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Opioid peptides: the heroin within?

Screen Shot 2014-11-07 at 10.36.51 PMBy: Emily Brown PhD

If you were to hear the words ‘opioid peptides’, they might not trigger much within your brain, other than that the former sounds a bit like opium and together they sound quite scientific. Opium (also known as poppy tears) is a dried substance or latex that originates, as the alternative name suggests, from the opium poppy. Beautifully intricate pipes of bamboo, ivory, silver, jade and porcelain have been carved over the centuries and used to vaporise and inhale the latex traditionally obtained by scratching immature poppy seed pods by hand. Numerous Empires including the Egyptian, Greek, Roman, Persian and Arab made widespread use of the drug, which was then the most potent form of pain relief available. This analgesic property is conferred by morphine, which constitutes approximately twelve per cent of opium and is chemically processed to produce heroin. Commonly known by the street names H, smack, horse and brown, among others, the effects of heroin will be well known by any ‘Trainspotting’ fans. What writer Irvine Welsh did not reveal, however, is that opiates such as heroin mimic the effects of naturally occurring molecules that can be generated inside our own bodies.

Opioid peptides are small molecules that are produced in the central nervous system (the brain and spinal cord) and in various glands throughout the body such as the pituitary and adrenal glands. These peptides can be divided into three categories (enkephalins, endorphins, and dynorphins), depending on the type of larger precursor molecule from which they are derived. Opioid peptides function both as hormones and as neuromodulators; the former are secreted in the blood system by glands and are delivered to a variety of target tissues where they induce a response, while the later are produced and secreted by nerve cells (or neurons) and act in the central nervous system to modulate the actions of other neurotransmitters.

Neurons are electrically excitable cells that process and transmit information through electrical and chemical signals that travel via synapses, specialised connections with other cells. These signals are transmitted across a synapse from one neuron to another by neurotransmitters. By altering the electrical properties of their target neurons and making them difficult to excite, opioid peptides can influence the release of various neurotransmitters.

Through these two different mechanisms, opioid peptides can produce many effects including pain relief, euphoria and altered behaviour such as food and alcohol consumption. The apparent connection between exercise and happiness has been explained at least somewhat by the release of endorphins, for example. Exercise is commonly recommended as a strategy for stress-relief and mood improvement, but less widely accepted forms of therapy might also be connected to opioid peptides. Evidence suggests that pain relief induced by acupuncture results from stimulation of opioid peptides – these peptides act through receptors on their target neurons, and chemicals that inhibit opioid receptor function have been found to reverse acupuncture-induced analgesia. Painful, stressful or traumatic events or stimuli can induce the release of opioid peptides, with the resulting euphoria and pain relief making the sufferer less sensitive to noxious events. Opioid peptides have been reported to affect the release of specific neurotransmitters such as dopamine and serotonin, but the response of the neurons that receive opioid-peptide stimulation depends on their excitatory versus inhibitory nature, making the outcome difficult to predict.

The words ‘opioid peptides’ may not have left a dazzling feeling of recognition within your memory upon first encounter, but these peptides act within the brain and wider body to influence a number of important functions. Although it is not easy to predict the effect of neuromodulators that alter the release of other neurotransmitters, there is little question that opioid systems play a critical role in modulating a large number of sensory, motivational, emotional and cognitive functions. Alterations in opioid peptide systems may contribute to a variety of clinical conditions, including alcoholism, obesity, depression, diabetes and epilepsy. Many questions still remain, particularly those concerning the exact role of opioid peptides produced within the body in relation to addictive and emotional behaviour and psychiatric disorders. Since these disorders are typically of a complex nature, seeking the answers to these questions is not a simple feat. Advances in genetics and genomics research that aim to explain function by studying our DNA are helping to pave the way. But perhaps if there is one thing that can help motivate our talented scientists to reach their challenging goals, a healthy dose of opioid peptide might be just the thing.

