did a little investigating.

I started listing for myself why I thought the full moon was fun and interesting.  

First the full moon always rises in the east and looks very very full..  It appears to be giant when rising in the east over a distant horizon. Photos of this effect are striking.  You can easily search for these photos. Do a google search for full moon rising, switch to the images tab, and look at the striking photos.

Second a full moon always rises at sundown.  This means everyone sees it at the end of a workday when they are tired and hungry and ready for dinner.  It seems most impressive then.  When it rises most people are not thinking they’ll be looking for the full moon tonight.  It just pops up huge and bright on the horizon.  

Third a full moon strikes people's mood.  It is what is meant by loony, lunatic, lunacy etc.

Fourth, the ob unit at the hospital always groans that a lot of labors are going to come in.  The feeling is that full moons means more laboring women. We all say “uh oh get ready”.  It'll get crazy. It'll get looney around here. But the purely logical folks say that is just an old wives tales. It means nothing right? Which prediction wins, logic or lore? Will the unit be busy or is it just an old wives tale? (midwives tale might be a better term)

Fifth a full moon is the brightest night of the month.  The moon shines bright and full.  Moreover it shines brightest right at midnight. Why? A full moon is always exactly opposite the sun from the earth.  That is pure astronomical  geometry and that is why the moon is full. So the darkest part of night becomes the brightest. And it is brightest right at midnight. That is just weird at midnight. It is like it is not even night. Especially on a winter night with snow on the ground. It is astonishingly bright on some full moon midnights.

There are a ton of human endeavors that are tied to the idea of a month. Paychecks, rent checks, contracts, meetings, mortgage payments, menstrual cycles, birth control pill packages,  and tons more.

So there I am thinking why would ob units get busy on a full moon night? This is very strong old lore. Maybe there is an old truth to be discovered here.  

Now that I have thought about it I think the answer is obvious.  

But first you'll need to come along with some math again. This time we will do date and time math.

You see a human pregnancy lasts just about 40 weeks. We have pregnancy dating wheels that show exactly 40 weeks. We Ob’s always bemoan that everyone calls it 9 months. It is hard to make 9 months out of 40 weeks. We would more likely make it 10 months, if the month is defined as 4 weeks. Many months are defined as exactly 4 weeks. A cycle of birth control pills is exactly 4 weeks, or 28 days. Many paycheck cycles are 2 weekly or 4 weekly. Now think about a pregnancy of 40 weeks. 40 weeks is exactly 280 days. 40 weeks is exactly 10 months, if a month is defined as 4 weeks. This is 280 days from the first day of the last menstrual period.

But conception happens 2 weeks later. Or 14 days after the first menstrual day.

So labor happens, mostly, about 266 days after conception.

So then I'm thinking what happens on bright full moon midnights? Walks on the beach… can't sleep… too bright … romance…. conception. That is what happens. Romance and conception happens. So if conception happens on full moons… where is the moon when labor happens? Where is the moon?

So I looked up how many days happen between full moons. I found it online. 29.53 days happen between full moons. That is a lunar month. There are a ton of different kinds of months. Calendar months are obvious. But lunar months is what I am interested here.

What is 266 days divided by 29.53 days?

Hold your breath…

9.007 moons happen.

This is astonishing. It is not astonishing that there are 9 moons. That is ancient lore.  It is pretty cool that the ancient lore gets a boost here. But, what is astonishing, is that, on average, a baby conceived under a full moon will, on average, labor under a full moon. In fact, labor should occur within a few minutes of 9 moons later.

So there you have it. The first real explanation ever given as to why the lore of Ob/Gyn’s and midwives expects extra work on a full moon night. It is the same reason so many songs are written about romance under a full moon.

If you doubt this then think about evolution of the human species. We have been on the planet as genetically and anatomically modern humans for 250,000 years. For more than 200,000 of those years, a moonless night would have been abjectly absolutely dark. A person would not have been able to find their spouse or their baby, even if they wanted to. They would likely have not even seen their hand in front of their face. So romance, conception, and delivery of babies, would have been really difficult. And very dangerous for the baby. The new mother would have really struggled without effective assistance from any midwives that might have been there. Babies would be far more likely to die. There would have been a very strong Darwinian Evolution pressure to not deliver on dark nights. Bright moon filled nights would have been no problem. For the 200,000 years before humans had fire the human race might have arranged for biology to make conceptions on full moon nights, and labors exactly 9 moons later.

40 weeks has nothing to do with 9 months.  Maybe more like 10 months. But ancient midwives 10000 years ago might have known that a bright moon now meant labor in nine more moons. Or, if not that, they certainly would have known that full moons meant more babies were to be born. That is something we talk about even today in a modern Ob unit. We usually joke about it. But this may be the ancient history of the 9 moons connection.

This 9 moons time frame is too much coincidence for me to ignore. Babies are generally laboring to within minutes of 9 moons after they are conceived. This is crazy. This is lunacy.

Thanks for reading.  

Comments are of course welcome. And questions are welcome as well.

John W Marcus MD FACOG PC

89 North Maple Ave

Ridgewood NJ 07481

Phone 201-447-0077

Fax 201-447-3560.

Family Powers of Two

I have just come back from The Valley Hospital where I delivered a beautiful baby boy, a first baby, to a wonderful couple. The baby came out right onto the mothers chest and abdomen, and he was moving around, pink, and of course crying. He took his first 5 breaths, which are mostly in breaths, before he started crying from being born. I think that babies do not like being born. It is like getting evicted from a warm easy 98 degree bath that one has floated in for 9 months. I can't imaging getting evicted like that. And then babies have to do the hard work of actually breathing and digesting. It is called transition by the baby care staff. Transitioning is important, and it can be difficult for babies that are born in a stressful manner. Difficult or stressful births might be a premee or an infection. This could include influenza or strep sepsis, for instance, or a placental abruption. Transition is also sometimes a bit difficult for C Section babies that have not experienced labor. I think that the babies that don't get squished or compressed by uterine contractions have a harder time with transition. They breath harder and faster, and sometimes need oxygen, suctioning, and stimulation. They have more amniotic fluid in their lungs that needs to get expelled somehow. We call this transitioning difficulty "Transitional Tachypnea of the Newborn".  Here is the Wikipedia page as of 2 PM on December 7th. https://en.wikipedia.org/wiki/Transient_tachypnea_of_the_newborn. Notice that Wikipedia calls it transient tachypnea. That is another name.

But as a mathematician and a amateur philosopher I have been thinking about generational genetic math again. One of my patients has done the 23andMe genetics service and has found out some genetic history. This may be very valuable to someone who has no known family history. It can elucidate particular genetic risks, and will be valuable for the whole family, and her kids. (I can use the pronoun "her" because I only have female patients, as per my board certification rules, which disallow male patients under most circumstances).

