More Germs, Less Asthma

More Germs, Less Asthma

This weeks New England Journal of Medicine adds an important addition to a very large body of evidence that exposure to more germs in childhood can actually dramatically decrease the chance of developing asthma.

The original observation from a large number of studies from around the world is that kids growing up on farms have a much smaller chance of developing asthma than kids growing up in cities.

What is becoming clear is that a large part of the reason has to do with exposure to a broad range of bacteria, and fungi (molds and yeasts).  The more a child is exposed to bacteria and fungi, the less chance they have of developing asthma.

The benefit of exposure to bacteria and fungi is large, it can drop the chance of developing asthma by 50%!

We have no actual recommendations regarding exposing our kids to bacteria and fungi.  But one thing is now much clearer.  The whole germ phobia phenomenon is now clearly pointing in the wrong direction.  In fact, it may be that the overall approach of trying to keep surfaces free of germs has caused a tremendous surge in a real illness, asthma.

Bottom Line:  

Bacteria and fungi are a radically different problem than viruses.  Viruses never just hang around, they can only cause illness.  But bacteria and fungi are an important, constant, valuable part of our lives.  No human alive has ever spent a moment of their life entirely coated by bacteria and fungi.  The whole planet is covered by bacteria and fungi.  If we could somehow rid ourselves of them altogether, it is very likely that many of our systems would fail, including our skin, gut, and lungs.  We would likely not be able survive well, or at all, in a bacteria free world.

Infections from bacteria almost always are due to some unusual opportunity our body gives them- a cut, a viral infection.  But for almost our entire lives, bacteria help us live and do not infect us.

Now we know that in our craze to banish these helpful partners of life, we have possibly and inadvertently caused a raging epidemic of asthma.

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.

Beware of Magazine Ratings of Colleges and Hospitals

Beware of Magazine Ratings of 

Colleges and Hospitals

In the February 21, 2011 issue of The New Yorker, Malcom Gladwell, the author of The Tipping Point, takes a close look at US News & World Report's rating system for colleges and hospitals.

What he finds is that there is essentially no meaning to the ratings.  The problem he exposes is that it is very hard to compare two very complex items that are meant to satisfy a complex list of needs.  

He starts his analysis by looking at a similar rating system, Car and Driver's ranking of cars.  He looks at their ranking of sports cars and finds that depending on what you like, the Porsche Cayman, Chevy Corvette, and Lotus Evora would rank 1,2,3, or 3,2,1, or 2,3,1, all depending on what you were interested in getting. If you use the same rating system for all cars you get one ranking, but if you adapt a ranking system to sports cars that elevates the value of sporty look and a fun ride, you get the opposite ranking.  Ranking by cost gives you a third ranking altogether.

Just so for colleges.

Gladwell then uses the example of ranking countries by the incidence of suicide.  That can be done and in that system each country gets one number to describe its rank.  But the problem is that nations vary in the acceptability of suicide in their culture.  Even in the US, where most deaths from isolated car injuries (one car, one driver, no known physical cause) are thought to be suicides, most such deaths are not listed as suicide.

Just so for colleges.

As Gladwell puts it, "There's no direct way to measure the quality of an institution- how well a college manages to inform, inspire, and challenge its students."  So, instead of measuring the unmeasurable but important, the rating scales of US News & World Report simply measure the less important, that they hope reflects the core purpose of college.  For example, 20% of US News & World Report rankings are based on faculty data, such as how much are the faculty paid.  But good studies find no correlation at all between a professor's salary and his/her teaching excellence.  The same goes for the reputation variable in the US News & World Report's rankings.  National university presidents have to rank about 250 other schools from one to 250 on reputation to help US News & World Report devise this rank variable, it makes no sense.

Hospitals

Now we come to hospitals.  Here Gladwell cites an important study from one of the world's top medical journals, the Annals of Internal Medicine.  The study looked at the US News & World Report ranking of top US hospitals, and looked at objective measures of hospital excellence such as the chance of a person dying from a standard surgery, patient safety records, key technology availability.  They found there was no connection at all between US News & World Report's reputation rating and the actual excellence in practice of a hospital.

The Absurdity of the US News & World Report College and Hospital Ranking System

Gladwell goes on to cite the fact a Michigan Supreme Court Chief Justice sent a ranking questionnaire to 100 of his colleagues.  Penn State at that time was ranked by these elite members of the legal community as the fifth best law school in the United States.  But at that time Penn State did not even have a law school!