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Protein supplements: powerful powder or powerful promotion?

protein supplementsGoogle the words ‘protein supplements for athletes’ and a number of links will appear in your browser. While apparently just a click away from learning the ‘truth’ about these dietary additions, it is advisable to consider the nature of whichever website you fall upon before hollering hallelujah. Company websites marketing protein supplements claim to give athletes the ability to ‘beat their best competition’ and to ‘get bigger and/or stronger’. Promasil, ‘the athlete’s protein’, for example, features seven of the world’s most powerful proteins. Imagine the industrial strength containers needed to keep these key ingredients from escaping. No more five dozen eggs a day to grow biceps the size of barges (the strategy adopted by Disney’s Gaston), a more palatable and practical solution is delivered in the form of a delicious flavoured powder. Since proteins are a major component of muscle, it surely makes sense that consuming more would result in extra bulk. But protein supplementation is not only about bodybuilding. For those more concerned about beating personal bests and leaving the competition trailing behind, protein supplements are also argued to directly enhance endurance performance and to optimise recovery of muscle function following exercise.

So how does it work? Naming a chocolate bar after a long-distance running event (and later rebranding using a word that sounds like underwear in British vocabulary – ‘Snickers’), no doubt taught the importance of carbohydrate as an energy source. Through reduced breakdown of carbohydrate during prolonged exercise, protein supplements are thought to enhance performance and to more quickly replete muscle glycogen (a specific type of carbohydrate) during recovery. By stimulating muscle protein synthesis, protein supplementation is also theorised to reduce muscle damage and speed up the recovery of muscle function. If you recently ran down a hill or lifted some weights, ideally not at the same time, you may later have felt soreness in your muscles, caused by damage to proteins that are required for muscle contraction. In such circumstances, rates of muscle synthesis and degradation are increased, and without sufficient protein intake, rates of degradation exceed synthesis and a negative net protein balance results. Consuming protein supplements during recovery from exercise should, however, promote the production of skeletal muscle (muscle that is attached to bones and contracts on demand).

Despite the logic behind these claims, a systematic assessment of the evidence to support or refute the relationship between the use of protein supplements and exercise performance, muscle damage and soreness, and recovery of muscle function has until recently been lacking. Earlier this year, Pasaikos, Lierberman and McLellan addressed this dearth by publishing two review articles in the journal Sports Medicine.  Examining publications reporting findings from ‘healthy human adults’ (no chimpanzees thankfully) between 18 and 50 years of age, they found no apparent relationship between recovery of muscle function, muscle soreness and muscle damage when protein supplements were consumed prior to, during or after a bout of endurance or resistance exercise. If supplemental protein was consumed after daily training sessions, however, beneficial effects such as reduced muscle soreness and damage became more evident. They also found that when carbohydrates were at optimal levels during or after exercise, protein supplements provided no performance enhancing effects. In particular, sparing of muscle glycogen stores was not supported as a mechanism leading to enhanced endurance performance.

Pasaikos et al. warned, however, that small numbers of participating adults and lack of dietary control limited the effectiveness of several of the investigations they examined. Since studies did not measure the effects of protein supplementation on direct indices of muscle damage or muscle glycogen, for example, the interpretation of the data was often limited. What does seem clear, however, is that if athletes maintain a healthy diet, by consuming enough protein and carbohydrate through traditional means (for example regular food), protein supplements are unlikely to generate record breaking results. Only when the healthy human adults involved in the studies examined by Pasaikos et al. were lacking in nitrogen (found in amino acids that make up proteins) and/or energy balance were performance enhancing effects of protein supplements found to be greatest. Endurance is of course built by training and not protein alone. Whilst Pasaikos et al. demonstrated the need for further high quality research on the potential benefits of protein supplements, a healthy diet, sufficient rest and undeterred dedication seem to be best recipe for success.

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An Apple a Day!

appleAn apple a day may keep the doctor away and is a good idea title for a book, but it’s probably a bad premise for a scientific study. The other day, a friend of mine drew my attention to a headline in the UK Telegraph “Eating an apple a day improves women’s sex lives, study shows.” Bad grammar not withstanding, I defied my better judgment and decided to read the article. The Telegraph doesn’t have the best track record of health reporting. Recently they wildly misreported a study about edible flowers and true to form they botched this one as well.

The article makes a number of claims. It says that that apples have “been show to be an aphrodisiac,” that “an apple a day can improve the sex lives of women” and that they “boost sexual pleasure in healthy women.” These are impressive attributes for a simple fruit, so I decided to read the actual study this report was based on.