Lets think about generational math. Realize that you have two parents. Your parents have two parents, meaning you have 4 grandparents. Your grandparents have two parents each. This means that you have 8 great grandparents. Notice that each generation has a power of two. Powers of two have very easy calculations, especially for a computer scientist as they deal with powers of two all the time. 2 to the 8th power is a byte, and there are 256 different bytes, starting at zero and ending at 255.

Anyway, lets continue. Two to the 16 is 65,536. This means you have 65,536 great great... 16th generation... grandparents. And so does everyone else.

Powers of two have an "exponential" growth rate. There is an astronomical amount of power in an exponential growth rate. Two to the 32 is 4, 294, 967,296.  

Here is the first kicker. 32 generations ago, was how long? If we allow 20-25 years per generation, we get 640 to 800 years. There was not 4 billion people on the planet back then. This was the European middle ages, the Ottoman empire, the Shogun's of Japan, the natives of the America's, which came over from Asia via multiple routes during the last Ice Age 10,000 or more years ago.

The Earth only got it's first 1 billion people as of the year 1800 or so. So how can you have 4 billion ancestors if there were much less than a billion people on the planet? The answer is that people share ancestors. This is another way of saying that we are all related.

Using this kind of math, we can show that in General, of the 8 billion people presently on the planet, we are no more than, maybe 64th cousins. This is a highly conservative estimate, because 2 to the 64th is 1.8 times 10 to the 20th power. This is trillions of times more than the number of people that have ever lived.

Or, another way to look at it, is that 2 to the 33 is about 8.6 billion. This is way more than the number of humans that existed 33 generations ago. Therefore, we all must share a lot of ancestors to get this high number.

How many generations of humans exist? Anthropologists and geneticists believe the humans evolved from a herd of homo sapiens consisting of about 40 woman, tracked through the mitochondrial genetics. This herd lived somewhere around 250,000 years ago, centered somewhere in Africa, and expanded from there. 250,000 years, divided by 20 years per generation, gives 12,500 generations. So your 12,500th grandfather, is most certainly the same as mine, no matter where you are in the world. The only way this could be different is if your family came from a different planet.

No matter how you do this math, the numbers will add up somewhere in the same ballpark.

We are likely no more than 35th cousin, and we are not possibly more than 12,000th cousin. No matter who you are in the world.

Can 12,000 generations evolve humans so differently? Pale skin was necessary in northern latitudes because humans would die of rickets without vitamin D. Pale skin was necessary to survive the low sunlight levels of northern latitudes.

Pale skin in equatorial Africa was similarly dangerous. A person like myself can get a sunburn in under 20 minutes of hot unmitigated sunshine. Everyday all day without coverage from the Sun and I would eventually get a tan, but I would be seriously challenged by the burn, the blisters, and the cancer that would likely ensue. A darker neighbor would most likely be healthier and have more successful reproduction. I believe that even a few generations like this would evolve humans to have different pigments. So yes, this many generations can evolve a lot of differences.

So, the bottom line, is that we are all related. All Europeans are no more than maybe 32nd cousins. All Asians similarly. All Africans similarly. But, assuming that the races of humans split up at the exact moment of creation of the species and didn't mix since, we can be no more than 12,000th cousin. I believe those conditions were not true, and that humans intermixed over history, so it would be difficult to find humans that are, say, more than a thousandth cousin.

We are all related. We are all one family.

Thanks for reading.

http://doctorjohnmarcus.blogspot.com 

Phone 201-447-0077

Fax 201-447-3560 

Member of: 

Lifeline Medical Associates at LMA_LLC.com 

Medical Society of New Jersey 

Past President of Bergen County Medical Society 

Member of Medical Justice 

Member of the U.S. Woman's Health Alliance at http://uswomenshealthalliance.com/index.php

Member of the American College of Ob/Gyn at www.acog.org 

Board Certified by American Board of Obstetrics and Gynecology at www.abog.org 

Member of The Valley Hospital Medical staff Department of Ob Gyn 

-ex Director, Associate Director, Secretary, Chief of Education, Chief of cancer committee. 

- present member of Ob Critical Care Committee 

Member of Hackensack UMC at Pascack Valley  Medical Staff at http://www.hackensackumcpv.com/

LISTERIA ALERT

Listeria is an infectious bacteria that is particularly dangerous to a pregnant woman's fetus.

Watching the news today I came across a story that all pregnant woman will have to know about. Listeria is once again in the news. 

Every once in awhile there will be a public health alert about some particular food that has become a danger to the public. The American Food and Drug Administration has the mandate to keep our food safe, identify the risks to the public, and eliminate or mitigate the risks somehow. Frequently that will mean recalls. Often the recalls will be some kind of vegetable. I can remember spinach, melons, packaged salad, and very frequently frozen hamburger meat. Once in the past it was Hummus. This time it is some kinds of Sabra hummus. Here is a link to the CNN article. I am sure this article will be updated as more information becomes available. 

http://www.cnn.com/2016/11/19/health/hummus-sabra-recalled/index.html 

Oddly, the article does not mention pregnant woman. In pregnancy the infection to the mother can be a relatively mild flu like illness, but the bacteria gets into the fetus and severely, permanently, or fatally injures the fetus. It is very difficult or impossible to identify the illness in the early stages. The most common diagnosis is on culture of the infected fetal tissues. By then, the damage is to late and many times irreversible. 

The best defense against listeria monocytogenes is avoidance. There are particular food rules that most pregnant woman are aware of to never eat certain foods. Like unpasteurized soft cheeses. This is a basic rule of pregnancy. I think I am going to survey my pregnant patients about this knowledge. And report the results here. Results to be announced. 

Here is the wikipedia page. I last looked at this on Sunday November 12th at 2:30 eastern standard time. (wikipedia pages can change all the time). 

https://en.wikipedia.org/wiki/Listeria_monocytogenes

Sabra is my favorite hummus. Hummus is vegan, extremely healthy, and really yummy. I will not stop buying it. But please throw away any of the listed versions. And for now, pregnant woman should avoid this Sabra hummus. 

It would be too easy to say that Sabra Hummus company is committing a malfeasance by producing hummus like this. I would ask all of you to consider an alternative view. My view, and your view should be, that Sabra is making an effort to keep their food safe, and doing this voluntarily. How many companies do quality control like this? It was not long ago that a peanut butter company did quality control but hid the results and shipped the infected food anyway. This led to unprecedented criminal charges against the leadership of that company. 

But worse, how many companies don't do quality control so effectively? How many don't do it at all? Large egg farms, for instance, have the hens living in poultry barns where there feces exist. This is utterly unavoidable as the birds cannot be potty trained. And keeping the birds on a grid to let the feces fall will only hurt their feet. 

