The New Electrolarynx For Intubated Patients

The New England Journal of Medicine (NEJM) recently published an exciting article showcasing some breakthrough technology: physicians successfully used a device called an electrolarynx, allowing an intubated patient to communicate with his providers and family members. If you've ever had to witness a loved one in a setting where they were intubated, you know how frustrating it can be for the patient, family and staff.  This new technology will be extremely helpful in intensive are unit (ICU) settings where doctors can change their treatment regimens based on feedback from the patient, improving care tremendously. The patient and device (white arrow) can be seen below.

Read the article here:
http://www.nejm.org/doi/full/10.1056/NEJMc1313379

Deciphering Your Recent Blood Test, Part 1 of 3

On your recent visit to the doctor's office, you had the pleasure of getting stuck with a needle and drained of a few small tubes of your blood. You were left with a painful memory, a small bruise at the site of injection and a printout of the results. You spend a few seconds looking through the words and values before giving up, but wouldn't it be helpful if you really knew what all of those numbers meant? 

The laboratory blood test is one of the most useful diagnostic tools of the modern physician. It allows the provider to peer inside the body like a mechanic checks under the hood. There are many blood tests available, from single tests on proteins to "panels" containing several different measurements. Two commonly ordered panels are the complete blood count (CBC) and the comprehensive metabolic panel (CMP).

CBC

Our blood is made up primarily of red blood cells (RBC) and white blood cells (WBC). The RBCs carry nutrients through the body, while the WBCs protect us either by filling holes (platelets) or by attacking and killing whatever looks suspicious (leukocytes). The colors are red and white because, simply, when you spin the blood around very fast, these cells separate based on weight and reveal red-colored and white colored fluids. The CBC is performed by a machine that lines the blood cells up in a single row and counts how many are present in a set amount (microliter) of blood. 

WBC. An increase in WBC typically suggests that our body is training an army to kill an infection. This can also be elevated in cases of cancer or with the administration of steroid medications. The specific types of WBCs (neutrophils, eosinophils, basophils, monocytes or  lymphocytes) help give insight as to what type of infection may be present (for example, neutrophils are released acutely for bacterial infections). Decreases in WBCs are seen most commonly as a side effect of medications such as chemotherapy, antibiotics and anti-seizure drugs. In other cases, a decrease may suggest that something is killing them (infection, alcohol, autoimmune, radiation) or that there is a problem within the factory that produces them (the bone marrow). 

RBC and Hemoglobin. The primary role of the RBC is to carry oxygen, using hemoglobin, to cells so they can use it to make energy. When RBCs are decreased, it is known as anemia. This can be caused by iron (holds on to oxygen) deficiency, blood loss from chronic diseases, genetic diseases such as sickle cell anemia, significant bleeding or a problem with the factory that produces RBCs (the bone marrow). Increased RBCs can be seen in cases of dehydration, chronic breathing problems (COPD) and some cancers of the bone marrow.

Hematocrit. This is simply the ratio of red to white fluid when the blood is spun around very fast in a centrifuge. Normally, 46% of blood is RBCs. If this number is low, it's an anemia. 

MCV. This is the size of the RBC, much like measuring the square footage of a house. Increased MCV is seen with alcoholism, vitamin deficiency (B12 and/or folate) and a stomach disorder called pernicious anemia. Decreased MCV suggests one of the anemias described above.

MCH and MCHC. These measure the amount of hemoglobin per RBC, helping the physician narrow down the type of anemia present. MCHC is decreased in the anemias described above, and elevated in some genetic diseases.

RDW. This compares the RBCs to one another. If there is a large discrepancy between them, meaning some are very large and others are very small, this number will be high. The most common cause of this is iron deficiency anemia.

Platelets. Platelets are very important because they plug holes and cracks to stop bleeding. Low platelets are dangerous because it increases the risk of bleeding, whether out of a wound or into body cavities like the head or digestive system. High platelets are also dangerous because they cause over-clotting, which can lead to obstruction of blood vessels and thus problems like stroke and heart attack. Platelets are often kept intentionally low with medication (such as aspirin) to reduce the risk of stroke and heart attack. Many rare diseases and some cancers can also cause low platelet counts. 