The study was published in the Archives of Gynecology and Obstetrics. Essentially researchers took 731 women and asked them how many apples they ate every day and then asked them to fill out a questionnaire about their sex lives in areas such as desire, arousal, satisfaction, pain, etc. Researchers found an improvement in lubrication and consequently in the total score, but not in any other area of the questionnaire. Here is an actual quote from the study, “No significant differences between the two study groups were observed concerning desire, sexual arousal, satisfaction, pain and orgasm.” (Interestingly, the group that ate less apples had a slightly higher satisfaction score 4.5 vs. 4.3). This strikes me as fairly convincing that apples are don’t affect the quality of women’s sex lives at least in terms of the metrics that actually matter. Having read this study, I cannot for the life of me figure out how the Telegraph could have generated their headline. I can only assume they didn’t actually read it and just parroted the press release.

Even if you accepted their one single positive finding, the study has a lot wrong with it. First off, it is not a randomized clinical trial. Even though the newspaper story seemed to imply that it was, here researchers simply asked women how many apples they ate and did not actually conduct an experiment. It is easy to image why women who ate apples on a daily basis would be different than women who did not. They were likely more health conscious, probably exercised more, and probably had a better diet overall. Those who ate more apples probably ate more bananas, more oranges, more pears and more fruits in general. Researchers did not ask about other fruits and they likely could have just as easily shown an association with kiwis or pomegranates. So why apples? I guess the link to the biblical story of Adam and Eve was too good to pass up. Of course, the fruit of the tree of knowledge wasn’t actually an apple but why quibble on details.

The newspaper article also then makes a number of claims that the benefits of apples are due to phloridizin and polyphenols.  This is pure speculation. This study, as I mentioned, did not measure any hormone levels or perform any tests on the apples themselves. It was purely the analysis of questionnaire sent out to women.  Clearly, throwing in a few “sciency” terms (and adding the requisite photo of an alluring women biting into an apple) made the article more appealing to the newspaper editors.

Apples are unlikely to improve your sex life and, while we’re at it, neither will oysters, chocolate, or ginseng. An overall healthy lifestyle with regular exercise and a balanced diet is probably your best bet (but admittedly this would make for a lousy headline). So what can we conclude overall about eating an apple day? No effect on sexual desire or satisfaction, great title for a book, and (from my point of view) it’s bad for business.

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Trumpet Plastic Surgery

tiger trumpetThe world of instrument making is a peculiar blend of tradition and innovation. Once a good design is found, it’s rare for major modifications to occur. The big names we have heard of, Stradivarius violins (or as Homer Simpson says, “Strada-who-vious?”), or Steinway grands, are physically quite similar to their ancestors – a quality openly sought by musicians who buy these makes. More often, the innovation occurs from within the constraints of the traditional form of the instrument. We’ve switched out the cat gut for more resilient plastics (though you can still find the purist who swears by the older string type), and moved away from wooden piano frames, which has resulted in much fewer pianos spontaneously collapsing, releasing their strings, bound so tightly they could cleanly remove a finger. It’s therefore rare to come across a trumpet that’s almost completely made of plastic.

The “tiger trumpet”, a plastic trumpet that comes in a variety of vibrant colours, is the latest in a trend of professional quality plastic instruments. Likely inspired by the “p-bone”, a plastic trombone, and the first (and arguably, simplest) of the brass instruments to depart from its metallurgical heritage, the tiger trumpet is the answer to the trumpeter with a penchant for ‘toys’, which if you know any trumpeters, is all of us. At the highly affordable price of $295, I was able to get my hands on a beautiful blue and yellow model and examine it.

The horn itself is almost entirely made of plastic. It seems like a cop out to begin by saying that plastic has its limitations, as the horn is truly quite impressive. However, the basis of function of the valves still requires a small amount of metal, and indeed, with exception to a thin layer of aluminum which coat the valves, and supply the mechanical energy in the springs, the tiger trumpet is all ABS plastic.

Acrylonitrile Butadiene Styrene – for the more seasoned chemists, or the well-informed consumer, this plastic may ring a bell. You’ve probably come across it in the form of the beloved (and sometimes painful) children’s toy Lego, but it’s used in a variety of other applications. The plastic is rigid through a large range of temperatures, and when molten can be coloured with a variety of dyes. The plastic does have a drawback, and this is best told by the tale of the world’s largest auto recall of which several million cars manufactured by GM were subject. As it would turn out, ABS is prone to photo oxidation, and the mechanism of the seat belts in several GM SUVs made roughly over a 10 year period contained this plastic, which degraded, and was the cause os several hundred car accidents. Beyond the inherent wastefulness in the manufacture of most plastics, which use impressive amounts of petroleum products for their synthesis, photo oxidation, and solvency in acetone (keep that nail polish remover away from your trumpet) are the principal causes for concern with an ABS trumpet.

