Daily Archives: November 3, 2010

Larimore Family Newsletter – November 2010

Here are the contents of our Family Newsletter:

  • Holiday Gifts
  • Family Update
  • Publication Update
  • New Writing Schedule for Hazel Creek
  • Continuing to Write Guy Talk
  • Nice Review of Bryson City Tales
  • Events of the last month
  • Upcoming Events

Holiday Gifts

It’s not to early to begin thinking about unique holiday gifts, and what could be more exclusive than receiving a best-selling book, autographed by the author, and personalized to the recipient. Most of my books are available for just such gifts. You can order them here. Better yet, some of them are on sale between now and Thanksgiving. Supplies are limited, so be sure to order yours now.

Family Update

We’ve had the most wonderful autumn in Colorado. It’s been unseasonably warm and, as a result, the color season in the trees has lasted longer than usual.

Last year, by this time, we had had two major snows. This year, not even a dusting, at least at our home. Of course, the mountains have had snow and a couple of the ski areas at higher elevations are already open.

We’ll miss the lazy days of summer, but as we head into a busy writing and speaking season, and begin, even now, holiday preparations, we hope all is well with you and yours.

Publishing Update

New Writing Schedule for Hazel Creek

Not too long ago, after I had just finished the final copy edits for my first solo novel, tentatively titled Hazel Creek, I was procrastinating about beginning the process of outlining and writing the second novel in the series.

Yet, for some reason, I had felt a check in my spirit for some weeks and never got started on the project. I wondered if I was lazy or whether it was that “still, quiet voice” of the Spirit. Now, I’ve learned why I was sensing the leading to wait:

My agent received an email from the editor at Howard saying:

Given the manuscript’s size—123,000 words—marketing had concerns that it’s too big for the price point.

Granted, we okayed the extra words—we were originally expecting about 90,000—and we can certainly go with the size it is.

But marketing pitched an idea that I think has merit. Jonathan (the publisher) and Becky (the head of the fiction division) are enthused about it as well. I’d like to get your thoughts before the idea germinates any further.

It was suggested that perhaps Walt could split this one book into two.

As I see it, the benefits to Walt would be:

  • Each story would be in a more digestible size.
  • Splitting one book is less work—presumably—than writing another whole one.
  • Walt is new to fiction; we could release his second book in a timely manner after the first, and keep him fresh in readers’ minds.
  • His contract would be fulfilled sooner, freeing him to tackle other projects. (I’m guessing he has some; he seems to have a fount of writing ideas!)

I’m excited and enthused about the idea, so I’ve gone to work implementing the suggestion. Since each book will end up being 70,000 – 80,000 words, I’ll be able to add some details I had left out of the first book. I still face additional edits, but overall this whole process should be much easier.

By the way, if you know anyone (or know anyone who knows anyone) who is a major fiction author that might be willing to look at the manuscript to consider an endorsement for me, please let me know.

Continuing to Write Guy Talk

I’m continuing my work on my newest book for young teen boys. It’s tentatively titled Guy Talk: A physician answers your not-so-stupid questions about your body. It’s a book for Christian boys and will deal with the very real questions boys have about puberty and all the changes that come with it.

I’m very fortunate to have the help of a group of pastors, theologians, physicians, parents, coaches, teachers, psychologists, and counselors who are reviewing the manuscript, as I write, to be sure it’s “medically reliable and Biblically sound.”

Also, I’m blessed that the Christian Medical and Dental Association will review the manuscript to consider endorsing it to their 17,000 members.

I don’t turn the manuscript in until early 2011, so I’m not expecting it to release until late 2011 or early 2012.

Nice Review of Bryson City Tales

Bryson City Tales, the first book of my Bryson City trilogy, has been on the shelves nearly 10 years, but it continues to garner positive reviews and sales – for which I’m very grateful. Here’s a very nice recent review:

A YOUNG MD’S FIRST YEAR – October 2010

Bryson City Tales by Walt Larimore, M.D. is a delightful true story of a young doctor’s first year of family practice.

