Sunday Morning – 05.23.21

I’ve finished looking at the newspaper. Afterwards, I started browsing my RSS feed and for some inexplicable reason I read an article on whole bowel irrigation at https://emcrit.org/toxhound/the-purge/.

Memo to My Life Underwriting Colleagues:

Retire before you get to this point in your career. Reading articles like this will not facilitate advancement in your chosen profession. Get out. Get a life.

Ten Commandments of Emergency Medicine Revisited

#2 Remember naloxone, glucose, and thiamine (NGT)
Original: Consider or give naloxone, glucose and thiamine
The number of patients presenting with opioid intoxication is growing, and the gentle reversal of patients without severe respiratory depression with naloxone is in the art of medicine – consider starting with 0.4mg and titrate to effect.

In contrast to empiric administration of glucose in the altered or ill patient, rapid assessment of glucose level with point-of-care testing is recommended.

Thiamine deficiency may be less prevalent than previously thought in intoxicated patients, but we now know that giving 100mg of IV thiamine can benefit other malnourished patients, including those with calorie-malnourishment from cancer, gastric bypass, hyperemesis gravidarum, and eating disorders. Personally, I use the ‘T’ of ‘NGT’ to remind myself not to miss alcohol withdrawal.

Ten Commandments of Emergency Medicine Revisitedhttps://journalfeed.org/article-a-day/2021/ten-commandments-of-em-revisited

Why does this matter? I hear you thinking we underwrite life insurance, we’re not doctors. So true. But if we think like doctors we will get better at what we do by recognizing the subtleties buried within the medical charts we read. Here’s what my eyes/brain picked up.

The bold in the excerpt above are mine to illustrate how the mind of a mortality risk expert works. In Emergency Department records pay attention to the initial treatments provided which in some cases hints to a serious condition impacting mortality. Naloxone and opioids are obvious. But would you have associated the administration of IV thiamine to malnutrition or alcohol withdrawal? I thought so.

So read and research widely. You’ll always find little jewels to improve your skills and to impress your friends with. Or in my case to make Dr. Lee think his old man knows more than he actually does.

Midlife Crisis? Just Another U Shaped Curve

Subsequent research discovered that this age-related U-shape in job satisfaction is part of a much broader phenomenon. A similar midlife nadir is detectable in measures of people’s overall life satisfaction and has been found in more than 50 countries. On average, life satisfaction is high when people are young, then starts to decline in the early 30s, bottoming out between the mid-40s and mid-50s before increasing again to levels as high as during young adulthood. And this U-curve occurs across the entire socio-economic spectrum, hitting senior-level executives as well as blue-collar workers and stay-at-home parents. It affects childless couples as well as single people or parents of four. In short, a mid-career crisis does not discriminate.

Why So Many of Us Experience a Midlife Crisis Harvard Business Review Hannes Schwandt — https://getpocket.com/explore/item/why-so-many-of-us-experience-a-midlife-crisis?utm_source=pocket-newtab

This post originally appeared on Harvard Business Review and was published April 20, 2015. A link popped up on my browser webpage.

U shaped curves are everywhere.

Eat More Pasta – Lose Weight!

In some cases, food companies can obscure their involvement through the use of what are known as “front groups,” third-party organizations disguised by innocuous-seeming names. (Until recently, for example, Coca-Cola funded a front group called the “Global Energy Balance Network” that conducted research on obesity.) Sacks and his team included front groups in their definition of industry involvement.

“It’s sometimes quite difficult to see when you’re looking at who’s funding a study, if [they] are related to the food industry,” he said. “So when we would see a paper funded by some random-sounding group, the challenge was actually digging in, going on their website and seeing who’s funding them. Because the food industry often tries to hide that.”

In the most popular nutrition journals, 1 in 7 articles have food industry involvement — https://thecounter.org/food-industry-involvement-nutrition-journals-studies/

At least 10 peer-reviewed studies about pasta published since 2008 were either funded directly by Barilla or, like the one published this month, were carried out by scientists who have had financial ties to the company, which reported sales of 3.4 billion euros ($4.2 billion) in 2016. For two years, Barilla has publicized some of these studies, plus others favorable to its product, on its website with taglines like “Eat Smart Be Smart…With Pasta” and “More Evidence Pasta Is Good For You.” And the company hired the large public relations firm Edelman to push the latest study’s findings to journalists.

Those Studies About Pasta Being Good For You? Some Are Paid For By Barilla. — https://www.buzzfeednews.com/article/stephaniemlee/pasta-barilla-science-funding#.dmmzapNdG

I just love writing obvious click bait headlines.