And smaller companies (and restaurants) that make smaller batches or more "homemade" like food will have no quality control at all, other than the skills and cleanliness of the chefs and workers. There are many instances of Norovirus spreading from mildly infected workers. Workers should voluntarily stay away from work when they are ill, but that will be looked upon as a black mark on their occupational record, and might lower their paychecks. Alternatively, workers should be rewarded for due care to protect the food and their customers. I don't know how employers can commit to this. Personally, I don't come to work when I suspect that I might harbor an illness. And, don't be too surprised, physicians and nurses do get sick. I remember the look of shock once when a delivery man came to my house when I was sick and raised his eyebrows when he saw that I was on a sick day. He said "doctors don't get sick" in surprise. I laughed and said I wish that was so. 

So I believe that Sabra hummus is committing to quality control with vigor and commitment. This will make me more likely to buy Sabra, not less. 

Please let me know what you think in the comments below. 

Thanks for reading. 

http://doctorjohnmarcus.blogspot.com 

Phone 201-447-0077

Fax 201-447-3560 

Member of: 

Lifeline Medical Associates at LMA_LLC.com 

Medical Society of New Jersey 

Past President of Bergen County Medical Society 

Member of Medical Justice 

Member of the U.S. Woman's Health Alliance at http://uswomenshealthalliance.com/index.php

Member of the American College of Ob/Gyn at www.acog.org 

Board Certified by American Board of Obstetrics and Gynecology at www.abog.org 

Member of The Valley Hospital Medical staff Department of Ob Gyn 

-ex Director, Associate Director, Secretary, Chief of Education, Chief of cancer committee. 

- present member of Ob Critical Care Committee 

Member of Hackensack UMC at Pascack Valley  Medical Staff at http://www.hackensackumcpv.com/

Why do I ask people about their religion? 

To boil the answer down to a simple one, it is because I don't wish to put people and patients into a state of spiritual strife. Or spiritual danger. If I mistakenly give people a plan of action that they later come to regret, I will feel like an ass.

My medical decision making can be precisely correct, scientifically sound, and delivered in a clear, compassionate, and skillful manner. Yet still it is possible to wreck someones life. I don't want to wreck anyone's life. From professional point of view it would make me a bad doctor. From a personal point of view I would feel like a jerk. I don't want to feel like a jerk.

How could a doctor create spiritual danger? It is remarkably easy. And it is sad to say but physicians don't get any education about spiritual issues. I think that leaders in the medical sciences want to say that modern medicine is "evidence based". Medical leaders want to be scientifically sound. They want all medical decision making to be factual. They want to be able to cite actual scientific journal articles to support one decision over another.

The older generation of docs used to complain bitterly about  this turn towards science, towards checklists, and away from the art of medicine. Older docs called it "cookie cutter" medicine. Or "recipe" medicine, or something like that.

A arrogant young medical doctor might scoff at the notion that a person's religious belief would interfere with sound medical care. A self important doctor might tell a patient that "there is only one way to do this, and it is my way. Religion has nothing to do with it.". This is spiritually dangerous territory. Even for atheists.

Let's give an example:

A newly married Catholic woman comes to my office to ask about contraception. She has strong faith. During the consultation I find that she has no knowledge of the Catholic rules pertaining to conception and contraception. If I didn't care for her overall well being I might recommend the birth control pill or an IUD. If I did this deliberately it is even worse. Catholics have some simple and important rules to follow when it comes to contraception. Catholic rules prohibit ejaculation outside the vagina. And even more importantly Catholic rules prohibit interfering with an embryo. If an embryo gets created, then it must be allowed to implant and grow. No one can take any action that prevents embryo implantation. Since the birth control pill will allow rare ovulations, there will be embryos created. But the birth control pill also thins the uterine lining. When the uterine lining is thin the embryo has nowhere to implant. So the embryo menstruates out. The Catholic theology is that an embryo is a human, And obviously no one wants to hurt an innocent human.

Notice that this is simply an extension of the right to life movement all the way back to sperm and eggs.

Personally I don't adhere to the notion that an embryo isn't human yet. I think embryos are human. There is no magical point of time when an embryo ceases to be inanimate, and suddenly becomes human. The embryo is and always will be human. It is silly to point out an event and say, now, the baby is human. Before, not so much. Embryos are constantly growing. Whether a person is pro-life or pro-choice, people have to get rid of such misconceptions.

Discussing these issues is important. These issues are deadly. Of life and death importance, Many gynecologists have been shot or bombed because of disagreement over these beliefs. Many people have died over this issue.

So yes, spiritual competence is an important skill for a physician to have. And when I ask you about your genetic heritage, ethnicity, and religion, I am simply trying to be a good doctor, and avoid things that might harm you. And if you don't tell me your religion, then I might inadvertently give you bad advise. My advise might be scientifically sound but spiritually wrong.

As an interesting aside, there are many times during consultations when people claim to not have a religion. They might even get annoyed by the questions. Many people claim to be atheists. But, many times, they are not. They are wrong. They are not atheists. What they really are is agnostic. When a person claims "there is no God", then they are an atheist. That is not so common. Many people really want to say, "I don't know if there is a God". That makes them agnostic.

For another example of spiritual danger, consider the Jehovah's Witnesses. Jehovah's Witnesses believe that they cannot take another person's blood into their bodies. If they do, they will not get to go to heaven when they die. Many people are flabbergasted when they hear that someone would rather die then take a blood transfusion. It is only comprehensible when you understand that going to heaven is for eternity, and our life here on earth is only temporary and short. No one wants to make a mistake that would cost them an eternity of happiness. So Jehovah's Witnesses would rather die than take a blood transfusion. So the standard surgical consent form now has a Jehovah's Witness clause. It is an answer to the question, "Will you accept a blood transfusion if it is necessary to save your life?". The question must be asked and answered. Because I don't want to destroy someones long term plans of eternal happiness in Heaven.

Another example is Ramadan. Many Muslim women want to fast during Ramadan. I can help them. There is some theological controversy about the fast in pregnant women. But if my pregnant patient wanted to fast, I will try give her good advice about how to keep it safe. But I cannot give this advise if I don't know she is Muslim. Ramadan starts today.

In some religions woman cannot be touched by men. Not even to shake hands. For these women, you will put them in a bind if you offer to shake their hand. Nobody wants to be rude by refusing. But nobody wants to violate their own beliefs either. Again, if I didn't know someone was of that religion there would be uncomfortable moments. Medical care requires physical examination, but does not require a handshake. So there is unnecessary stress over a handshake.

If anyone asks about me, I am a theist. I am not an atheist.

Thank you sincerely for reading.

Dr John W Marcus
89 North Maple Ave
Ridgewood NJ 07450

Blog is at doctorjohnmarcus.blogspot.com.

Latest Zika News

Zika continues to be in the news. 

The country of Columbia has widespread Zika virus. But Columbia is claiming that they are not seeing the increase in microcephaly that is being found in Brazil. There is no known explanation for this discrepancy. The scientists in Columbia that are not absolutely convinced that Zika causes microcephaly. Columbian scientists think that this connection between Zika and microcephaly might be scientific misdirection based on bad statistics. What amounts to a correlation/causation fallacy. This kind of scientific fallacy has happened plenty of times in the past. As of yet I think that most people believe there is a link between Zika and microcephaly. 