The small town of Bryson City lies in the foothills of the Great Smoky Mountains. The people there are in need of young doctors to reinforce the present medical personnel, most of whom are nearing retirement.

Fresh out of Duke University Medical School, Larimore is trained in all the latest technology, but he finds that he has a lot to learn about the local people and their way of life.

He is also the coroner and the emergency physician on his shift. His patients, some of them animal, become his teachers in many ways.

As Dr. Larimore and his family settle into their new hometown, he shares his hopes, and dreams with the homespun warmth that is reminiscent of James Herriot’s stories. He reveals the character, motives, and sometimes the disappointments, of a first-year family doctor.

This is a warm, good-feeling read. I loved it.

Of course, my medical school days were spent at LSU School of Medicine in New Orleans (I call it “Harvard on the Bayou”) and my family medicine residency and sports medicine training was at the Duke University Medical Center and Durham County General Hospital. But, nevertheless, as a young reader, I adored James Herriot’s books, and to be compared with him is a compliment I deeply cherish.

Events of the last month

  • Oct 5 – 8, Barb and I were in San Antonio where we enjoyed a delightful visit with our dear friends, Dr. Fred and Marian Brown, and enjoyed the River Walk. On Tuesday evening, I spoke at the annual CMDA Banquet on the topic of “A Person is A Person, No Matter How Small: My journey into becoming a pro-life physician.”
  • Then, on Wednesday evening, I spoke at the Christus Santa Rosa Medical Center on the topic of “The Spiritual History in Clinical Medicine.”
  • Oct 15 – 16, I flew solo to Lincoln, Nebraska, and presented three talks on “His Brain, Her Brain: How Understanding the Differences Can Impact Personal & Professional Relationships” at the Critical Issues in Medicine Seminar at the BryanLGH Medical Center East Medical Center.
  • Oct 23, Barb and I attended the annual Life Network Banquet and Silent Auction in Colorado Springs. It was a wonderful and very uplifting event and evening.
  • Oct 27 – Nov 2, I served as a Visiting Professor at In His Image Family Medicine Residency in Tulsa, OK.
  • Oct 27 – Nov 2, Barb and Kate were in Baton Rouge to celebrate Kate’s birthday and to visit with Barb’s family.

Upcoming Events

  • Nov 11-12, I’ll be in Louisville, KY, speaking twice at the Global Medical Missions Conference at Southeast Christian Church. This is the largest Christian medical missions conference in the world. It’s held every year and usually has between 2500 and 3000 young Christians who are praying about and considering becoming international missionaries.
  • Nov 12-13, I’ll scurry back to Colorado Springs and out to the Rocky Mountains where Barb and I will attend a Life Network Board retreat.
  • Nov 17, we’ll celebrate our 37th wedding anniversary.
  • Nov 25-28, we’ll enjoy a quiet Thanksgiving weekend together.
  • Dec 2-5, Barb and I will travel to Asheville, NC, where I’ll address the North Carolina Academy of Family Physicians. Of course, we’re looking forward to visiting with old friends, especially Rick Pyertiz, MD, with whom I practiced in Bryson City, NC, from 1981-1985.
  • Dec 9-14, Barb and I will be in Baton Rouge at a family reunion with Barb’s side of the family.

Past Issues

You can get more information on many of my upcoming events here. www.DrWalt.com/schedule

Government warns parents not to use baby sleep positioners

The government is warning parents and caregivers to stop using infant sleep positioners — those soft fabric products that anxious parents put in the crib to keep babies safely sleeping on their backs. Here are the details from the AP:

The Consumer Product Safety Commission and the Food and Drug Administration said Wednesday they know of 12 infants in the last 13 years who died when they suffocated in a positioner or became trapped and suffocated between the positioner and the side of a crib.

The infants were between the ages of one month and four months.

Most of the babies suffocated after rolling from a side to stomach position.

CPSC has also received dozens of reports of infants who were placed on their backs or sides in sleep positioners and later found in potentially dangerous position in or next to the sleep positioners.

