Hand washing- how does it help, does it help?

Hand washing- How does it help, Does it help?

Washing your hands is a time-honored bit of advice we have heard from our parents and grandparents for a long time, probably since soap was invented.  As a bit of advice, it belongs to other such honored items as, "Wear a hat when it's cold, or you'll get sick," "Don't cross your eyes or they'll get stuck," and ""Clean your plate, don't leave food on it."

But, does washing your hands really do anything?  The answer is yes, it really does have an impact on the spread of germs, but of course that impact all depends on where you are- at home, in the hospital, in the operating room, for example.

The germs hand-washing might stop from spreading

Before we get into just what hand washing does, a word on what sort of infections it might prevent.   In the United States, nearly all the infections we encounter in daily life are either from germs called viruses or germs called bacteria.  They are quite different.  Viruses are the germs that cause infections such as colds, flus, stomach flus, mono, viral pneumonia, chickenpox, and warts.  Bacteria are the germs that create pus, such as ear infections, bacterial pneumonia, strep throat, abscesses, and impetigo.  Viruses are very contagious, bacteria less so.  Viruses turn out to be bits of DNA that land on you and make you make more copies of that viral DNA, essentially causing an information cycle that just happens to irritate the cells forced to participate.  Bacteria are more like us, they are cells that land on us and eat our cells, just like we eat. Antibiotics kill bacteria, but have no effect on viruses.

What does handwashing do in the home?

With all that in mind, let's look at what hand-washing can do in the home.   It turns out at home and in school, the vast majority of infections that spread around are from viruses.  With the exception of strep throat there are no very common infections that are spread by bacteria.  So, if hand washing is going to make a difference at home, it would have to stop the spread of common viruses seen in the home or school.  Those viruses split into two main types- those that infect the nose, throat, eye, and lung (colds and flus), and those that infect the stomach and gut (stomach flus).    The respiratory viruses tend to spread in the air, and the gut viruses by hand contact.  You might see now that if you wash your hands it has no impact on what happens if you sneeze or cough, or even just breath.  You can even have your hands soaking in disinfectant, and if you sneeze, the virus will spread just fine.  But it is the case that if you are very careful about hand washing, you an decrease the spread of stomach flus which need a handshake to go from one person to another.  So, it turns out that hand washing has very little impact on the spread of colds and flus, but can make a difference on the spread of stomach flus.

What about in the hospital?

The hospital is a special place for germs.  There is a very unfortunate irony that the more we gather sick, really sick people, into one building, the more nasty bacteria will be in that building.  And this is clearly the case for hospitals.  There are loads of studies that prove that hospitals are unique places for the number and concentration of really dangerous bacteria.  And we also know that perhaps the #1 way dangerous bacteria travel from person to person in a hospital is on hands.  And so it comes as no surprise that it has been proven that if everyone washed their hands after touching anyone, anytime, in a hospital, many lives would be saved by preventing the spread of dangerous bacteria.  

BOTTOM LINE

• If visiting anyone in a hospital, even the newborn nursery section, wash your hands, a lot!  Everytime you enter a room, after shaking a hand, holding the baby, wash your hands.
• At home, handwashing is a really good idea if stomach flu is circulating, and not a bad thing to do to stay clean, but has little impact on the spread of respiratory infections like colds and regular flus.

Dr. Arthur Lavin

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*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.

Pregnancy- the time to start Obesity Prevention for your Child

Pregnancy- the time to start Obesity Prevention for your Child

In December, 2013, the New England Journal of Medicine published an important essay on the timing of preventing obesity in one's life.   http://www.nejm.org/doi/full/10.1056/NEJMp1310577

The compelling point of the essay is that the situation during pregnancy and early infancy can, to a large degree, determine if the child will become obese.    The article establishes that a critical opportunity to prevent obesity in your child is during your pregnancy and the months after birth.   

Of course, eating habits remain central to the effort to prevent obesity, but the actual structure of fat cells in a person can be determined during that person's pre-natal period and during their early infancy.

