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).