Autism and Childhood Vaccinations: The Myth is Finally Debunked

In a number of previous blogs, I’ve discussed vaccine myths, in an attempt to bring you information about vaccines that is reliable, trustworthy, and medically accurate. I recently found this review of the myth that vaccines cause autism and wanted to share it with you. It’s a discussion between Robert Dachs, MD, FAAFP (Ellis Hospital Family Medicine Residency Program, Schenectady, New York), Andrea Darby-Stewart, MD (Scottsdale Healthcare, Scottsdale, Arizona), and Mark Graber, MD, FACEP (University of Iowa Carver College of Medicine, Iowa City, Iowa) and was published in the American Family Physician (2010 Sep 15;82(6):586-592).

Are childhood vaccinations associated with subsequent development of autism?

Bob: In 1998, a British gastroenterologist, Dr. Andrew Wakefield, published a report in the Lancet on eight children who developed symptoms of autism within one month of receiving the measles, mumps, and rubella (MMR) vaccine.1 Since then, the media, advocacy groups, and celebrities have promulgated the link between childhood vaccinations (particularly the MMR vaccine) and the development of autism. But, is it true?

This month’s article clearly outlines the epidemiologic and biologic studies that should reassure physicians and parents that there is no connection between childhood vaccinations and autism.2 For the family physician, the data in this article are impressive and can be used to counter most parental concerns.

What does this article say?

Bob: This article reviews the three most commonly proposed hypotheses for vaccine-induced development of autism:

  1. the MMR vaccine damages the intestinal lining, allowing the entrance of encephalopathic proteins;
  2. thimerosal induces central nervous system toxicity; and
  3. multiple vaccinations overwhelm and weaken the immune system.

This article looks at the genesis of each theory and the data that debunk them.2

In regard to the MMR vaccine, Dr. Wakefield noted lymphoid nodular hyperplasia on endoscopy in eight children with gastrointestinal symptoms and signs of autism within one month of receiving the MMR vaccine. He then postulated that this intestinal inflammation allowed nonpermeable peptides into the bloodstream, subsequently affecting brain development.1

There are many holes in this argument.

  • First, this was a self-referred cohort without a control group.
  • Second, in Great Britain, approximately 50,000 children one to two years of age receive the MMR vaccine each month; this is a time when autism typically presents, making this likely a coincidental association.
  • Third, the MMR vaccine has not been found to cause chronic intestinal inflammation.
  • Fourth, no toxic encephalopathic proteins traveling from the intestine to the brain have ever been identified. Instead, genes that code for endogenous proteins, which influence neuronal synapse function, have been identified in children with autism.3

Mark: The most glaring flaw in the argument connecting an MMR-induced intestinal hyperplasia and subsequent autism development is assigning cause and effect to a potential association. Association should not be confused with causation.

Without a control group in the original study by Dr. Wakefield, it is imprudent to even suggest that there is an association between the MMR vaccine and intestinal lymphoid hyperplasia. Large-scale studies are often needed to demonstrate whether an association is statistically present.

Bob: The authors of this month’s article reviewed 13 such large-scale studies that demonstrate no association between the MMR vaccine and autism.2 These are separated into three types of studies:

Ecologic (studies comparing vaccination rates with autism diagnosis). In California and the United Kingdom, the diagnosis of autism increased through the 1980s and 1990s, yet MMR vaccination rates remained stable during this time.4,5 In Quebec, Canada, autism rates increased despite a decrease in MMR vaccination.6

Retrospective observational (studies comparing vaccination status with autism diagnosis using national registries). The best study was one conducted in Denmark in which 440,655 children born between 1991 and 1998 who received the MMR vaccine were compared with 97,648 children born during the same years who were not given the MMR vaccine. There were no differences in autism rates between the two groups.7

Prospective observational (a long-term vaccination project allows researchers to prospectively record adverse events associated with the MMR vaccine). In Finland, 1.8 million children were prospectively followed after MMR vaccination, and no cases of vaccine-induced autism were recorded.8

Andrea: To further refine the concept of association and causation, there are times when an association does represent a cause and effect. A good example is smoking and lung cancer rates. Clearly, smoking is associated with increased lung cancer rates, and a randomized, placebo-controlled trial is not needed to prove this. The association between smoking and lung cancer meets all of the following criteria: strength and consistency of the scientific data; existence of a temporal relationship (between smoking history and lung cancer); existence of a biologic gradient (increased exposure results in increased risk); a scientifically plausible association; and experimental interventions that work (smoking cessation decreases cancer rates).9 However, in the case of MMR vaccine–induced autism, none of these criteria are present. The data, in fact, overwhelmingly support no association.