Correlation/Causation fallacies are very easy to fall into. I remember when hairy ears were thought to be connected to heart disease. So people would trim their ears, as if that would help their heart. It was ridiculous. And in my field, it was thought that estrogen treatment for older women prevented heart disease. It required many years to correct this wrong idea. We now know that estrogen treatment is preferentially taken by fit women. This explained the fact that women on estrogen hormones had less heart disease. In a randomized trial, there was no protection from heart disease. This false conclusion took many years to correct. 

The estrogen link to breast cancer is still not understood at all. Even by very smart people. Estrogen is about as carcinogenic as a nose. It is a normal part of a woman's body. (Please note that noses do form cancer.) In the Woman's Health Initiative it was found that estrogen increased the breast cancer risk in women about 7 in 10,000 cases. But it similarly lowered the risk of colon cancer. So in the worst case scenario the cancer risk is a wash. Also note that changing 7 cases from colon cancer to breast cancer should save lives. In the WHI, after two years, the increased breast cancer risk was just about gone. The risk line was just about to cross over to lowered risk (consistent with many older studies) when the WHI was cancelled prematurely. I would invite anyone to go and read the WHI report and see that the risk for breast cancer was just about to cross over into protection. There is one graph that shows this. Cancelling the study early was a violation of the study protocol and wiser calmer heads should have kept the study going. 

The Aedes mosquito continues to spread. It is an invasive species anywhere in the Americas, so eliminating it should not damage the ecosystem in any way. Right now there are plenty of videos of insecticide trucks fogging entire cities, and workers with leaf blower sized backpack devices fogging inside homes. There appear to be an army of them working in South America. 

Even though removing Aedes mosquitoes will not hurt the environment, widespread insect fogging may have a detrimental effect on the environment or on human fetuses. It will certainly create resistant forms of other insects. 

There is no chance that insecticide is going to remove Aedes. There are just too many of these mosquitoes in too many places. Insecticide will reduce them, but it will not eliminate them. So humans are now seemingly committed to large scale long term continuous insecticide exposure everywhere there are Aedes mosquitoes. 

There is a much better strategy that has worked in the past. It is mosquito birth control. There is a British biotech firm, a small firm, that can create sterile Aedes male mosquitoes. These mosquitoes then go and mate with wild female Aedes. The offspring will not grow to adulthood. This British firm has also tagged their Aedes mosquitoes with a color that glows red in the presence of some kind of special light. Maybe a black light. This is a great way to follow the progress of their birth control measures. As a Gyne, I am familiar with birth control. Birth Control sometimes works. 

Here is a news story that is right now 3 hours old, at the Independent News in the UK: 

http://www.independent.co.uk/news/uk/home-news/zika-british-team-say-they-have-a-remedy-for-the-virus-a6859046.html

So if the sterile males go out into the wild and shoulder aside their more fertile cousins, then the Aedes mosquitoes will not successfully reproduce. 

So birth control can work. There are several theoretical problems here. According to the principle of natural selection, the more fertile members of a species should survive. So if there are some female Aedes out there that can smell out their nonfertile mates, and not mate with them, then this won't work for them. Also, fogging of insecticide will kill the Sterile males too, so those two methods will work against each other, not support each other. This exact birth control technique has been used in the past to remove pests from agriculture. It sounds a lot safer than insecticide to me. 

I tell my pregnant patients to avoid insecticide while pregnant. There are not enough studies to prove that these chemicals are safe for fetuses. It may be that fogging reduces Aedes, but that pregnant women exposed to insecticide have some other birth defects from the insecticides. Hopefully someone has figured out that risk. Eventually, the scientists will get to the bottom of this. 

Thanks for reading. 

Dr John Marcus 

blog at doctorjohnmarcus.blogspot.com 

89 North Maple Ave 

Ridgewood NJ 07450 

Comments are welcome. 

Surgical Skin Closure, Staples vs Sub-cu

Yesterday I posted about Zika virus and how it is dangerous to neural tissue, especially for a fetus. This Zika problem will be with us for a couple of years until we can get a handle on it. I've seen pictures of the "war room" at the CDC where the epidemiologists have their daily meetings. I think the CDC is in Atlanta but it might be located at least partially near Washington DC.

Today a patient came in for her PP visit and we discussed her surgical closing technique. I had a doctor covering my practice who is a very skillful and caring physician. The patient needed a C-Section and I wasn't on.

My covering doc closed her skin incision with cosmetic subcuticular dis-solvable stitches.  So my patient has had the skin closed both ways now. First with staples, second with sub-cu.  And she now has a strong preference.

I know that the staples are a bit more work, and patients are worried about the removal. The removal is usually almost painless as the staples slide ride out once they are unbent.

Why are the staples beneficial?

-They are completely removable.
-They are very smooth and shiny, so no germs can get a hold of them.
-They never break down and fail their job of holding the skin
-When they are gone, they are utterly gone, leaving nothing behind to dissolve.
-When they are gone there is skin touching skin and nothing else in between. This is far more comfortable, softer, and smoother.

Why don't people like staples?

They feel and look unsightly while they are in. And they have to be removed.

In my opinion staples just do a better job and are worth the extra work.

The science does not show a preference between between staples and subcu dissolvable sutures. There have been a number of randomized trials. Obviously the trial cannot be blinded because the doc doing the stitching can see what they are doing. I suppose the incision can be evaluated later by someone who is blinded as to the closing technique.

In any case the studies showed no difference in the quality of the skin incision outcome. Of note, though, the studies that I read were done in academic medical centers where the infection and complication rates were far higher than a private community hospital. The academic centers infection rates were about 8 times higher than my hospitals. This surgical complication rate is a reflection of the socio-economic stress of poverty, the higher workload of the staff, and the riskier patient mix. I doubt if the less experienced staff has anything to do with it, but it remains possible. It is possible that the older facilities have less modern infection control technologies, such us laminar flow air handling in the operating room.

I think that if that same study were done in a place like my hospital, there is possibly a different outcome.

In my experience the staples provide a better outcome. Once they are removed they provide a far more comfortable and smoother incision.

Every once in awhile a patient will pick a doctor based on their known closure technique. I would like everyone to know that I will do whatever technique they want. I will give them my advice and then honor their wishes. Hopefully that will satisfy the needs of those who don't like the idea of staples. I am perfectly qualified to do cosmetic sub cu. I studied 6 weeks of cosmetic surgery at the Cook County Hospital in Chicago Illinois. That was a great time for me. I learned a lot. And I have been doing surgery every since.

So if you don't want staples, then I will do the sub cu. But if you want the best, then ask your surgeon if they can do metal removable staples. (The dissolvable staples are more like the sub cu).

Zika Virus in Pregnancy. 

Zika Virus has been in the news quite a bit. It seems very bad. How bad is it? 

