An Apple A Day

One of the most popular antibiotics, azithromycin, has now been shown to cause fatal heart rhythms in some people.  You might have heard of it as ZITHROMAX, or in a conveniently packaged series of doses called Z-PAK.  Although rare, the severity certainly grabs our attention and warrants concern.

This lethal adverse effect is not a new one.  It is known to occur with many other common drugs taken by themselves, or most dangerously, when combined.  On rare occasion a large number of antibiotics, decongestants, antidepressants, drugs for heart irregularities, GERD medication, pain killers, diuretics, blood pressure pills, seizure medications and antipsychotic drugs are known to cause this type of lethal heart disorder.  Many of the medications that have been withdrawn from the market over the last 30 years are gone now because they caused this syndrome too frequently. Even drinking grapefruit juice along with many medications can increase the odds. There is heightened risk for those whose electrolytes (especially potassium or magnesium) are low. 

People who are elderly and people who have heart disease should not take the antibiotic. Even people who just have slow heart rate, which is common in athletes and often indicative of good cardiac health, should not take the the antibiotic. Those with liver disease or hypothyroidism should be wary as well.

For that matter, the bottom line is that we ALL should be wary, ALL the time about taking medications.  Saving them for when you really need them is the safest approach and will give you the best results.

Needing to wear glasses has long been viewed as a mark of geekiness without any other real significance.  “Just bad luck”, the medical experts said.  “Your eyeball is just shaped wrong and there is nothing you can do about it”. Dissenting voices, especially from the fuzzier end of the alternative medical spectrum, promoted eye exercises to improve vision and health and full spectrum lights (like the ones in my office).

We have learned that near-sightedness (aka myopia) makes a person more likely to develop glaucoma or retinal detachment.  The risk of glaucoma is 14 times higher in those with really bad nearsightedness. Two thirds of those who develop a retinal detachment had nearsightedness before the detachment occurred. Those are pretty serious consequences

Many years ago, I heard a wise young female Asian opthalmologist comment that children were spending too much time indoors and reading.  She agreed with the fuzzy thinkers that continual and intense focus on nearby, unmoving objects in poor lighting, was unhealthy.  She and they were right.

Since 1970, the rate of nearsightedness (the most common reason for needing glasses) in the USA has risen a staggering 65%. Rates are even higher in Asian countries, inspiring researchers in Taiwan to conduct a study to learn if requiring children to spend 80 minutes out of doors, each day they were in school would have any impact on nearsightedness.  It did.

A Danish study discovered one possible explanation.  As the shape of the eye determines focal length and, greater focal length is the cause of nearsightedness, that was the focus of their investigation.  By measuring the eyes of children through the extreme seasonal changes of the Nordic year,  they learned that the less daylight exposure children experienced, the longer their eyes grew.

My conclusions?  Simple things have hugely positive effects.  Being outside is healthy for a person’s eyes and so much else.  Full spectrum lighting is the healthiest artificial light.  

We have become increasingly isolated and fearful, unconcerned about others in our community and often afraid of “them”.  Or have we? 

Like everyone else, I have been thinking a lot about the Boston Marathon terrorist attack.  We all have our own take on the event.  

Many of you know that part of my sports medicine work is as medical support for marathons.  Security has increasingly become a concern.  At the Olympic Trials in Houston last year, the dark early morning walk from my hotel to the finish line medical area was doubled and complicated by the 11 foot high fencing that had been erected after I went to sleep. I had to explain my role to the police over and over, asking their help in finding my way around all the barriers to reach my station.

For nearly 35 years I have wanted to participate in the Boston Marathon, as a runner in the dim past when I had the athletic quality to do so, or more recently as a physician volunteer.  This year I REALLY wanted to be there, but decided to make a business visit to Pittsburgh instead.  

In New York City, I learned of the bombing a few minutes after the explosions.  I called the administrative head of our group of marathon medical directors in Washington to find out if she knew whether our colleagues were safe.  Turns out that she was at the finish line herself, and my call was the first one to get through as her cell service came back on.  There were no injuries among the medical staff.

Watching videos from the scene, I immediately recognized the medical personnel, because we are always uniformed in some easily identifiable way (here white jackets and red caps, with many foregoing the caps).  A number of thoughts ran through my head, as I am sure they ran through yours.  Besides my horror at the carnage, I was looking for friends.  I was thinking about how often we tend to mill about at the finish line, cheering on the runners, whenever we are less than 100% occupied with patients.  I was delighted that this horrific attack took place at the precise location where medical services are so intensely concentrated.  There could not have been a “better” place for the attack anywhere on the 26.2 mile course.

The most dramatic impression was the bravery of my colleagues, first responders, runners and bystanders who all rushed to help. In fact, one way to identify suspects was their reaction – nonchalantly walking away instead of rushing towards the bomb blasts.  Isn’t that amazing? 

The finish line was flooded with heroes.  Strangers charged into danger to help others in need.  After running 26 miles over four hours, many runners immediately ran another 2 miles to the hospital to donate blood. 

Boston is a big city with all the big city problems, stereotypic and real.  Why help?  Why get involved?  In the face of bombs and the likelihood of more violence, the normal response was to dive in, not to run away. 