• Parts 2 and 3 of this section, coming soon, will cover the CMP and other specialty tests.

• Your physician should discuss any abnormal blood test result with you. 

• Visit our resources at thedailydiagnosis.com for more trusted information on blood tests.

References

Chapter 5. Laboratory Diagnosis: Clinical Hematology. In: Gomella LG, Haist SA. eds. Clinician's Pocket Reference: The Scut Monkey, 11e. New York: McGraw-Hill; 2007. 

Klepin HD, Powell BL. Chapter 103. White Cell Disorders. In: Halter JB, Ouslander JG, Tinetti ME, Studenski S, High KP, Asthana S. eds. Hazzard's Geriatric Medicine and Gerontology, 6e. New York: McGraw-Hill; 2009. 

Verhovsek M, McFarlane A. Chapter 173. Abnormalities in Red Blood Cells. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS. eds. Principles and Practice of Hospital Medicine. New York: McGraw-Hill; 2012. 

Are Artificial Sweeteners Safe For Your Children?

You're mindful of what your child eats or drinks, but do you really know what they're putting in their bodies? Studies by NHANES over the last 40 years tracked childhood obesity as it steadily increased before plateauing at 20% in 2008. Many attribute the changes to a national focus on the importance of low-calorie, low-sugar foods. You grew up on foods that contained sucrose, the gold standard of sugar derived from cane or beets, but nowadays children are consuming foods with sugar substitutes such as aspartame and sucralose. As with any new product, there is little in the way of research on associated long-term health effects. How sure are you that these foods are safe for your developing children?

Not all sugar is created equal. Low calorie sweeteners (LCS) are not a novel concept: sugar of lead was first used by the ancient Romans, often causing lead poisoning in chronic users. The sugar substitute cyclamate, banned by FDA for it's association with bladder cancer in rats, is still used today in countries such as the UK and Russia. Today, the most commonly used sugar substitutes include the expensive natural sugar substitute Stevia (Truvia®) and those colorful packets of sugar substitutes-aspartame (Equal®), saccharin (Sweet'N Low®) and sucralose (Splenda®). 

Sucralose (Splenda®), the top-selling sugar substitute found in many sodas and foods, has been deemed safe for human consumption, from conception to old age. Since the majority of the molecule is not broken down or absorbed by the body, it is considered calorie-free. In the laboratory, studies on toxicity in rats failed to show any increased cancer risk even at the equivalent of 100 pounds of sucralose consumed daily throughout a lifetime. Long-term clinical studies have shown that human adult consumption of up to 1000 mg (~25 diet sodas) per day for up to 6 months did not lead to abnormal blood work or adverse clinical effects. Similar findings exist for the other sweeteners. 

As adults consume more of these sugar substitutes, they are making their way into the lives of children and adolescents. What research has been conducted on their behalf?

Several studies have explored the relationship between consumption of artificial sweeteners and weight changes in children, but results are conflicting. A major obstacle in these investigations involves controlling for genetic, cultural and environmental parameters. In all, they seem to suggest that when children consume sugar-free foods, many will actually GAIN weight. How could this be? Other studies explore this question, and investigators believe that children compensate for the low-calorie meals and beverages by eating more to make up for the "missing calories." This is not unreasonable, since the same phenomenon has been observed with fat-free diets in adults. 

Due to all this speculation and lack of conclusive research, and partly because artificial sweeteners tend to displace milk and 100% juice at mealtimes, the official position of the American Academy of Pediatrics is that foods and beverages containing LCS should not make up a significant part of a child's diet.

The medical community clearly needs to perform more studies on LCS consumption in children, including long-term health consequences and weight management effectiveness, as more of these mystery products find their way into your home.

• Foods and beverages containing artificial sweeteners such as aspartame, sucralose, saccharin and stevia should only be a small part of your child's diet. Substitute high-sugar drinks such as cola, chocolate milk and some fruit juices for healthier options such as milk and water whenever possible. Studies attempting to link fruit juices to obesity have been conflicting.

• Always use food labels to select lower-sugar foods and beverages, and encourage your children to do the same. Use of food labels has been associated with consuming a higher-quality diet. Consult your pediatrician, family physician or dietician with any questions.