7 days ago there were very few cases known and published in the US. 

3 days ago there were 33 cases. All were cases caught outside the US, and brought here. 

Yesterday was the first case caught in the US, given from one person to another by sexual exposure. Sexual transmission seems to be a previously unknown method of transmission of Zika Virus. 

As of yet, there are no known mosquito transmissions in the mainland US. Although Puerto Rico, Guam, etc may be at higher risk, because of their tropical climates. 

It seems inevitable that there will be mosquito borne cases in the US. 

In Brazil, there are 4000 cases of microcephaly in newborns. This is a huge increase, and is thought to be possibly from Zika infections. Zika seems to have an outsize affect on neural tissue. Zika gives adults a case of Guillen Barre Syndrome: 

https://en.wikipedia.org/wiki/Guillain%E2%80%93Barr%C3%A9_syndrome 

Guillen Barre is a disorder of neural tissue. 

And in fetuses, it somehow affects the neural tissue of unborn children. Somehow the neural tissue is destroyed. I have seen the CT scan pictures, and the brains are seemly destroyed, at least partially. It is a real disaster for these children, families, and societies. I don't think anyone knows for sure how the neural tissue is destroyed but it is certainly possible that the virus gets into the cells, grows there, and kills the cells. Once the brains are destroyed, the head stops growing, and the child has a small head. This is called microcephaly.

There are no antizika antiviral medicines.

There is no Zika vaccine. 

The official position of the Brazilian Government is that women should put off being pregnant until something more is known about Zika Virus.   This will take some time. Delaying an entire countries childbearing has not been done in recent memory. Again, this is something new. 

As of this moment, there are far more questions than answers about Zika. 

Here are a few helpful links: 

http://www.cdc.gov/zika/pregnancy/question-answers.html

http://wwwnc.cdc.gov/travel/page/zika-information

http://www.cdc.gov/ncbddd/birthdefects/microcephaly.html

http://www.cdc.gov/zika/pregnancy/index.html

http://mothertobaby.org/fact-sheets/deet-nn-ethyl-m-toluamide-pregnancy/pdf/

There are a few facts:

Eliminating mosquito bites will likely eliminate risk. How can we eliminate mosquito bites?
-Keep doors, windows, and screens closed.
-Don't travel to tropical climates right now, without precautions.
-Don't have unsafe sex with anyone who has been to a Zika prevalent area.
-When summer comes use air conditioning. Mosquites prefer the warmth. Cold keeps the mosquitoes out or inactive.
-If outside, use long tight pants, sleeves, socks, etc.
-Use special clothes that are permeated with permethrin. Personally, I have never seen such clothes for sale, but this is what the CDC says to do. I suppose if you can get Permethrin, you can spray your own clothes with it.
-Use highly effective insect repellent. DEET seems to be the best, in my opinion. Use it on all exposed skin, and even on your clothes. And use it even if pregnant. Use it copiously.
-Don't go outside when mosquitoes are active and present.
-Remove all standing water from the land. This is where mosquitoes breed.
-Treat standing water with insecticide or some other effective treatment.
-Use insect foggers outside, on a personal or municipal basis.

And finally, as a society, we need to control the Aedes Aegypti  mosquitoes.
https://en.wikipedia.org/wiki/Aedes_aegypti.
This is not the only nasty virus or disease transmitted by this mosquito.

There are some biological control mechanisms to control this mosquito. But we will have to get over our natural inclination to protect species. It is rare for humans to conduct deliberate annihilation of a species, but it has been done before. Smallpox has been destroyed. Some agricultural pests have been destroyed. Other infectious diseases are on their way out. If we can vaccinate everybody we can stop more infectious diseases. But vaccinating everyone requires some force, as there will always be selfish individuals who wish to take advantage of the herd immunity we provide them, while not simultaneously helping to provide that immunity. These individuals will need to be either convinced or coerced. Somehow. My personal politics preclude the use of force on people, but I would support some kind of strong coercion for this. Like keeping unvaccinated kids out of schools.

Worldwide, 140,000 people die of measles every year:
http://www.usatoday.com/story/news/2015/07/02/measles-death-washington-state/29624385/
These deaths are preventable with the vaccine. Everyone who declines the vaccine is part of the problem, not the solution. We all must accept the risk of the vaccine in order to benefit from the vaccine. And the risk of the vaccine is very very low. My children have been vaccinated as per the normal schedule. There was no doubt in my mind that it was a good idea. And now my kids cannot kill anyone by transmitting measles to someone. This, to me, is profoundly beneficial. And sensible.

So this Zika virus is going to infect a lot more people.

We can control it in the USA because we have measures to control mosquitoes that other nations don't have. Of note, living in a cold climate is not a protection. As anyone who has fished in Canada or Alaska knows, in the summer, there are tons of mosquitoes. And the mosquitoes come back every year. They survive the winter.

We have been down this road before. West Nile Virus was a similar kind of event. Ebola had a very high mortality, but was controlled with really heroic efforts by some people who deserve a Nobel Prize, like Doctors Without Borders. There are significant new epidemics every year or two.

And in fiction, I have read several doomsday novels about killer viruses. Mostly man made viruses.

Steven King wrote "The Stand". There is a very good movie as well.
More recently, Russel Blake wrote "Upon a Pale Horse".
Both are good books.

Here is a list of books about epidemics:

http://www.goodreads.com/list/show/19535.Best_Fiction_Books_About_Diseases_or_Viruses

Please use the links above. I hope to be able to give better answers in the future.

Thanks
Dr Marcus
Blog is at doctorjohnmarcus.blogspot.com

89 North Maple Ave
Ridgewood NJ USA 07450 

Hummus Food Recalls and Listeria

Food Recalls and Listeria

As part of my job as an Obstetrician I like to follow the news.

One thing that is frequently in the news is Food Recalls.

Not too uncommonly there will be news that the various Departments of Health will recall a particular type of food because there is some food-born illness lurking in that food. Sometimes companies will recall food on their own.

It is always something different.

Sometimes, the spinach farm is next to the pork farm, and there is heavy rain, and the pork "droppings" run into the spinach. So the spinach might be found to harbor E Coli bacteria.

Sometimes the barn that grows eggs is found to have bird droppings on the eggs, because the wrong kind of bird has flown into the barn. And those bird droppings carry bird borne infections. Egg farmers have been shut down for this.

A few years ago it was Melons. Before that it was brussel sprouts.

And recently a peanut butter company executive was charged with a crime because he didn't do enough to make sure the peanut butter was uninfected. I don't know the outcome of that trial.

Sometimes the recall is very specific. Like frozen food from a specific shift of a factory.

A few weeks ago a pregnant women informed me that she had a mild flu like illness. Then she informed me that she ate food that was subject to recall for listeria.

Listeria is dangerous to fetuses. It does unspeakable damage to them, or they die. I have seen these babies. Listeria hides because the maternal illness is very mild or nothing, but the fetal illness is extreme.