The article notes three major influences on whether a baby will grow up to be obese:

1. The weight status of the baby's mother during pregnancy.
2. Rapid weight gain during 3-6 months of age.
3. Whether solid foods are introduced before 4 months of age or not.
4. Exposure to endocrine-active compounds during pregnancy, after birth, in the food.

The weight status of the baby's mother during pregnancy.

The evidence strongly suggests that if the mother is obese during pregnancy, the developing child is more likely to have more and larger fat cells.  If those structures move in that direction, that person may be more likely to be obese, even eating the same foods as someone who has fewer and smaller fat cells.

Obesity during pregnancy also greatly increases the chance of the mother developing the diabetes of pregnancy, or gestational diabetes.  Gestational diabetes can directly impact the development of fat cells in the baby leading to greater risk for obesity for that baby when an adult.

Rapid weight gain during 3-6 months of age

Surprisingly, if an infant gains weight very rapidly during the period 3-6 months of age, that baby will grow up to have a significantly greater chance of being obese and of having heart problems.   This is an issue whether the infant is nursed or formula-fed.

Whether solid foods are introduced before 4 months of age or not.

In formula-fed infants only, starting solid foods before 4 months of age increases the child's risk of being obese by age 3 years old sixfold!

Exposure to endocrine-active compounds during pregnancy, after birth, in the food.

This category of risk was not described in any detail, but there are substances, mainly in plastics, which have estrogen-like impact on people.  The include specific substances such as BPA, and categories of substances such as phthalates.  Exposure to such substances during pregnancy can increase the risk of obesity later in life for the developing child.

Bottom Line

What happens during pregnancy can have a powerful impact on whether your child will be at risk for developing obesity, no matter how much they eat.  

We recommend that:

• Women exert any effort possible to keep their BMI in the, or at least towards, the normal range during pregnancy.   
• We should resist the excitement of explosive weight gain during 3-6 months of age.  Steady weight gain is quite fine.
• Solid foods should not be started until 4 months of age
• Efforts to minimize exposure to phthalate or BPA containing plastics should begin at conception and throughout the pregnancy, infancy, and childhood.

Dr. Arthur Lavin

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*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.

Is Soy Safe for Pregnancy, Safe for Baby?

Is Soy Safe for Pregnancy, Safe for Baby?

The soybean is a wonderful food.  It is rich in a wide range of nutrients, and an excellent source of protein.

From a food use perspective, the soybean is nearly infinitely adaptable in its ability to take on any taste and texture.

As a result, soy finds its way into a surprising number of foods we eat.   Of course these include foods where the soybean is visible in the food or name, such as edamame, soy sauce, tofu, soy-based infant formulas, and soy milk.   But if you consider the number of foods that have an ingredient with the word vegetable in it, with phrases such as vegetable flavoring, vegetable emulsifier, vegetable gum, vegetable starch, the exposure to soy in our food is extensive.

If soy is so wonderful, what controversy surrounds it?  The controversy is limited to one chemical in soybeans, phytoestrogens.   Phytoestrogens are molecules in plants that look like the molecule found in humans called estrogen.  As you know, estrogen is the paradigm hormone of being female.  It is estrogen that makes breasts develop, that helps control the menstrual cycle, and that helps maintain pregnancy and nursing.

The concern is whether the estrogen-like compounds in soybeans actually have estrogen effects in the human body.  It turns out very tiny differences in hormone molecules lead to dramatic differences in function.  Estrogen, for example, when altered by a very tiny amount becomes testosterone, the male hormone.  So we know tiny differences change function quite a bit!

So the question is, if you eat phytoestrogen from soy, does it do anything?  So far, the evidence leans heavily towards this answer: No.  If it did act as an estrogen in humans, we should see breast development in children, puberty pushed early in girls, and later in boys.   There is no evidence that any of these events occur in people who eat soy products.  Some research actually raises the possibility that phytoestrogens may decrease the incidence, in adults, of developing breast and prostate cancer.  But again, there are essentially no data on any group of people having a measurable difference in their lives in any way from eating or not eating soy.

Therefore, at this time, pending finding any actual impact on people, we are recommending to people that eating soy is safe for pregnant women, for infants, and all people.