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FOLLOW DR. KO: Medical Mission to Haiti – Paul’s last days and a few highlights

It was one of those happy endings. Paul, albeit still frail, was now smiling, eating, and chatting with his family. When I first met him, as described in my last post, he couldn’t even breathe on his own. He had been lying listless in the Intensive Care Unit (ICU) bed for days, skin and bones, barely moving a muscle. It was New Year’s Day, and I couldn’t think of a better time to tell him that he was ready to be discharged home.
Paul was one of my first patients on a medical volunteer trip to Haiti earlier this year at Bernard-Mevs Hospital. Paul had been admitted to the ICU for acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease. I had made it my personal project to find him the best treatment regimen with the very limited resources we had. Often, especially at night, I was the only physician covering triage, the emergency room, the inpatient unit and the ICU, and I had only my pocket medicine book to rely on. That, and my own judgment.
It is pretty amazing how quickly a resident physician can grow when forced to think and act by herself without the usual close supervision of an attending, as is the usual case during residency. I remember my second night shift when, while all the volunteers went out to dinner, I was assigned to stay behind to woman the fort. With a mere one and a half years of experience in internal medicine under my belt, it was a tad daunting to be left in charge of the entire hospital. Lo and behold, an ambulance rolled in with blaring sirens, bringing in a young man who was in a motorcycle accident. Just as I was evaluating this patient, another ambulance pulled in, followed by another. Just like that, I was in the entrance of the hospital, surrounded by three ambulances and a crowd of spectators. Seeing as we had our hands full, the third ambulance was diverted to MSF (Médecins Sans Frontières) France which was about 15 minutes away.
As I gave instructions to stabilize the motorcycle accident victim’s neck with a neck collar to prevent worsening of potential cervical spine injury, I tried to gather some history about my second patient. “He has high blood pressure” was all that I could obtain from the paramedics. He was a transfer from another hospital, and apparently they couldn’t handle him so sent him to Bernard-Mevs. No one could tell me what his latest set of vital signs were, or what symptoms he had, so I jumped into the ambulance to take a look for myself.

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Beware of the new contrarian embrace of dietary fat

dietBy: Christopher Labos MD CM FRCPC

 Some of you may have heard about a new book called The Big Fat Surprise. The basic premise of the book is that fat is not bad for you and that you should eat more of it. When I first heard about this book and recovered from my apoplectic fit, I marvelled at how many times we can keep having the same discussion. Most diets can be lumped into two broad categories of either low-fat or low-carbohydrate diets.

 The notion that fat is associated with cholesterol and heart disease goes back several decades with research programs like the Framingham Heart Study and the MRFIT study, and initially led physicians to recommend low-fat diets as a way to stave off heart disease. The problem with this strategy was two-fold. First, as people sought out low-fat alternatives to their favourite junk food, companies simply took out the fat and added more sugar.

 Thus they were able to preserve the taste while still being able to label their food fat-free. As you might imagine, this did not translate into health benefits. As a result, most studies of a low-fat diet have been negative, and this fact is proudly proclaimed in the book.

The second problem with the low-fat diet is more subtle. Our understanding of fat and cholesterol has evolved considerably since those early studies. Now we speak of LDL and HDL (bad and good) cholesterol, rather than total cholesterol, as we once did. Also, instead of talking about total fat, we now talk about good fats (mono and polyunsaturated fats) that we get from fish and vegetable oils and bad fats (trans fats) that are present in fried foods. So a problem with the low-fat diet is that people reduced their intake of both good and bad fat, which essentially cancelled out the effects of each.

 Admittedly, the evidence for different fat sources is not rock solid. Although it is incontrovertible that smoking causes lung cancer, and that high blood pressure leads to a stroke, trying to prove that good fats are protective while bad fats are harmful is very difficult. There are a number of reasons why nutrition-based research is hard to do, but the main difficulty is that people’s diets fluctuate over time and rarely stay consistent.

The book I mentioned starts by poking holes in the evidence for good and bad fats, which is fair enough because, like I said, it is not perfect. It then goes on to state that sugar and carbs are the real enemy. For those of you who realized that this is essentially the Atkins diet repackaged, congratulate yourselves on an astute observation. Finally, it makes the rather bold claims that we should eat more fat and butter in our diet. This strikes me as a very bad idea.