If we know of the exposure we can monitor and treat the mother and fetus with antibiotics. Ampicillin can  be effective, but it takes a high dose. So high a dose that the pharmacist calls to ask if I am sure. Ampicillin is very safe, and Listeria is very dangerous, so I will treat preventatively if possible.

Most of the time we don't know of the exposure. And the baby and family pays the price. It is rare, but it really does happen. And most Obs have seen the terrible end results.

The latest recall is from a popular brand of Hummus. It was found to contain Listeria.

Do a google search for Hummus Listeria Recall and you will find the brand. It is called Sabra.

Here is the CNN link:

http://www.cnn.com/2015/04/09/us/sabra-hummus-recall/index.html

Please, if you have Hummus in your fridge, check the recall and throw out the Hummus. It is just not worth it.

I have put a poster up in my office as this particular Hummus is really good and it is really popular around here. It is my favorite brand.

So watch the news for food recalls. Especially if you are pregnant.

Thank you very much.

Dr John Marcus
doctorjohnmarcus.blogspot.com

89 North Maple Ave
Ridgewood NJ 07481

Friday Night

Hi Everybody.

It is Friday7 about 8 pm and I just got back from rounds. I signed out for the weekend to my friend Dr Damien-Coleman. She is a very nice person and a great doctor. For my goals this weekend I am looking at about 8 hours of work going through my lab results and reports from other doctors. I will restart on this tomorrow as I have been working 12 hour days since Monday. I will get my lab results interpreted and my opinions out to my patients. I hope to use my "patient portal" for most of my results. More about that later in this post.

Today's belated blog is about the future. The future is here, and it is bringing tremendous changes to our culture and society. A hundred years ago calling on someone meant going to their door and knocking. It was like that for thousands of years. But since 100 years ago or so calling on someone meant dialing your phone. At first, 80 years ago, it was picking up the phone and asking the operator to plug your phone line into someone else's line. 50 years ago, the operator was replaced with equipment. Every person's phone had a ring with holes to actually spin to dial. Kids nowadays have no idea what that means. The next change, when I was young, a person could pay a few dollars a month to push buttons instead of turn the dial. Nowadays, I doubt if a dial phone would even work any more. Only push buttons with tones remains. Then, when I was in high school,  the cell phones came. Now, people are dropping their home "land line" phones like hot potatoes. People are just using their cells. But there are two further changes that have come up unexpectedly.

The first: most people don't even answer the phone anymore. Most people don't even use the phone anymore. People have moved to cell texts to move information around. Some people still call others. But most don't. And the kids, forget it. A phone call? They don't want it. It is much too slow. In the time of one call, then could have made 20 texts. Now we are also losing email.

The second change: kids have abandoned email. The kids now are no longer filling in the email spot on application forms. They don't want email. It is too slow, cumbersome, and polluted with spam.  It still has business uses. But for rapid personal connections, email is dead. Everyone is using texts and micro-blogging sites.

Why am I wasting time on a gynecology blog to say this?

Because today I received about 10 phone calls from patients asking for some information or advice. I called every one of them back before I closed up the day. And only one answered the phone. There are now 9 calls into me that are just completely unanswered. I feel awful about it.

The phone, as a reliable form of communication, is completely useless. Nobody uses it reliably any more.

But I have a solution to this awful and vexing problem.

But first, let me explain the technology changes in my office. We of Lifeline have moved our EMR software to a much bigger package called NextGen. We have been doing this for months now.  Those of you who have read my blog in the past will realize the huge difficulties of moving from paper to EMR. I have described how hard it is here on this blog.

But now, the original software package was not fulfilling our needs. So we, as a group, moved ourselves, our practices, and our Electronic Medical Records, to a new software package called NextGen. The move to NextGen EMR software was just as big and just as traumatic as our move to our original EMR. But NextGen has some much more powerful functions.

One of the more powerful functions is called the "Patient Portal". The patient portal is a website. The patients can log on to this encrypted and secured website and access a ton of functions related to their health care on the portal. They can review whatever medications the computer thinks they are taking. They can ask for, get, and review their appointments. They can read their "patient plans". This is the end of the medical note that is created for them when they are in for their appointment. The patient plan function is still being rolled out so don't expect it there every time. But it is nice to see. In the patient plan people can see their "problem list". The problem list is generated by myself by the conduct of general medical practices.  The problem list has already generated questions to me about something they don't understand. So the resolution of their lack of understanding is... wait for it... Their Understanding. And that is a Good Thing. And if there is a Mistake in their records (theoretically that might be possible), then there can once again be a correction, and then an... Understanding (an understanding that goes the other way, patient to doctor). And any correction to the medical records is a Good Thing.

It goes without saying that I am starting to love the patient portal.

But the biggest lesson here is that of Communication.

Today, on Friday afternoon, I made 10 phone calls and only one phone call was actually answered. I left no protected health information on any answering machine. At the very same time, I made about 15 protected email responses, some with multiple round trips both ways. And each and every one of them was at least potentially received and read by patients. And the information was received and understood in a completely secure and confidential manner. There is no way that a nosy neighbor, a jealous husband, or a worried mother, can read or hear the information in that secure portal controlled email. Remember the email never went out on a normal email server. It is only fake as an email. The email is really only served by an encrypted web site. That only one person can read. The person who holds the password for that email.

So today I made 10 phone calls, 9 of which went nowhere with no results, as I cannot leave any substantially private information on an answering machine, and 15 secure portal messages, all of which went through, and many of which were started by patients themselves. All of which contained highly valuable personally important information.

How secure is this information? I can tell you that it is as secure as NextGen can make it. NextGen is based on some very advanced encryption. It satisfies the requirements of HIPAA. It satisfies the Feds. If HIPAA is violated without due care, there is a potential for a fifty thousand dollar per incident fine. So you can be sure that I am keeping my passwords secure.

The hardest part of making the portal work is getting the patients actually started on it. Starting a portal account requires some hard work making sure that patients actually get secure access. So the account is set up with some very personal communications of passwords, followed by a round trip of emails to a pre-existing email account.

This set up process is actually too much of a hurdle for some people. There are many people out there who either will not or cannot go through this process of creating a secure account on the portal. But for those who do, there is a connection with really fast and secure access to communication between them and myself.

And that connection can do a lot to help people. I promise to do my best.

But I'll tell you what. 90 percent failed phone calls vs 100 percent successful secured emails tells a story.

I'll take the successful communications vs the failed ones any day of the week.

....

I haven't posted a blog here in some time. It has been much too long. Perhaps I need an editor who can give me assignments and deadlines.  Like I've said before I have not abandoned this blog. I have been working very hard. One of the things that has been keeping me busy has the process of moving my EMR over to NextGen. NextGen is a much more complicated piece of software. It requires a tremendous amount of work to make it go. I am working and succeeding at it.