Bob: Let’s briefly look at the second hypothesis of thimerosal-induced neurotoxicity. Thimerosal is an antibacterial agent that has been used in multidose vaccine preparations for more than 50 years. It is 50 percent ethyl mercury by weight. However, mercury poisoning has a distinctly different presentation than autism. The CDC has also demonstrated that the mercury in vaccines has not resulted in any subtle signs or symptoms of mercury poisoning.10 The authors of this month’s article review seven large-scale studies—again, ecologic, retrospective, and prospective studies—all demonstrating no association between thimerosal and autism.2

Mark: And, by the way, live vaccines like MMR do not contain thimerosal.

Bob: The third and final theory suggests that the simultaneous administration of multiple vaccines overloads the immune system, triggering autism in a susceptible host. However, because of advances in protein chemistry and DNA technology, the immunologic load has decreased from more than 3,000 immunologic components in the seven available vaccines in 1980 to less than 200 in the 14 recommended vaccines today.2

Andrea: Two more points: (1) an infant’s immune system is capable of handling the thousands of antigens it is exposed to early in life; and (2) autism is not an autoimmune disease. Therefore, this theory has no credibility.

Should we believe this study?

Bob: This month’s article clearly provides the science and statistics to dispel the theory that childhood vaccinations induce autism.2 A Cochrane review came to the same conclusion in October 2005.11

Andrea: Large-scale studies, smaller studies, retrospective studies, prospective studies, and case-control studies (you name it) all come to the same conclusion: there is no connection between vaccines and autism. The only outlier is Dr. Wakefield’s study, which suggests this possible link.1

Mark: Lo and behold, 10 of the 13 authors of Dr. Wakefield’s Lancet article have since publicly retracted the interpretation they reported.12 The editor of the Lancet has acknowledged that, had they appreciated the full context of Dr. Wakefield’s study, “… publication would not have taken place the way that it did.”13 On further review, the Lancet also recently published an official retraction of Dr. Wakefield’s study (http://press.thelancet.com/wakefieldretraction.pdf).

What should the family physician do?

Bob: Get this month’s article. It’s an easy read. Keep it handy for when parents are apprehensive about immunizing their child.

Andrea: A national survey conducted in 2003 to 2004 indicated that more than one fourth of all U.S. parents were either unsure of vaccine safety or refused or delayed vaccination of their children because of safety concerns. However, the most important take-home point from that survey was that the parents who changed their minds and immunized their children did so because of information and assurance provided by their health care professional.14 Indeed, we do make a difference!

Mark: Understand the consequences if we just give in to fear and myths. In 2008, only three fourths of preschool children in the United Kingdom received two doses of the MMR vaccine. The result: measles infection rates have reached more than 1,000 cases per year, the highest since monitoring began in 1995.15

Main Points

There are no epidemiologic or biologic studies that support a connection between childhood vaccinations and autism.

EBM Points

An association does not confer causation.