 Although we can say that the evidence on trans fats is not as good as we would like it to be, no reasonable researcher out there is going to claim that they are protective. That is just ridiculous, and eating more trans fats is not going to make you healthier.

Of course we need some fat in our diet, just as we need some carbs and proteins for everything to work properly. I’ve always suggested people should get their fat from fish and vegetable oils rather than fried foods, that they should get their carbs from whole grains rather than sugary treats and baked goods, and they should top it all off with a little bit of protein (either from lean meats, fish, lentils or nuts). I thought about writing a book and calling it the Labos diet, but then somebody told me that it already has a name. It’s called common sense.

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Raw Milk Is For Calves

calvesBy: Christopher Labos MD CM FRCPC

While I was down in the US recently, I discovered that one of the great debates going on that country is whether producers can sell unpasteurized milk. Raw milk has become the fad du jour with advocates claiming that it is safe and good for you. Sadly, neither point is true.

To understand the debate we have to go back to the beginning of pasteurization and to one of the greatest scientists of modern times, Louis Pasteur. Interestingly, Pasteur’s initial work had nothing to do with milk but with wine. He was commissioned to figure out why wine spoiled and turned to vinegar. He discovered that tiny microscopic organisms were present in the wine and caused it to spoil. It was the birth of the germ theory and the founding of a new field of medicine, microbiology.

To be fair, Pasteur didn’t actually invent the idea of heating a substance to kill the bacteria inside, that honour belongs to Nicolas Appert. However, heating a liquid to boiling would frequently change the taste of the wine and give it a more acidic flavour. Pasteur determined the optimal temperature and time required to kill the bacterial contaminants without affecting the taste. So French wine was saved, and the process became known as pasteurization in his honour.

It was Franz von Soxhlet, a German chemist, who first suggested in 1886 that pasteurization could be applied to milk. At the time, and into the early 20th century, milk was a common source of food borne illness, particularly tuberculosis and brucellosis. As a result of pasteurization and a policy to slaughter TB infected cattle, bovine tuberculosis fell drastically. While prior to 1917 it accounted for somewhere between 20-30% of TB cases, it now accounts for about 1%.

The main theme of the raw-milk lobby is that raw milk is safe, and that the bacteria in raw milk are the “good” bacteria. In fact, pasteurization was applied to milk specifically because it wasn’t safe and often transmitted disease. The raw milk literature often makes semi-scientific claims like “Staphylococci, Streptococci, Lactobacillis and Ent. faecalis in raw human milk inhibit pathogenic Staph aureus.” Clearly there is a lack of understanding here as Staph, Strep, and Enterococcus infections are very common and can be very dangerous if left untreated. If they had seen what I’ve seen, namely someone developing meningitis from a listeria infection they would sing a different tune.

The second major claim of the raw milk people is that pasteurization damages the milk and removes the health benefits. Well first off, you don’t really need milk to be healthy and milk consumption is rare in large parts of Asia and Africa. I drink milk daily because my mother made me drink a glass of milk with breakfast every morning and I fear that I am too old to break that habit now. Milk is a good source of calcium (and in Canada of Vitamin A and D because it is added to milk by the government to prevent deficiency). However, these vitamins and minerals aren’t going to be affected by temperature changes and so pasteurizing the milk will have no effect. Most expert organizations agree that apart from a change in the flavour, there is little nutritional difference between raw and pasteurized milk.  Raw milk enthusiasts make a number of other claims that raw milk will boost your immune system. Believe me when I say that if there were a way to “boost your immune system” we would be giving it to chemotherapy patients and those with HIV rather than wasting our time with this debate. The argument centers on the fact that raw milk contains leucocytes and other immune components that will help your immune system. Leucocytes, a.k.a. white blood cells, are the cells that fight off infection. Unfortunately, any leucocytes in milk came from the cow, and a cow’s leucocytes won’t do you any good. In fact they could theoretically do some harm because a cow’s leucocytes see your cells as foreign and would attack them (a concept in medicine we see in transplant patients called graft-versus-host disease). However, in the concentrations observed, they are unlikely to do much any good or harm.

