2013-10-16

Arsenic: What it Does, Why to Worry, and What to Do

Arsenic:  What it Does, Why to Worry, and What to Do


Recent reports have brought to all our minds the concern that arsenic may be causing us harm in our food supply, particularly from rice and apple juice.

This note will take a look at arsenic.  What is arsenic?  What sort of harm can it cause?  Should we be worried, and if so, what exactly is worrisome and what is not?  And given any real worry, what can be done?

What is Arsenic?
Most of us know arsenic as a poison, perhaps out of familiarity with the 1939 play by Thomas Kesselring, Arsenic and Old Lace.    And, indeed, this grey metal can be made into a powder that is quite poisonous to nearly every form of life, including insects and humans.   But what is arsenic?  Arsenic is an element that forms metal-like crystals, and is useful in making copper and lead more better in items we use, and is an important element in the materials that make electronic components.

How does Arsenic cause Harm?
Arsenic hurts nearly any living cell by blocking its ability to make energy.  Only a handful of unusual bacteria can live in the presence of arsenic, all other life is killed by the ability of arsenic to block the production of ATP, the currency of energy for all life.  Another famous poison, cyanide also blocks ATP production, but this poison creates a total and complete cessation of energy production, and hence sudden death.  Arsenic leads to varying levels of blocked energy production and so its typical method of harm has more to do with various organs and systems not working well, and eventually failing.  Death from arsenic is the result of various organs failing to work.

What is the Sort of Harm Most Often Seen Caused by Arsenic?
More typically, at the lower levels of the more common exposures, arsenic weakens organ functions, leading to a variety of complex problems and scenarios.  There is some indication that over time, continued exposure to even low levels of excessive arsenic can shorten life, but the most typical problems are more chronic in nature rather than deadly.

On September 20, 2013, the New York Times published an important article on findings on what arsenic is actually doing to us now. http://well.blogs.nytimes.com/2013/09/20/the-arsenic-in-our-drinking-water/?ref=health

The current evidence suggests that ongoing, low level exposure to excessive arsenic can cause people to increase their chance of having heart disease and strokes, diabetes, and cancers of the skin, bladder, and lung.  Curiously, the recent studies have found that arsenic can cause people to experience far more colds, even during infancy! 

Some studies found that people exposed to levels of 19 parts per billion (ppb) in their drinking water began to show signs of chronic lung dysfunction, and at 120 ppb, their lung function was as abnormal as a chronic smoker.   In one country whose drinking water had levels of arsenic as high as 1,000 ppb, 24% of all deaths from all chronic illnesses could be blamed on the impact of arsenic.

Who Should be Worried?

Drinking Water
In the United States, arsenic is found in varying concentrations in the drinking water, depending on two key items:
1.  Does the family use a water system supply, or a private well?
2.  If they use a well, do the rocks in their region have a lot of arsenic in them or not?

The areas of the United States that have the highest levels of naturally occurring arsenic in the ground water are:
1.  The Southwest.  Areas of Nevada have well water with levels as high as 500 ppb.
2.  The Upper Midwest.
3.  A band of New England- from the coast of Maine to an area midway in Massachusetts.

Water supplied by a municipal water system is mandated by Federal law to keep the level of arsenic below 10 ppb.  This means you are very unlikely to be exposed to arsenic in your tap water if the water is from a municipal source.   Private well users must measure their arsenic level to be sure it is not over 10 ppb, particularly in the US Southwest, Upper Midwest, and the swath of New England noted above.

Food
Arsenic exposure can cause harm via the ability to concentrate in certain foods.  Rice, for example, is a plant that sucks arsenic out of the soil quite well, and so if it is planted in soil with arsenic contamination, that arsenic will end up in the rice grains and potentially cause harm to those eating rice.

Other foods that concentrate arsenic include leafy vegetables, seafood, and apple and grape juice.

Juice
In July, 2013, the FDA set a standard of 10 ppb, the same as drinking water, for apple juice, ensuring that apple juice that meets the FDA standard is as free of arsenic as safe, metropolitan, drinking water.

Rice
The problem with American-grown rice is that much of it is grown in fields that used to grow cotton- for a very long time.  Cotton was doused with arsenic very heavily- after all no one ate it.  But over the last few hundred years that meant the soil of these fields got good and soaked with arsenic.  As noted, rice sucks arsenic out of soil really well, and so rice from the American South can contain too much arsenic.

Bottom Line
Arsenic is a very dangerous and very insidious poison.  If you get too much you don't just keel over, you get chronic illnesses.  It is worth taking efforts to avoid exposure.  Here are the top 3 things to do to avoid eating too much arsenic:

1.  Make your water tap water.  If you must use a well, find out the arsenic concentration and don't drink it if it is over 10 parts per billion (ppb)
2.  Commercial apple juice is now regulated to have arsenic levels below 10 ppb, it should be safe.
3.  Rice is a real problem.   American rice from California is probably the safest bet.  Rice from the American South likely cannot be trusted to have low enough arsenic levels to be safe, and rice from the rest of the world, who knows.  So try to stick to California rice.