Multiple criteria should be examined when considering if an association implies causation, including strength, consistency, specificity, temporality, dose-response relationship, plausibility, coherence, experimental evidence, and analogy.9

REFERENCES:

  1. Wakefield  AJ, Murch  SH, Anthony  A, et al.  Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children [retraction published in Lancet. 2010;375(9713):445].  Lancet.  1998;35(9103):637–641.
  2. Gerber  JS, Offit  PA.  Vaccines and autism: a tale of shifting hypotheses.  Clin Infect Dis.  2009;48(4):456–461.
  3. Sutcliffe  JS.  Genetics: insights into the pathogenesis of autism.  Science.  2008;321(5886):208–209.
  4. Dales  L, Hammer  SJ, Smith  NJ.  Time trends in autism and in MMR immunization coverage in California.  JAMA.  2001;285(9):1183–1185.
  5. Kaye  JA, del Mar Melero-Montes  M, Jick  H.  Mumps, measles, and rubella vaccine and the incidence of autism recorded by general practitioners: a time trend analysis.  BMJ.  2001;322(7284):460–463.
  6. Fombonne  E, Zakarian  R, Bennett  A, Meng  L, McLean-Heywood  D.  Pervasive developmental disorders in Montreal, Quebec, Canada: prevalence and links with immunizations.  Pediatrics.  2006;118(1):e139–e150.
  7. Madsen  KM, Hviid  A, Vestergaard  M, et al.  A population-based study of measles, mumps, and rubella vaccination and autism.  N Engl J Med.  2002;347(19):1477–1482.
  8. Peltola  H, Patja  A, Leinikki  P, Valle  M, Davidkin  I, Paunio  M.  No evidence for measles, mumps, and rubella vaccine–associated inflammatory bowel disease or autism in a 14-year prospective study.  Lancet.  1998;351(9112):1327–1328.
  9. Simon S. Children’s Mercy Hospitals and Clinics. Causation. http://www.childrens-mercy.org/stats/ask/causation.asp. Accessed January 8, 2010.
  10. Thompson  WW, Price  C, Goodson  B, et al.; Vaccine Safety Datalink Team.  Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years.  N Engl J Med.  2007;357(13):1281–1292.
  11. Demicheli  V, Jefferson  T, Rivetti  A, Price  D.  Vaccines for measles, mumps and rubella in children.  Cochrane Database Syst Rev.  2005;(4):CD004407.
  12. Murch  SH, Anthony  A, Cassen  DH, et al.  Retraction of an interpretation.  Lancet.  2004;363(9411):750.
  13. Horton  R.  The lessons of MMR.  Lancet.  2004;363(9411):747–749.
  14. Gust  DA, Darling  N, Kennedy  A, Schwartz  B.  Parents with doubts about vaccines and reasons why.  Pediatrics.  2008;122(4):718–725.
  15. Health Protection Agency. Measles figures soar. http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1227774034336?p=1204186170287. Accessed December 6, 2009.

For more information on EBM terms, see the EBM Toolkit here.

ConsumerLab.com Finds Quality Problems with Nearly 30% of Fish Oil Supplements Reviewed; “Fishy” Claims Identified

Fish, krill, and algal oil supplements now account for approximately $1 billion in sales in the U.S. To help consumers choose among products, ConsumerLab.com selected 24 of the best-selling oil supplements and tested them for EPA and DHA, contamination, freshness, and, if applicable, proper release by enteric coatings. Amazingly, nearly 30% of the fish oil supplements that they selected for testing failed to meet minimum quality standards.

As discussed in the news release below, ConsumerLab found PCBs in all fish oil supplements (including krill and algal oil supplements) but typically at extremely low levels (addressing questions raised by the California lawsuit in March that I discussed here).

ConsumerLab also we found that price is not an indicator of quality with fish oil and that a person need not pay more than about 6 cents a day to get a good product (as I discuss in another blog, here); they also point out that the term “pharmaceutical grade” on products is meaningless; and they note out that actual amount of omega-3’s will range from less than 20% to over 80% of the “fish oil” shown on the front label, so you need to read the Supplement Facts carefully.

Here are more details from the ConsumerLab press release:

Softgels and Liquids for Adults, Children and Pets Tested, Including Krill Oil and Algal Oil Supplements

White Plains, New York – Tests of fish, algal and krill oil supplements revealed quality problems with 7 out of 24 products selected by independent testing organization ConsumerLab.com.

Three products contained less of the omega-3 fatty acids EPA and/or DHA than claimed, spoilage was detected in one of these products as well as in two others (including a children’s supplement), an enteric-coated product released its ingredients too early, and a supplement for pets exceeded the contamination limit for PCBs.