It is possible to drink raw milk and not die in the same way that you can eat raw meat (steak tartar) and not die. But steak tartar is meticulously handled and carefully prepared to minimize the risk of bacterial contamination. However, the risk of infection is not zero and is not recommended for pregnant women or those with compromised immune systems. Sushi is also made of raw fish, but it too is carefully prepared and (in Canada at least) must be flash frozen prior to serving to kill off any bacteria. However, all this preparation incurs some cost which is why these products are somewhat more expensive and only served at fairly high end restaurants. Ordering cheap steak tartar at a local diner, much like buying sushi from a gas station, is no deal in the long run.

Raw milk is managed in the same way. The cows are well treated, fed only the best grain, allowed to roam free and generally treated better than we treat most humans. Importantly, they test their cows and milk for tuberculosis, listeria, and other bacteria and throw away anything contaminated. This is of course incredibly wasteful and costly. It also leads to the destruction of perfectly good food that would be fit for consumption if pasteurized. I know we have been blessed with an abundant food supply here in North America but wilfully destroying food seems wasteful to me when you consider how many people have to do without it.

Clearly, the people advocating raw milk will try to capitalize on the growing “natural is better” delusion that grips our society. It’s important to ask anyone that extols the virtue of raw milk if they have any financial interest in its sale, which of course they always do. So when it comes to raw milk, remember why we started pasteurizing it in the first place because if we forget our history we will be doomed to repeat it.

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Please don’t eat the daisies

daisiesBy: Christopher Labos MD CM FRCPC

Like most people I get most of my news by scanning the headlines and picking a few choice articles to read in depth. In general, political scandals get a pass and world events get a second look. But one day I awoke to find this headline in my Twitter feed: Eating flowers ‘could help reduce cancer risk.’

I really couldn’t let this slide.

I had to read this article if only to find out why “could help reduce cancer risk” was in quotation marks.

The article was published in the British newspaper The Telegraph and opened with this paragraph: “Eating flowers grown in British gardens could help to reduce the risk of heart disease and cancer, according to a new study.”

It made me wonder whether the chipmunks that harass my garden all summer might be on to something.

The article itself was sparse on details, so I went back to the original study, which was published in the Journal of Food Science. This is hardly a high-end medical journal, with an impact factor (how we measure the quality of medical journals) of 1.775, which is pretty underwhelming.

Already skeptical, I read on. Essentially a group of researchers measured the levels of phenols in various species of flowers and reported their antioxidant effects using a variety of chemical tests. Nowhere did the report mention cancer or heart disease, nor did they do any tests on human subjects. Clearly, the Telegraph reporter decided to editorialize a bit.

The big leap was that antioxidants must be good for you because everyone is talking about them. In fact, the clinical evidence for antioxidants is very poor.

It is true that antioxidants can neutralize free radicals. It also true that free radicals have been implicated in a number of diseases, including heart disease and cancer. But clinical trials of antioxidants have come back negative.

Vitamin A, vitamin C, vitamin E and carotenoids (all antioxidants) have been studied in large trials like the Physician’s Health study and the Women’s Health Initiative and have been found to have no benefit in preventing heart disease or cancer.

A recent Cochrane Review came to the same conclusion. Certain supplements like beta carotene have actually been seen to increase cancer risk in certain subgroups like smokers. Will phenols, the latest class of antioxidants to gain popularity, have better outcomes? We shall see; but so far the track record for antioxidants is not stellar.

Clearly, the conclusions of the newspaper account went beyond what the scientific study had reported. The danger of these types of stories is that, firstly, the public becomes misinformed. Although some flowers are edible and can be part of very appetizing dishes, some can be poisonous when ingested. Lilies, azaleas and poinsettias can cause health problems if eaten, although serious health consequences are fairly rare.

What happened here is that a study with very limited clinical applicability was given undue prominence by a British newspaper that capped it off with an eye-catching title that had little evidence to back it up.

Fortunately, most North American media outlets didn’t pick up the flower story and the National Health Service in Britain did a fairly good job of exposing the flimsy evidence behind the headline.

Although I recognize that most people are not going to start reading obscure medical journals, it is worthwhile to go beyond the headlines and read news reports all the way to the bottom. It is especially important to do so if the headline contains the word “miracle cure” or “breakthrough,” because by the end of the article you will probably realize that it is neither.

So my advice to you is not to go eat the flowers in your garden, not to go buy something simply because it has the name antioxidant on the label, and always read health related articles all the way to the bottom. For those of you who made it to the end of this article: well done.