I just reviewed my side of this blogspot site. I have sort of the "back" side of the site. I have about 20 blog posts that have been started and are at some  stage of completion. There is never enough time to write and complete these posts but I do enjoy writing them. And it has been very popular. I haven't looked at it in awhile but there are still thousands who find these blog posts and read them, from all over the world. I have more readers from worldwide than from the USA. There are many readers from Germany, from Africa, from Russia, and of course from Canada. Here near NY City I am only a few hours driving time from Canada. But the readership continues, even when I am not actively blogging. Thank you all for reading this. It is really rewarding.

...

Now for something new.

I have a problem that I have been thinking about for a long time.

This really should be a new blog post but I want to start it now.

One of my jobs as a Gyne is that of dealing with the problem of Breast Cancer. The problem is that about one in 8 women are destined to get breast cancer. That means if you personally know 100 women, you know that 12 of them will get breast cancer.

The good news is that breast cancer is treatable. It is something that can be removed. People can be saved. Lives saved. Wives, mothers, sisters, can be saved.

But the key is diagnosing it early.

There are three ways to diagnose it early, before it becomes an obvious and deadly problem. The first is by routine Gyne checkups. This is basic good medical care, and all women need a Gyne checkup once a year, without fail. A Gyne checkup can get a history and examine the breasts and pelvic parts of women. It is important and it is my job.

The second early diagnosis is mammograms. Mammograms have gone through a process of technical improvements through the years. They are constantly evolving. There are more improvements than you can count. Sterotactic, 3D, computer enhanced, tomographic, focal, compressed, and on and on. Then there are other imaging techniques, like ultrasound, sonograms, CT, MRI, thermography, etc. All of these may have their uses. But they have challenges too, like expenses, scheduling hassles, radiation exposure, lack of scientific proof, lack of financial resources, coverage limits, etc.

But the final and cheapest early warning system for breast cancer is "Self Breast Examinations". For the last 25 years I have been asking women to examine their own breasts for lumps. There seems to be good science that says that SBE works for women. And it can easily save lives. Once women get over the shock of finding a lump, they can get down to the hard work of diagnosing it. And they can get down to the hard work of protecting their own children's mother, who is a very important person. An irreplaceable person.  Or, if they have no kids, then they can get down to the hard work of protecting their mothers daughter. Who is also very important.

There is an overwhelming problem with Self Breast Examination.(SBE). Most women recognize this problem. And they complain about this problem to me a dozen times a day.

The problem is women examining their breasts are not experienced enough to know what they are finding.

I explain to them a hundred times a day that all women go through this same problem. There aren't any women with a tremendous amount of experience doing SBE. All women who do SBE are beginners with an experience level of one and only one set of breasts to examine.

I have a solution.

It is radical and will be roundly criticized. And it will be viciously criticized.

But I believe that it will save a lot of lives.

If what I am going to propose comes to fruition, the problem of SBE might be solved.

I will propose to form an organization organized around the principle of generating a group of people dedicated to one thing and one thing only. The examination of each others breasts.

This will take the "Self" out of "Self Breast Examinations". And it will replace it with "Shared Breast Examination". I am not proposing that a women expose her breasts to the world. But that she come together with other women who have a similar goal in life, and train each other in the principles of breast examination.

I think that woman can learn how to examine breasts. And by sharing and teaching and learning, the knowledge can expand.

Women can learn how to feel the difference of glands, ducts, cysts, and tumors.

In my office I used to buy breast lump models. These were artificial breasts that had artificial lumps. They were pretty cool teaching aids but they got grungy really fast and fell apart in a matter of weeks.

But imagine instead that I had Real Breasts to show women. Well, this is what I am going to propose.

I would propose that this organization become real. With a mission statement. And a website. And all that goes with it. And some means of protecting women's privacy and rights as well.

I am in the early stages of thinking about this proposal. I have not come up with any insurmountable problems

For instance, the first probem: One needs a medical licence to examine someones breast. Solution: we are teaching women to examine their own breasts. And using many real breasts as examples. And besides, these are consenting adults. They can examine each others breasts as they need to without hassles from outsiders.

Another problem: There is no scientific proof this will work. Answer: we will not know unless we try.

Problem: woman may be harmed by anxiety and unnecessary biopsies. Solution: there is tremendous anxiety now, and lack of skill as well. And biopsies can be minimized by using needles and fine needle aspiration instead of open procedures.

I would ask the reader and the community to think about the meaning of breasts to the world. Breasts are perceived as beautiful. Boys fantasize. Girls compare. Babies love and feed. Women have surgery to make them bigger, smaller, and firmer. Breasts are part of birth. Breasts feed life to babies. Breasts are much visible to world, appreciated, and loved by everyone. But they are also one of the biggest sources of fear. Most women fear breast cancer more than a heart attack. And heart attacks are more than 15 times more likely to strike a woman dead, as her breasts. All breasts are beautiful, no matter the shape nor size. But the fear surrounding their health is so out of proportion that it is unreasonable. I don't think there is any subject in the world that has such a dramatic juxtaposition of beauty, love, fear, and danger, as human breasts.

It is time we started helping women get over their fear of SBE and bringing reason back to the subject of early diagnosis of breast cancer.

I hope to be part of the solution.

I realize this is a big dream.

But it might be possible to do better than we are doing now.

Thank you for reading.

Please pass the link to this blog on to others.

Thank you sincerely,

Dr John Marcus
doctorjohnmarcus.blogspot.com

Member of Lifeline Medical Associates

89 North Maple Ave
Ridgewood NJ 07450

Comments are of course welcome. Please post comments.

Delivering physicians as patients.

Yesterday I delivered a fellow physician. A 37 year old cardiologist at 40 weeks.

She started her labor naturally, a few hours after breaking her water. The labor progressed well, naturally and on it's own. She arrived in the hospital at a very appropriate 3-4 centimeters dilation, and progressed at better than 1 centimeter per hour (this is the standard rate for the first baby).

She received her epidural at 5 cm, as she didn't want to continue with the natural discomforts. She still felt some pressures and a bit of pain with the contractions, but I assured her that feeling some of the contractions is a good thing. She certainly did not appear to be in any distress from the pain.

This physician was medically healthy and was planning a normal labor. And she and her husband were really nice to be around.

The thing about physicians, nurses, and pretty much any other licensed professional, is that their life may be bit more stressful than, for instance, a hairdresser, a truck driver, or a chef, for instance. And undue stress makes any pregnancy high risk.

Because of the requirements of being a licensed professional, I consider a licensed professional to be a high risk pregnancy. This is my opinion. I don't know if the textbooks or medical journals would confirm this or not. High risk pregnancies would of course include lawyers.