• Communicate with your child and know what he or she is eating at school when you aren't present. Additionally, studies have shown that eating dinner as a family leads to more responsible food choices and healthier eating throughout life. 

• Avoid using sugary foods and beverages as rewards, which increases a child’s preference for that food. For more information, view our list of resources.

References

Artificial Sweetener Use Among Children: Epidemiology, Recommendations, Metabolic Outcomes, and Future Directions. Pediatrics Clinics of North America, Volume 58, Issue 6 (December 2011). W. B. Saunders Company.

Foreyt J. The use of low-calorie sweeteners by children: implications for weight management. J Nutr. 2012; 142(6): 1155S-62S. 

Grotza VL, Munrob IC. An overview of the safety of sucralose. Regulatory Toxicology and Pharmacology, Volume 55, Issue 1 (October 2009). Pages 1–5.

Update in Childhood and Adolescent Obesity. Pediatrics Clinics of North America, Volume 58, Issue 6 (December 2011). W. B. Saunders Company.

Why YOU May Have Gluten Sensitivity

Unless you've been living under a rock for the past year, you've noticed the words "gluten free" advertised in your local grocery store or muttered by that coworker who always boasts about her latest fad diet. You may even have peeked at a gluten-free section of the store and had to pick your jaw up off the ground in response to the exorbitant prices. What is all this nonsense? As it turns out, this nonsense is being scientifically validated, and may concern you or someone you care about. 

Our journey begins with those amber waves of grain that sway in the wind and symbolize our country. The grain is essentially grass, typically wheat, barley or rye, containing small seeds. These grain seeds are made of two key proteins called gliadin and gluten. Grinding gliadin and gluten into flour creates an extremely sticky powder that, when added to water, forms dough. 

Over 10,000 years ago, humans discovered dough, thus introducing the gluten/gliadin combination to their guts. Over time, the human gut began tolerating these foreign proteins. As many as 1 in 100 individuals, however, have not been as fortunate and instead developed gluten intolerance known as Celiac Disease (CD). Their immune systems viciously attack the gliadin in the gut as soon as it's introduced, typically between 6 and 24 months of age, causing severe abdominal pain, chronic diarrhea and vitamin malabsorption. By the 1990's, doctors had nearly deciphered this autoimmune disease, including it's association with conditions such as Down syndrome and type I diabetes, concluding that a gluten-free diet (GFD) cures over 90% of patients. 

Fast forward to the 21st century. The term "wheat belly" and the GFD are adopted by select non-celiac Americans. The feeling they get on this diet is so unmistakeable-less bloated with increased lucidity and energy-that they're willing to pay a premium for gluten-free foods. These patients are thought to be suffering from non-celiac gluten sensitivity (NCGS). NCGS is a mild disease characterized by normal small bowel biopsies (a diagnostic criteria for CD). NCGS likely affects 6-7% of the population, with some reporting incidences as high as 50%. Still, it's estimated that nearly 1/3 of the American population has tried a GFD, leading to nearly 5 billion dollars a year in profits for the gluten-free industry. Studies continue to disagree on whether this trendy diet is truly palliative or yet another case of the placebo effect. More research is needed to determine the true characteristics of gluten sensitivity.

1 in 14 people may be suffering from gluten sensitivity, and the gluten-free industry wants YOU to join the ranks... is it worth the cost?

• Recent research has revealed that the toxic effect attributed to gluten may instead be due to another substance within grain seeds called wheat germ agglutinin (WGA). Studies are reporting the toxic effects this lectin may have on human cells. Stay tuned for more on this topic.

• Implementation of a true GFD is not as simple as it sounds, considering wheat is found in many sauces, processed lunch meats, candies, pre-seasoned meats and marinades. Alternative dietary sources of carbohydrates tolerated by celiacs include rice, soybeans, potatoes and corn. Always consult your physician or dietician before significantly altering your diet.

• NCGS remains a distinct and benign condition, and is not considered a precursor for CD. Therefore, there is no elevated risk of developing cerebellar ataxia, peripheral neuropathy, seizures, dermatitis herpetiformis or cancers such as intestinal T cell lymphoma.