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*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.

Breaking News on the Prevention of Autism (Really)

Breaking News on the Prevention of Autism (Really):

Folic Acid in the First Days of Pregnancy

I have been honored to be working with Dr. Irva Hertz-Picciotto of the University of California at Davis, who is widely regarded as the world's leading expert on the epidemiology of autism.   She has very recently informed me of some very exciting news, news that for the first time opens the door to possibly preventing autism.

Many of you may recall that I met Dr. Hertz-Picciotto roughly 2 years ago in preparation for leading a roundtable on finding the reversible causes of autism convened and hosted by Senator Sherrod Brown in the US Senate Meeting Rooms.

The exciting news is the result of years of work on the part of Dr. Hertz-Picciotto and her team in the MARBLES study (Markers of Autism Risk in Babies).   Her colleague Dr. Rebecca Schmidt has just reported that mothers who take sufficient folic acid in the days prior to and just after conception have sharp reduction in their risk of their babies developing autism.   This is how dramatic the news is:  if your folic acid levels are high enough, your baby's risk of developing autism drops FIVE-FOLD.  This is very dramatic news.

The impact is supported by other studies, so it is a replicated result, making it unlikely to be disproven with further studies.

How much is enough?   When do you have to take it to get the protection?  These are key questions.

How much is enough? 

The actual answer is only determined by testing a blood level of folic acid, but Dr. Schmidt states that for nearly everyone, taking 800 micrograms a day will get you to the levels needed to see a five-fold reduction in the chance your child will develop autism.

When do you have to take it to get the protection?

The protection works best the earlier in pregnancy that it is taken.   After one month of pregnancy, the protective effect already weakens.  This means for best protection, your folic acid levels should be at the protective level before conception.  We recommend that all girls and women take 800 mcg of folic acid a day from their first period to their last.  That way, whenever pregnancy occurs, the protective effect of folic acid will be in place for the first days of embryonic development, the key time the protection is necessary.   If this routine cannot be sustained, then it is critical that the folic acid be taken the whole period of your life when you think you may be having a baby.

How certain is this finding to work?

At this point it is highly likely to work.  The last step in proof is for the population to take 800 mcg before every pregnancy and then see if autism does drop five-fold as anticipated.

Bottom Line:

Good evidence is now in hand to strongly suggest that if you take 800 mcg of folic acid every day the month before and then throughout pregnancy, your child will drop their risk of developing autism quite substantially, perhaps as much as five-fold.

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*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.

Beware the Untested Drug

Herbal Supplements may not Have Herbal Supplements in Them

This week, the New York Times reported one of the most interesting health articles:

http://www.nytimes.com/2013/11/05/science/herbal-supplements-are-often-not-what-they-seem.html?src=me&_r=0

Someone took 44 bottles of various herbal supplements and analyzed the DNA in the herbal supplement in each bottle.

In one-third of all the bottles tested, the DNA revealed there was no herb present that the label promised would be in the bottle.

For example, one bottle of echinacea, had no echinacea in it, only rice.  Rice was a common substitute, as were various weeds, and even plants that could cause harm.   Bottles with no herbal remedy in them included bottles of ginko balboa.

In our view, herbal supplements should be held to the same standard as any drug, namely:
1.  Does it work?
2.  Is it safe?

For us the answer has to be yes to #1 for sure, and it has to be safe enough to justify use if it works.

Herbal supplements have been given a pass on both questions, very few have been tested to see if they work, and often when they are tested they are found to be powerless.

The price paid for pretending is now upon us.   In this study, 1/3 of the herbal supplements were frank frauds, the worse type of scams- the label promises you are buying one thing, but the truth is you are buying powdered rice or lawn weeds that have no relation to the herb you seek.


BOTTOM LINE
Herbal supplements were recently tested using DNA analysis proving that in 1/3 of the samples, there was no trace of the herb promised on the label.

This is yet more reason to value actual proof that something works before believing it works.

It turns out it is very hard to find substances that reliably can end a problem.

Dr. Lavin

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*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.

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.

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*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

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*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.