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Playing chess with pigeons

pigeons and chessBy: Christopher Labos MD CM FRCPC

I get a surprisingly large amount of hate mail when I advocate for such “radical” things like vaccinations, water fluoridation, and suntan lotion (yes even suntan lotion).  Some people just flat out insult me but some try to re-educate me with their version of the “evidence.”

A similar thing happened this week with the release of a document from an organization called Action on Smoking and Health, which has as its main goal to lobby for tighter restrictions on cigarette sales. Their report focused on the growing use of electronic cigarettes in the UK, which has tripled from 700,000 to about 2 million in the past 2 years. It has shown that electronic cigarettes are a very popular product in the UK and that most people are trying them as a means to quit smoking.

I had several problems with these assertions. Firstly, the sheer popularity of a product doesn’t make it a good idea.  There was of course a time when combustible cigarettes were very popular too. So I got on Twitter and pointed out that this report doesn’t actually provide any new evidence on the long term safety or effectiveness of this product from a medical standpoint.

What happened next was quite amazing. A flurry of e-cig supporters descended upon my post and started offering up “evidence” that e-cigs will “millions of lives” and that I was in the pocket of the big tobacco companies and wanted people to keep smoking. I calmly pointed out that the two biggest manufacturers of e-cigarettes, blu and Vuse, are owned by Lorillard and Reynolds, two of the biggest tobacco companies. Consequently the biggest promoter of e-cigarettes is the tobacco industry (note that Jenny McCarthy, the great luminary of our generation, has become the spokesperson of blu). This sparked apoplectic rage on Twitter where many claimed that what I said wasn’t true and that they were “fighting 4 lives now & future.”

I was then presented with a reference that the Royal College has stated “E-cigarettes will save lives, and we should support their use.” I looked up the reference and pointed out that it was actually an editorial written by a single person not a professional endorsement from the medical community. I was told in response, “What ever you wish to call it, the meaning is plain, Huge Health dividends can be had with Ecigs.” At this point I realized that I was wasting my time and that logic can seldom overcome this degree of idolatrous zealotry.

I remembered a quote that I heard a while back. It is attributed to Scott Weitzenhoffer in a review on Amazon of Eugenie Scott’s book “Evolution vs. Creationism: an introduction.” The quote was “Debating creationists on the topic of evolution is rather like trying to play chess with a pigeon — it knocks the pieces over, craps on the board, and flies back to its flock to claim victory.” Numerous versions of the quote now exist and is often applied to Internet trolls and most other groups who can never change their minds despite evidence to the contrary.

The astute reader will realize that I’ve never actually said what I think about e-cigarettes. I am reserving final judgment on the products, but I have some concerns. First, the widespread marketing so clearly aimed at children (why else would you make the product in cotton candy and bubble gum flavour) is unsettling. Second, while everyone is talking about these products as smoking cessation one company states “blu eCigs® electronic cigarettes are not a smoking cessation product … nor are they intended to treat, prevent or cure any disease or condition.”   The companies have to state this in order to be able to market and sell their product without restrictions or governmental oversight. They let Twitter make the health claims for them.

Sadly, it may take over 10 years before we have enough data to see if e-cigarettes actually do make people quit smoking, reduce cancer incidence, or have any health benefits. Until then I will remain cautiously skeptical, as all good scientists should.

Although I suspect my new found friends on Twitter, (who are seldom right but never in doubt, as Joseph Dobrian put it) will not be so circumspect in their assumptions and continue to claim that their product is the greatest thing since sliced bread. So as they fly back to their flock to claim victory and I pick up the dropping covered chess pieces lying on the floor, I have learned a valuable lesson about arguing with people on the Internet: you can’t win against someone who doesn’t understand the rules.

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FOLLOW DR. KO: Medical Mission to Haiti – Paul, the patient who couldn’t breathe

Paul was a thin and frail-looking man in his sixties. He walked into Hôpital Bernard-Mevs accompanied by his teenage nephew on my first shift volunteering in Haiti. He was complaining of worsening shortness of breath for the past couple of days. He suffered from asthma, he told me, and confessed to a history of heavy smoking.

From Paul’s barrel-shaped chest and his long history of tobacco abuse, I thought chronic obstructive pulmonary disease, or COPD, was more likely than asthma. However, definite diagnosis would require a pulmonary function test during which the subject sits in a chamber connected to a spirometer that measures various pulmonary parameters such as lung volume during expiration and inspiration.

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