The only variable that the US News & World Report college ranking firmly correlates with is how much money the school has.  Wealthy schools alway outrank less wealthy schools.

BOTTOM LINE

When it comes to complex needs, such as those we require from colleges and hospitals, put the magazines away.  Their rankings can only serve one purpose- to sell the magazine.

For colleges, think about what your child needs and is interested in and seek the college that provides that unique set of needs best for her or him.

For hospitals, keep in mind that no hospital actually solves a medical problem, only a person or a small group of people- your doctor, your specialist, your nurse.  So one should only use the medical system with a clear eye towards what the questions are, what the needs are, at that moment, and be sure your doctor can organize the best team possible to help get those needs met.

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.

An Occassional Reminder of Magnificence

This morning, the morning of George Washington's birthday, the residents of the Greater Cleveland area were treated to one of nature's most astounding sights- a burst of light as the morning sun's rays wildly illuminated all branches and wires coated with ice and snow.

This is a rare treat, and only occurs when several events in nature come together at just the same moment.

The first condition is that it has to be winter, since all depends on ice and light.  The second condition is that it has to be cold enough to freeze water to ice, but not to cold to force precipitation into snow.   At just this right temperature in sky and on ground, a sleety, slightly wet, freezing rain can fall, and on hitting branches and wires turn to ice.  If the conditions are just right, a smooth coating of ice will cover these round branches and wires.  We had such perfect conditions in Cleveland on Sunday night the 20th, but we were missing one final element, sunshine.

Last night, the 21st, we got a coating of snow over the ice, transforming the background to the ice-encrusted branches to a fresh, bright, white appearance.

This set the stage for the final element to appear during the dawn of the 22nd, a bright, blazing sun in a deep and perfectly blue sky.

Put it all together, and we were treated to an astonishing site this morning outside of the windows of our homes, cars, and offices.  Against the stark white background of the earth, and the azure blue of the sky, every branch and wire blazed with a light that could not shine any brighter.  The color of the blaze is white, but a white that carries the intensity of the sun.  It is striking to think that on any sunny day, the air carries light of this intensity, but rarely do we get to see its full blare unless the right material catches it, and holds it for us to see.

And that is just what these ice-covered branches and wires have done this morning, they can catch the morning sun's rays and hold them, seeming to concentrate them, so that we get to see a very intense slice of the sun's power without being overpowered.

The fact that the light is held by branches offers another treat, the chance to see the full network of a tree's branches in their full glory.  It turns out that all branching networks of life share a similar shape, a geometry known as fractals.  Fractals are designs of lines that repeat themselves up and down the scale.  So a web of large arteries has the same shape as the web of smaller arteries they flow into, and as the web of capillaries they flow into.

These fractal networks are the shape of life itself, and are seen in the patterns of tree branches, the blood vessels of our body, and the network of air tubes of the lung.  In fact, if you are looking at a glowing tree today, imagine if you could cut the trunk at its base, hold it upside down by the end of the cut trunk, and see the branches branching downward instead of upwards.  You would be seeing a very close representation of the branching lung.

Another observation- all life requires energy to operate, and all energy for all life on land comes from the sun.

So this morning, we get a fleeting glimpse of the magnificent improbability of life.  We get to see the power and beauty of sunlight on branches that normally cannot hold such light long enough for us to see it.  And, the light illuminates the underlying structures of life's networks, the shape of networks inside all living organisms.

I learn to affirm
Truth's light at strange turns of the mind's road,
wrong turns that lead
over the border into wonder.... 

by Denise Levertov

So, I hope you too got to see this extraordinary sight this morning, a rare treat.

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.

Catching a Cold is More Complex that You Might Think

Catching a Cold is More Complex that You Might Think:

You Don't Tend to Catch it in Class or at Home

For many years, Advanced Pediatrics has viewed the spread of viruses more like wind rather than a handshake.  The wind idea proposes that viral epidemics sweep across communities and continents, offering no real ability to stop the spread.  The handshake idea is more comforting, it states that if we only avoid shaking hands with everyone we know is sick, the virus will not spread.