Contrast these impressions with those of the bombers.  As is always the case, the perpetrators were marginalized, alienated individuals, with a depersonalized allegiance to some abstract, hateful worldview.  The word “inhumane” fits perfectly.

During my life in Minnesota, the winter months provided frequent reassurance of a collective humanity.  When you drive through the snow, getting stuck at a stop sign or on a turn is common.  Snow-suited strangers come to the rescue, and everyone is happy, with only a wave of thanks. 

That is nothing compared to what happened in Boston.  We are not as disaffected as we have come to believe.  Our concern for each other is real and it holds us together.  New Yorkers, also not renowned for being all warm and fuzzy, where deeply emotionally moved and supported by their customary rival Bostonians.

I believe that the only real cure for this “disease” of terrorism is our humanity, our caring for each other and refusal to allow terrorists to split us apart.  That is their goal after all.

Sports-related concussions have been gaining attention lately.  Far, far too late in my opinion.  It is almost like our thinking about this issue has been as impaired as the post-concussion brains of the afflicted athletes.  Our cavalier attitude, so entrenched for so many generations, is truly bizarre.  Before I get too self-righteous I need to confess. Buried in my confession is some useful insight, assuming that my concussion addled brain is capable of insight.

As a soccer player, I suffered a series of concussions.  I learned from them – mostly about what they were like, less so about proper care.  I was never knocked into unconsciousness but stitches, dulled brain, fatigue and difficulty chewing were familiar. I wanted to play.  By the time I been medically trained, the lessons were that as long as I was not unconscious or unable to remember what had happened, there was no reason for stopping.  With no medical or training staff there to keep me off the field, I usually went to the sidelines and, unless I needed stitches, I would go back in after a few minutes. If I did not remember something, I did not remember that I didn’t know it.  When I played on a medical school team, we would tell each other what to do on the field during games but none of us would tell anyone else they needed to come off.

My brother was a hockey superstar in our hockey crazed home state of Minnesota.  He suffered a series of concussions worse than mine.  In his highly visible situation, playing in big arenas with media attention even in high he got more attention, thankfully as he needed it. He went to the hospital more than once.  I was very concerned about him.  At the same time, he ignored very serious symptoms occasionally. The time that still scares me was when, as a proud freshman, he was playing a regular shift on his college team.  He was hit and lost one half of his vision.  He vomited in the locker room between periods but continued to try to play.  When he first joined a professional team, he sustained another concussion and, in the new environment, did not recognize his team mates or the arena.  That experience made him realize that this was probably not the best way to make a living.

As a physician, I have always treated patients with concussions at least as cautiously as authorities recommend.  Nearly 15 years ago I began urging athletes involved with contact sports to be much more cautious about these head injuries including baseline cognitive testing so that we could better assess the status of their brain after an injury and when it might be safe to return to activity.

It is easier for me to tell patients what to do that it is myself.  This is why I am pleased by increasing awareness and the new regulations in many states and some athletic associations, requiring those around the athletes to intervene, removing players from the game whenever concussions are expected. The idea of outside intervention is a good one but only a partial solution as you can see in this story.

I used to direct referee instruction for coastal Northern California and also taught the highest level referees about physical training. Some of them still keep in touch.  One of them in Ohio shared his story about his first time implementing Ohio’s new concussion law. A player in a game he was reffing went down in a collision.  The referee could tell the played was “stunned”.  The player wanted to continue and the coach did not want to remove the player from the game.  A nurse, who was watching the game, assured the referee the player was fine.  The player stayed on the field. Over the next five minutes, the referee determined that the player was not acting normally.  He asked the player simple questions about the game (score, opponent’s name etc). Finding that the player could not answer these questions, he insisted that the player leave the game despite the coaches objections. Although it is evident that the player should have been removed immediately after the injury (“stunned” is NEVER okay) I applaud the referee’s character and determination to resist those who should have stepped in themselves on the player’s behalf, especially the coach.

The lessons?  What we need is a cultural change.  We need to recognize that smashing our heads is dangerous even when there is no visible blood or brain tissue on the ground.  When we can change what is considered normal behavior, we will no longer tolerate such dangerous circumstances.

I am disturbed by a recent study of advanced breast cancer among young women.  Published in the Journal of the American Medical Association February 27, the study tracked breast cancer rates from 1976 to 2009.  Over those 34 years, the incidence of metastatic breast cancer increased by 1.37 cases in 100,000 women.  That is a very small number.  Because breast cancer, especially metastatic breast cancer, is so rare among young women, this could be a statistical quirk. However in 1976 the incidence of advanced breast cancer was only 2.9.  That means that the rate went up nearly 50%.  When you look at it that way, these are pretty distressing numbers.

There was no similar increase among older women.  The increase in young women was in estrogen dependent cancers, cancers whose growth is driven by estrogen.  That catches my attention because our bodies have been facing an onslaught of estrogen mimicking chemicals in the environment.  Those chemicals have been linked to a very, very wide range of health problems (obesity, miscarriage) and diseases (cancer, diabetes, allergies, etc). We know that environmental chemicals cause breast cancer. It is not far-fetched to wonder if there could be a connection between these widespread estrogen-dependent cancers in young women and increasing levels of man-made estrogen-like chemicals in our environment.  Hopefully not.