• For more information, visit celiac.org or one of our many trusted resources accessible from TheDailyDiagnosis.com

References

Biesiekierski, JR. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterol 2013; 145(2): 320-8.

Biesiekierski et al. Gluten Causes Gastrointestinal Symptoms in Subjects Without Celiac Disease: A Double-Blind Randomized Placebo-Controlled Trial. Amer J of Gastroent. Advance online publication, Jan. 11, 2011.

Fasano A et al. Clinical practice. Celiac disease. N Engl J Med. 2012; 367(25): 2419–26.

Pietzak, M. Celiac disease, wheat allergy, and gluten sensitivity: when gluten free is not a fad. JPEN J Parenter Enteral Nutr. 2012; 36(1 Suppl): 68S-75S.

Why Health Literacy Affects YOU

One of the most important things I try to keep in mind as a physician is health literacy, or the degree to which patients can obtain, understand and process basic health information. This idea may seem arbitrary at first, but try to remember your last visit to a physician: It may have been in an emergency room or a walk-in clinic, or perhaps your primary care doctor or specialist might come to mind.  Was there a point during your visit when you didn't completely understand information that was provided to you? Did you leave the building with questions unanswered? If you later decided to look up those questions on the internet, were you unsure about which resources to use?

If so, you're not alone: the National Assessment of Adult Literacy previously reported that 88% of American adults do not have competent health literacy skills. This number is disturbing, since low health literacy has been correlated with poor personal health knowledge, poorer health status, incorrect medication use and higher rates of hospitalization. I've heard countless stories of the most extreme cases of poor health literacy: one patient placing her birth control pill in her vagina, another spraying an albuterol inhaler in front of his face and attempting to "suck the air in." Yes, of course, these are extreme cases, but for every one of these there is another occurring much less conspicuously. 

Consider a situation where a well-educated female is prescribed tetracycline, an antibiotic, to clear her acne. She fills the prescription and, upon taking the first pill, experiences extreme gastrointestinal (GI) upset. As a result, she refuses to take the medication again. This is a relatively common situation that could have been easily avoided. If the prescribing physician or the pharmacist had taken the extra few seconds to inform the patient not to take the pill with dairy food, the stomach discomfort (a major and well known side effect) could have been avoided. 

Health literacy does more than save time and money- it can also play a major role in preventing further injury or illness, or even death.  Have you or a loved one experienced a healthcare-related situation where you felt misinformed, unaware or uncomfortable? Have you ever started a fad diet, supplement or activity that was later deemed unhealthy? I invite you to please share your story in the comments below.

You haven't been in school for 11 years receiving medical training, and professionals understand this. But, with doctors now being forced to see more patients just to keep their practices afloat, they typically won't take the time to explain specific concepts and instructions unless they are prompted to do so. So, what can you do to improve your health literacy before your next visit? 

• Don't be afraid to request that your doctor take a moment to explain a drug, prescription, blood test result or diagnosis. 
• Know the specific function of each medication you are taking (i.e "this is my blood pressure pill, this is my water pill.") If unsure, don't be afraid to ask.
• Use trusted resources when seeking answers to your health questions at home. I've included several reputable resources on our website. 
• Keep in mind that your physician is here to help you. He or she will never get upset or offended that you are asking for clarification. 
• Continue to follow The Daily Diagnosis, as we will keep you informed by consistently adding healthy living tips and opinions on the latest topics in healthcare.

References

Grossman S, Arabshahi F, Gunter D, Harrell G, Patel S, Schaap S, Quest TE.Chapter 218. Psychosocial, Cultural, and Spiritual Aspects. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS. eds. Principles and Practice of Hospital Medicine. New York: McGraw-Hill.

Health literacy and public health: a systematic review and integration of definitions and models. Sørensen K - BMC Public Health - 01-JAN-2012; 12: 80.

Literacy, cognitive function, and health: results of the LitCog study.

Wolf MS - J Gen Intern Med - 01-OCT-2012; 27(10): 1300-7

Low health literacy: a barrier to effective patient care.

Seurer AC - S D Med - 01-FEB-2013; 66(2): 51, 53-7