On January 31, 2011, one of the nation's top scientific journals published a study that took a close look at just how one virus, the H1N1 influenza virus, spread in a small Pennsylvania community.

http://www.pnas.org/content/early/2011/01/28/1008895108.full.pdf+html

On February 4, 2011 the New York Times reported on this study. 

http://www.nytimes.com/2011/02/08/health/research/08flu.html?ref=health

The study looked at 370 children in 295 households and their 899 contacts outside of school and home.  The investigators tracked the flow of infection from child-to-child, child-to-adult, and adult-to-adult.  Today's common sense would demand that if you get sick, it is far more likely to be from the person sitting next to you in class or from a family member, than otherwise.

As with much common sense, the facts often prove otherwise when someone takes the time to look at what actually happens.

Here is what they found:  

• Kids are more likely to catch the flu from playmates than classmates.  Looking at fourth-graders, boys were much more likely to catch it from boys and girls from girls, even if a boy and girl sat next to each other.
• Adults were more likely to catch the flu from someone outside the home than their own children.
• Closing the school during the height of the flu epidemic had no impact at all on the spread of flu.

These three observations are strong proof that our usual ideas on stopping the spread of virus are no more than wishful thinking, and turn out to be nearly useless.  Keeping your child home from school when sick, closing schools when viral epidemics flare, worrying about catching the virus from someone you live with, each have very little to do with how you or your child will most likely catch their next virus.

If one takes a look at the big picture, this all makes perfect sense.  Just consider the influenza virus.  It infects no one on the planet during the summer.  But in the winter nearly every village and city is soaking in the virus.  This means that the influenza virus sweeps across continents, infecting all in its path every December and just as dramatically disappears from every nation by the end of April.  If that is what is actually taking place, how could closing a school stop the flow of this global viral storm?  As the study published proves, closing a school turns out to make no difference at all.  Not a surprise if one keeps in mind that viral epidemics are like global weather events, they sweep through our lives like a storm, and staying home or going out has little impact on the flow and exposure.

This more informed perspective also ends the dearly held belief that if a child in a family has a cold, and then someone else gets sick, that first child had to be the source.  When an actual epidemic was tracked, it was found that adults were more likely to get infected from someone outside their home than their sick child.

If the facts are so clear and fit with the global movement of virus, why are we all so sure that we can control the spread of viruses?  I think it is a deep-seated need for some comfort.  After all, the image of a global wind of illness is not very comforting.  It is far more reassuring to think of what Aunt Rose used to tell us- wash your hands, stay home if you are sick, cover your face when you cough, that school should close with everyone getting sick there.  After all, if Aunt Rose is right, then maybe, just maybe we could do something to stop our loved ones from getting sick.  Not a bad hope, and what a powerful desire.  When desires are that strong, beliefs that suggest they could come true are not easily set aside.

But, if we really are ever to defeat viruses, we can only hope to do so if we approach the challenge with the actual facts.

So next time colds and flus strike your school or home, keep in mind the virus most likely came from outside your school or home.  It is unfortunate that we cannot control the sweep of virus, but it does keep us from blaming those we love for getting us and others we love sick.

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.

A Tragic Loss that Teaches No Lessons

A Tragic Loss that Teaches No Lessons

Recently we were all shocked an upset to hear that a young 7 year old girl died, apparently from an infection.

This is a tragedy.  A life cut short for a reason that is profoundly unsettling, frightening.

I do not yet have sufficient details to discuss exactly what happened.  The public information available is limited to the fact that a particular germ was identified from tests on the girl.  That germ is a commonly circulating bacteria, Streptococcus pneumoniae, that is known to cause infections, but these days it is extremely rare to hear that this germ could prove fatal in an otherwise healthy 7 year old.  

Given the limited information available, can we offer any advice or learn anything from this tragedy?

Not too much, but here are some items that can be offered:

SOME ITEMS

• The germ Streptococcus pneumoniae is also called the pneumococcus, and is a common cause of very common and minor infections such as skin infections (impetigo), ear infections, as well as more serious infections like blood infections (bacteremia, sepsis), bacterial pneumonia (not the mild and common walking or viral pneumonias), and bacterial meningitis.
• Streptococcus pneumoniae, or the pneumoccocus, is not the germ that causes strep throat.  That germ is related, but far different, and is called Streptococcus pyogenes.  This means that no one with strep throat is contagious for Streptococcus pneumoniae, or the pneumoccocus.
• Thankfully, infections with bacteria, including those like Streptococcus pneumoniae, or the pneumoccocus, are almost always not contagious.  There are some minor exceptions, typically limited to minor infections on the surface of the body that cause no real hazard or harm, like impetigo, bacterial pink eye, and strep throat.  But any bacterial infection inside the body, like an ear infection, bacterial pneumonia, etc., tends not to be contagious.  Think about the rare cases of bacterial meningitis, usually only one person in a family or school comes down with it, a particularly large outbreak may reach only 3 cases.  
• This is wildly different than how viruses behave.  One cold virus can sweep across literally millions of people before it is done spreading.  Bacteria simply do not act this way.  This means the child with the tragic infection likely posed no risk to those she had occassional contact with.
• Streptococcus pneumoniae, or the pneumoccocus, is around.  Most people have the germ on them sometime in their life.  The real story of bacterial infection is that these infecting bacteria come and go across our lives, and only cause infection rarely.  Consider the fact that each of us is coated with bacteria all our lives, even now, but only get infections of our skin very occasionally.   So a bacterial infection is not so much about "catching a disease," as much as a bacteria finding its rare opportunity to get inside the body and grow.  This is another way of saying that serious bacterial infections do not tend whip through groups of people, but rather, reflect something complex about that one bacteria managing to find its way into that one person.
• Streptococcus pneumoniae, or the pneumoccocus, also turns out to one of several bacteria that we can immunize against.  You may recognize the name of the relevant vaccine, derived from the name of this germ- it is the pneumococcal vaccine.  It goes by various names, pneumococcal vaccine, prevnar, PCV.  It comes in dozens of forms.  The first generation of the vaccine protected against 7 forms, and the current one we use protects against 13.  In both instances the 7 and 13 forms are the ones that most commonly cause serious infection.  The use of these vaccines has made serious infection from Streptococcus pneumoniae, or the pneumoccocus, much rarer, but sadly, not extinct.  Use of this vaccine across the United States has also, nicely, sharply reduced the number of ear infections and complications from ear infections as well.
•  Finally, we really do not know the full story of what happened to this very unfortunate 7 year old girl, and in our experience, the details of a situation make all the difference in understanding it.   And so, we hesitate to draw any lessons from this tragedy.  

LESSONS FROM THIS TRAGEDY

• The primary lesson to take is that there is no lesson.  As noted above, this situation likely reflects very individual circumstances.  Circumstances that are, actually, not contagious, and that are very likely very reflective of details pertinent only to that particular instance of connection between that germ and the specific person.  Such very individual circumstances do not generalize, and hence there are few lessons to be learned in this tragedy.
• Some lessons that should not be learned:
• All people get colds, fevers, runny noses, congestion, and coughs.  The fact that this girl had these symptoms does not mean that others with these symptoms are at risk.  If you have a cold, and seem to be comfortable and acting normally, you have a cold, nothing more.
• There is no deadly epidemic about to break out.  These tragedies are always limited to very small numbers of people, usually one.  Never has such an infection whipped across a large population in recent history.
• There is no point to running to get an antibiotic just because this one case took place.  The same approach to deciding how worried to be still is in place- if you are comfortable, in no serious pain, able to achieve normal alertness, have no serious trouble breathing, you are safe.  If you have a stiff neck, cannot breathe, cannot wake up normally, have serious pain, then, of course, you should seek medical advice.

Bottom Line

A terrible loss has struck our community, our hearts are with the family that has suffered an inexplicable and terrible loss.

The events that caused this loss are not fully known, but the germ implicated and the infection that took place pose no or very little threat to any one else in the community.  This was a quite unusual event, very, very likely not to recur.

This means that despite this tragedy, families should manage their illnesses as they always have, specifically:

If you or your child has symptoms of a mild viral illness, namely, fever, cough, runny nose, feeling lousy, not eating well, not sleeping well, you should make yourself comfortable, and know that this tragedy has no implications for you and should have no impact on how you care for your mild viral illness.

And, of course, if symptoms of more serious disease appear, specifically having serious pain, or serious trouble breathing, difficulty achieving alertness, stiff neck, or a fever reaching 106 or higher, then call immediately for medical attention.

Advanced Pediatrics stands by ready to help if you have any questions, and certainly if you need help knowing if an illness is mild or more serious.

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.

ProLoquo2Go- A Breakthrough Approach to Augmented Communication

ProLoquo2Go:

A Breakthrough Approach to Augmented Communication

Thanks to a parent in the practice, I would like to bring to your attention a new approach to help children who have trouble speaking, ProLoquo2Go  (http://www.proloquo2go.com/). 