Our best,
Dr. Arthur Lavin






Much of the powdered arsenic in our food and water supply got there through the extremely widespread use of arsenic as insecticide.







*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

The Back Up Throat Culture Becomes Optional

The Back Up Throat Culture Becomes Optional

Summary
The back up throat culture has been done in our office for many years when the rapid strep is negative.   The accuracy of the rapid strep in our office combined with increased regulatory requirements to perform in office throat cultures leads us to a decision to move back up throat cultures to a reference lab and to make the back up throat culture process optional.  That lab will be Child Lab  (http://www.childlab.com/, 1-800-934-6575).


Nearly every child gets a sore throat at some point in their life that makes us wonder, is the child infected with strep?

There are two ways to tell.  Both involve swabbing the back of the throat.  With one of those swabs we do a chemistry reaction in our lab that within 5-10 minutes tells us if any proteins found on the strep germ are on your child's throat.  This is the rapid strep test.

The other way is to take the second swab and rub it on a culture plate.  This is like planting seeds in a garden.  We then wait a day and see if any strep grows.  This is the back up throat culture.

For many years we have used the two tests as follows:

1.  If the rapid strep test is positive, we diagnose your child with strep throat and offer antibiotic therapy.  In this situation there is no need for a back up throat culture.

2.  If the rapid strep test is negative, we make an initial diagnosis that your child does not have strep and has some other cause of their sore throat- usually, but not always, a viral infection.   We have done back up throat cultures in this instance, because the manufacturer of the rapid strep test informs us that a negative test is not 100% reliable.

Over the last 10 years, we have seen the rapid strep perform very, very well, even when negative.  Of course, we do occasionally see someone with a rapid strep test negative on one day, only to have the back up throat culture come back positive.

Recently we have conducted three surveys of just how accurate a negative rapid strep test is.

In the first two surveys, we simply looked at 200 negative rapid strep tests and asked, how many of the back up throat cultures came back positive?   We did this twice.  

In the first run of 200 consecutive negative rapid strep tests, 0 of 200 of were found to have their back up throat culture come back positive.  

In the second run of 200 consecutive negative rapid strep tests, we found 1 of 200 back up throat cultures came back positive.

Then, in August of 2013, we chose one person from each month of the last 2 years who had a back up throat culture, and found in 25 cases reviewed, not one had a positive back up throat culture.

So, out of 400 consecutive throat cultures, one back up was positive.  And in a 2 year review of fairly randomly selected cases, no back up throat culture was positive in that 2 year review.

Put it all together, and the data are compelling.  Yes, some people come back positive after a negative rapid strep test, but it turns out to be a very small number.

The key finding is that if your child is found to have a negative rapid strep test, there is a 99.9975% chance they do not have strep and do not need a back up throat culture.

Because of these findings and increased regulatory requirements to perform throat cultures in a doctor's office setting, we decided to stop doing back throat cultures in our office.

We will still make the back-up throat culture available to your family at the sore throat visit.

But instead of that back up throat culture happening in the office, we will send it out to our reference laboratory, Child Lab.

We have been impressed over the years with Child Lab.  Based out of Nationwide Children's Hospital in Columbus with labs in Cleveland, they only do tests for children.  As such they are the only such lab in our region with special expertise in pediatric lab services.

So, we will continue to use two swabs when we test your child for strep throat.  And we will continue to run the rapid strep test in our office so you can get results in a few minutes.  The back up throat culture, however, will only be done at the family's request, or if your child's history suggests a strong chance of a wrong rapid strep test.

Keep in mind, that if we run a back up throat culture, it will be done by Child Lab.  So we want you to check with your insurer to be sure that will cover a back up throat culture for strep throat at Child Lab.
Their official name is Child Lab, their web page address is http://www.childlab.com/, and their phone number is 1-800-934-6575.

Bottom Line 
The performance of the rapid strep test in our hands is highly reliable.  If positive, we are confident your child has a strep throat.   And, if negative, we are so confident that your child does not have strep throat, we can say that the chance we are right is 99.9975%.   And so we are no longer going to do in office back up throat cultures for negative rapid strep tests.

But, we will continue to offer the back up throat culture to any family that wants that test done, and in those unusual situations where someone has had several positive throat cultures when the rapid strep is positive.

These throat cultures will be sent out to Child Lab, so check with your insurer to make sure that you are covered if we, together, decide your child needs a back up throat culture after a negative strep.

We hope our efforts to improve quality of care continue to advance your child's health, and we continue to appreciate the opportunity to work together to do so.

Dr. Arthur Lavin




*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.