Malpractice attorneys are even higher risk. Most physicians hate taking care of malpractice attorneys. I don't. They are people too. They require very good care. I provide that for sure. Most physicians think that malpractice attorneys are lying evil bastards. The attorneys don't think of themselves like that, but as defenders of the weak, downtrodden, and injured. The attorneys believe that they are seeking the truth for justice sake. Most physicians believe contrarily that they are liars one and all. Physicians call them "Trial Liars", which is a play on the name the lawyers call themselves, "Trial Lawyers". In any case, they are also high risk pregnancies. It is clear that the trial lawyers have an unbelievably stressful life. And you can see it in their eyes when they are not working.

There is a big disagreement on the meaning of "truth" between doctors and lawyers. The lawyers engage in what they call "truth seeking" behaviors in courtrooms and pretrial activities. The physicians see those same courtroom activities as remotely disconnected from the truth. Physicians see trials as complete shams, as nothing but highway robbery by brigands and liars. With briefcases instead of guns.  Why such a discrepancy in the belief in truth? Physicians see truth scientifically. Especially if it has been experimentally established, as is done in medical science. Lawyers see truth as a culmination of belief, by whatever method makes it believable. The lawyers believe that truth is whatever the Judge and Jury believe it to be.

Personally, I believe that truths exists in the space of ideas. There are real, absolute truths, as Plato would have described them. They are not physical things. You cannot weigh a truth with a scale. This is similar to a human soul, and mathematical theorems. These truths are real, but you cannot hold them in your hand. Only in your head, and written down on paper. So, physicians and lawyers will never agree on what the truth really is. Physicians ignore this reality of truth at their own peril, when a skillful attorney rips them apart as part of a trial strategy.

Anyway physicians are not immune to the stresses of being a professional. Therefore physicians have a high risk pregnancy. I think this risk is manifested in several ways.

One, they work ungodly hours. Pregnant women are supposed to be off their feet once every three hours, resting for 15 minutes. This will let the natural adrenaline of a normal day fade down a bit. These are work rules that are enforced by the federal government for everyone. But most physicians will not stop working after three hours. Especially if there are sick patients that need their attention, and they are behind schedule. All physicians are behind schedule, because there are people with unpredictable needs. And no one wants to say to someone, I think you have a tumor, but we will talk about it next week. So, we do our best to comfort the patient in front of us, and then get behind schedule a bit.

Two, physicians know about pathology personally. They see it on a daily basis. And if they do not see it in themselves, they will be hard pressed to believe that it is there. So many physicians will ignore indications of serious trouble.

Three, physicians still get "medical students disease". This disease is an inappropriate belief that some pathology affects them. To mix a metaphor, they are in a forest but cannot see the forest because they can only see the trees. Physicians make poor doctors to themselves, and have a fool for a doctor, and a fool for a patient. These are old sayings in medicine. Every doctor should have a good therapeutic alliance with another good doctor, to keep these anxieties in check. And the doctor for the doctor should have a calm demeanor, and a lot experience. This will prevent medical students disease by proxy.

Anyway, this particular patient was doing beautifully in labor. She was physically strong, and a very good pusher when it was time to push. But, as a physician, we need to consider this is a high risk patient, and we need to be ready for complications.

So, after pushing for an hour, the babies heart beat starts going much faster than normal. I discussed with her and husband the reasons why this might be the case. A common reason might be infection. Another reason might be the babies head getting squished in the birth canal. Ultimately this was the cause for her. But no one wants to leave the baby in a stressed out condition, so I decide to help the baby come out a bit sooner. Before the baby really gets stressed from the rapid heart beat. She obviously agrees.

When the baby was on the "outlet" of the vagina, I decided to use the vacuum forceps. This will help the baby be born a bit sooner. And there are many studies which show that "outlet forceps" have as good a prognosis as natural labor, or better.

So I used the vacuum. True to form, the high risk factors start coming in to play.

First of all, there was a loose nuchal cord.

Then, there was a "shoulder dystocia". This means the baby is stuck with it's head out, and the shoulders are holding the baby in. Shoulder Dystocia is a bad thing to happen. Babies can get injured or worse by the difficulties associated with delivery past the stuck shoulders. I have an entire blog post already written about shoulder dystocia. I still need to edit it some before it becomes good enough for publication on this blog, but that blog post is coming.

So, we wind up doing two basic maneuvers to relieve the shoulder dystocia. We did a McRoberts, and suprapubic pressure by a very skilled nurse. The shoulder dystocia was then released and did not cause any harm to the baby, thank God.

Then we had the third stage of labor. The placenta came out. And then she had a postpartum hemorrhage.

In a normal pregnant woman, the baby gets about half of the mothers cardiac output of blood, directly to the underside of the placenta. The uterus gets it's blood supply from the mom via very very large blood vessels. They may be as thick as your thumb. What stops the blood flow normally is that the uterus contracts down tightly. These uterine muscles, which just finished pushing the baby and placenta out, need to continue to contract, and get very tight, to close the placental blood flow. Without the placenta blocking it, and if the uterus doesn't contract, the blood flows out of the mother like a river. It literally pours out like a thick waterfall. In the presence of postpartum hemorrhage, a woman can bleed to death in minutes. Postpartum hemorrhage is the number one cause of maternal death in advance countries. The last I looked, about a hundred women a year die from postpartum hemorrhage in our country alone.

So here we are with a high risk pregnancy, a fellow physician, and we have already dealt with a shoulder dystocia. Now we have blood pouring out like a faucet. What to do?

The first thing is to get the uterus to contract. We literally compress it with our hands. One had in the vagina, and one hand on the top of the uterus. At the same time we compress the uterine vessels with our vaginal hand, and give the new mom some medicines that will further tighten the uterus. We not only compress it, but we massage it. That seems to work better than just squeezing it. A hemorrhaging uterus can be more or less controlled by physical pressure. In fact, all bleeding, from anywhere, responds to pressure, if there is a way to press on either the bleeding place or the blood vessels feeding the bleeding. In this case we can do both. Just remember that pressure stops all bleeding, no matter where it comes from.  Anyone can save a life by remembering that bleeding stops with pressure. That is the point of a tourniquet that all boy scouts learn about.

So then I stopped the bleeding with pressure, massage, and medicines. Thankfully she had an epidural. Without the epidural these pressures are very uncomfortable, to say the lease. I even had our anesthesiologist come and boost her epidural quite a bit. This worked to keep her comfortable.

After the pediatric physician checked the baby, and declared the baby healthy, our new mom got her new baby while I finished up the vaginal repairs.

The next day on rounds, she and the baby looked wonderful. She was walking around with a big smile.

So, we have to be ready for pathologies like Shoulder Dystocia and post partum hemorrhage at any time.

A good obstetrician will review the protocols many times in their career, and stay up to date, and ready, willing, able, and confident, to manage these things on a moments notice. For that matter, midwives need to stay on top of these things as well.

Thanks for reading my blog. Comments are encourage.

Available at doctorjohnmarcus.blogspot.com

Doctor John W Marcus MD FACOG PC
89 North Maple Ave
Ridgewood, NJ, 07481

Phone 201-447-0077
Fax     201-447-3560

Thanks for reading.