Seventeen other products passed testing as did 15 products similarly tested through ConsumerLab.com’s voluntary certification program. ConsumerLab.com’s report is now available online to its members.

ConsumerLab.com reported these additional, notable findings:

  • Labels on some products included terms such as “pharmaceutical grade” and “tested in FDA approved laboratories,” which are meaningless as there is no  basis for either claim.
  • A krill oil supplement that failed for both spoilage and low omega-3 levels claimed to be quality assured under GMPs (good manufacturing practices).
  • Another “krill oil” supplement contained more fish oil than krill oil.
  • Most products met ConsumerLab.com’s strict contamination limit for dioxin-like PCBs of 3 picograms per gram (3 parts per trillion). However, one product (a pet supplement) slightly exceeded this limit with 3.14 picograms per gram. However, this exposure is still very small compared to that from fish meat — a small serving (3 ounces) of fatty fish such as salmon may easily provide 170 picograms of dl-PCBs as well as a significant amount of mercury. Trace amounts of dl-PCBs were found in all supplements, despite claims on some of being free of contaminants. There was no detectable mercury in any of the supplements.
  • The cost to obtain 100 mg of EPA and/or DHA from fish oil ranged from about 1 cent to 15 cents among fish oil supplements, and was about 30 cents from krill or algae oils. A fairly standard daily dose of 500 mg of EPA + DHA from a quality-approved product could be had for as little as 6 cents.  Higher prices were not associated with higher quality.
  • Concentrations of EPA and DHA ranged from less than 20% to over 80% of the marine oil content listed on front labels — which is why consumers should specifically look for the amounts of EPA and DHA which typically appear on side labels.

“Supplements providing EPA and/or DHA are a great alternative to fish as a source of beneficial omega-3 fatty acids, as they typically have far fewer contaminants, cost less, and are more convenient to obtain. But products vary in quality, strength, odor-reduction, and price, so you need to choose carefully,” said Tod Cooperman, M.D., ConsumerLab.com’s president.

Consumption of EPA and DHA appears to reduce the risk of coronary heart disease and may be helpful in the treatment of rheumatoid arthritis, other inflammatory diseases, and psychiatric illness. EPA and DHA may also reduce the risk of certain cancers and macular degeneration. Fish oil supplements are given to pets to help maintain their coats and skin.

U.S. sales of fish oil supplements in 2009 were $976 million, up 20% from the prior year, according to Nutrition Business Journal. A recent survey by ConsumerLab.com showed that fish oil had become the most commonly used supplement among people who regularly use supplements, exceeding, for the first time, the use of multivitamins. Seventy four percent of respondents reported using a fish oil supplement.

The new report includes test results, quality ratings, comparisons and reviews of products from the following brands: Advocare, CardioStat (Amerifit), Carlson, CVS, Dr. Sears, Finest Natural (Walgreen), Garden of Life, Kirkland (Costco), Life Extension, Liquid Solutions, Master Omega, Natrol, Natural Factors, Nature Made, New Chapter, Nordic Naturals, NOW, NSI (Vitacost), Olympian Labs, OmegaBrite, Origin (Target), PregnancyPlus, Puritan’s Pride, Quest Longevity (Canadian), Res-Q, Solgar, Source Naturals, Spring Valley (Walmart), Swanson, Trader Joe’s, The Simpsons, Vital Nutrients, VitalOils (VitalRemedyMD), Vitamin Shoppe, Vitamin World, Weil, Wellements, and 1-800-PetMeds. The report also includes information about dosing, side-effects, cautions, reduced-odor products, and proper storage of fish oil.

In addition to the products reviewed, two krill oil ingredients by Enzymotec USA have been tested and approved for quality through ConsumerLab.com’s Raw Materials Testing Program.

ConsumerLab.com is a leading provider of consumer information and independent evaluations of products that affect health and nutrition. The company is privately held and based in Westchester, New York. It has no ownership from, or interest in, companies that manufacture, distribute, or sell consumer products.