This is an intervention designed for children with special health care needs that include a serious impairment in the ability to talk, but who retain the ability to construct thoughts.  Children in this situation often experience very painful frustration:  they have many thoughts and feelings to share, but physically are blocked from communicating them.  Sign language helps those who have sufficient hand function to do so, but many children in this situation also have limited hand function as well.

For many years, developers have been seeking devices that will allow a person to indicate their ideas by tapping a button or series of buttons.  Once tapped, the button will communicate to the listener what the person would like to say.  For example, one button might communicate the thought, "I am hungry," or another that says, "Yes," or, "No."

Typically devices that allow this approach to communication have been very expensive to obtain, often costing many thousands of dollars.

This is where ProLoquo2Go comes in.  It transforms your iPhone, iPod Touch, or iPad into such an augmentated communication device for $150-250!

Families that have used ProLoquo2Go have stated that it makes a real difference.

So if you have a child with such a special need, or know of someone who does, I do recommend that you take a look at ProLoquo2Go and see if it might help. 

Many thanks to the parent who brought this to my attention,

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.

Constant Contact: Why it doesn't matter if you are contagious

Constant Contact:  

Why it doesn't matter if you are contagious

With very rare exceptions, it does not matter at all if you or your child is contagious with an illness.

This is because we are all very heavily exposed to the viruses that cause nearly all the illnesses that circulate in a community, namely colds, flus, and stomach flus.

This is not the message we are usually taught by schools and by our parents.  

We have all been raised to think that it is only common courtesy to stay away from friends when ill for fear of "giving them" our cold or flu or stomach flu.  Everyone has complained at some time or another about the child who returns to school or co-worker who returns to the office while sick, and upset that they might gives us or our child their illness.

So how can it makes sense to say it does not matter if you are contagious?

The reason lies in the superabundance of viruses in the air and their extraordinary ability to jump from person to person.

Virus Stats
Let's start with the numbers:

• Every single human being gets viral infections, and loads of them.   
• The average is 8 every year from birth through the elderly years, and every year in between.
• With colds, people fill the air with their virus with every breath for about 3 weeks, that means every person is pumping virus into the air about 24 weeks every year.
• With some stomach flus, the viruses can be spread by a person for a whole year after the illness.
• For mono the virus can be spread easily for a year after the illness.
• Given that just for colds the average person is pumping virus into the year nearly half of every year, it is hard to imagine just how much virus fills the air of a major city.
• Put it all together, and with every breath, we breathe in about 1 billion live viruses, every breath!

How well do Viruses Get Around?

Now, how about how well viruses move around?

Viruses turn out to be little packets of genetic material, either DNA or RNA.  They are wrapped in proteins that hold the key to entry in a cell.  Once in a cell, the viral DNA/RNA activates the cell to make more virus.

That's it, that's what viruses do.

Viruses have been doing this for about 3 billion years.  Humans have only existed for about 100,000 years.  So viruses have been jumping from cell to cell 10,000 times longer than humanity has even existed.

The point is, they are very, very good at getting around and spreading.  

We are all soaking in virus- contagion is essentially irrelevant

So if you or your child has a viral illness, it turns out to not matter at all if they are contagious, because everyone, including their family and friends, is so heavily exposed to viruses with every breath, that they will be heavily exposed to virus whether you or your child are with them or not.

When a well person wonders if someone with a cold or flu might make them ill is very much like a group of people playing in the ocean wondering if a new person, who happens to be wet, can play with them for fear the new person can make them wet.

Exceptions to the Rule

What rare situations demand isolation for contagious persons?

The main such situation is if someone has a weakened immune system and is actually isolated from other people.  For example, someone critically ill in a hospital, or some people undergoing intense chemotherapy, or a recent organ transplant recipient.  Most of people in this situation are avoiding contact with nearly everyone, and are fairly isolated, so a visit from someone who is contagious could make a difference.

Bottom Line

• Viruses surround us, we breath in a billion with every breath
• People are contagious after a viral illness for weeks or months
• So, with the rare exception of a person who is critically ill, it makes little sense to remain fully isolated if you are contagious for a virus.
• Schools and families need to reconsider their traditional approach to limiting the spread of viruses, such policies have a nearly 100% failure rate and so should no longer be used.
• If you have a viral cold or flu, stay home if you feel sick, but do not remain isolated just to avoid the spread, the virus has already spread.

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.