Meanwhile in Oklahoma — First-of-Its-Kind Med School Makes History

Ashton Glover Gatewood, 31, a member of the Choctaw Nation and descendent of both the Chickasaw and Cherokee Nations, has long lamented the glaring lack of Native American physicians. So she decided to become one.

Gatewood is a student in the inaugural class of the first tribally affiliated medical school in the United States, the Oklahoma State University (OSU) College of Osteopathic Medicine at the Cherokee Nation. The school opened this fall on Cherokee land in Tahlequah, the capital of the Cherokee Nation’s 14-county reservation in the rolling hills of rural Oklahoma, about an hour east of Tulsa.


First-of-Its-Kind Med School Makes History — https://www.medscape.com/viewarticle/941187?src=rss#vp_1

I’ll have to ask Project #1 on my Project List if he will be teaching any classes at the new medical school.

COVID-19 and Diabetes, Sub-types of DM2, B Vitamins in Diabetes Incidence and more

This article provides an overview of the clinical evidence on the poorer clinical outcomes of COVID-19 infection in patients with diabetes versus patients without diabetes, including in specific patient populations, such as children, pregnant women, and racial and ethnic minorities.

COVID-19 and Diabetes: A Collision and Collusion of Two Diseases — Diabetes 2020 Oct; dbi200032. https://doi.org/10.2337/dbi20-0032

In the article above the researchers reviewed nearly 90 studies.

Novel diabetes subtype characteristics. Overview of distribution and characteristics of subtypes generated by clustering based on clinical parameters in the Swedish ANDIS cohort.

Type 2 diabetes (T2D) is defined by a single metabolite, glucose, but is increasingly recognized as a highly heterogeneous disease, including individuals with varying clinical characteristics, disease progression, drug response, and risk of complications. Identification of subtypes with differing risk profiles and disease etiologies at diagnosis could open up avenues for personalized medicine and allow clinical resources to be focused to the patients who would be most likely to develop diabetic complications, thereby both improving patient health and reducing costs for the health sector. More homogeneous populations also offer increased power in experimental, genetic, and clinical studies. Clinical parameters are easily available and reflect relevant disease pathways, including the effects of both genetic and environmental exposures. We used six clinical parameters (GAD autoantibodies, age at diabetes onset, HbA1c, BMI, and measures of insulin resistance and insulin secretion) to cluster adult-onset diabetes patients into five subtypes. These subtypes have been robustly reproduced in several populations and associated with different risks of complications, comorbidities, genetics, and response to treatment. Importantly, the group with severe insulin-deficient diabetes (SIDD) had increased risk of retinopathy and neuropathy, whereas the severe insulin-resistant diabetes (SIRD) group had the highest risk for diabetic kidney disease (DKD) and fatty liver, emphasizing the importance of insulin resistance for DKD and hepatosteatosis in T2D. In conclusion, we believe that subclassification using these highly relevant parameters could provide a framework for personalized medicine in diabetes.

Subtypes of Type 2 Diabetes Determined From Clinical Parameters — Diabetes 2020 Oct; 69(10): 2086-2093. https://doi.org/10.2337/dbi20-0001

Not just potential for personalized medicine in the treatment of diabetes but perhaps a framework for better risk stratification and selection in life insurance.

Intakes of Folate, Vitamin B6, and Vitamin B12 in Relation to Diabetes Incidence Among American Young Adults: A 30-Year Follow-up Study

RESULTS During 30 years (mean 20.5 ± 8.9) of follow-up, 655 incident cases of diabetes occurred. Intake of folate, but not vitamin B6 or vitamin B12, was inversely associated with diabetes incidence after adjustment for potential confounders. Compared with the lowest quintile of total folate intake, the multivariable-adjusted hazard ratios (95% CI) in quintiles 2–5 were 0.85 (0.67–1.08), 0.78 (0.60–1.02), 0.82 (0.62–1.09), and 0.70 (0.51–0.97; Ptrend = 0.02). Higher folate intake was also associated with lower plasma homocysteine (Ptrend < 0.01) and insulin (Ptrend < 0.01). Among supplement users, folate intake was inversely associated with serum C-reactive protein levels (Ptrend < 0.01).

CONCLUSIONS Intake of folate in young adulthood was inversely associated with diabetes incidence in midlife among Americans. The observed association may be partially explained by mechanisms related to homocysteine level, insulin sensitivity, and systemic inflammation.

Intakes of Folate, Vitamin B6, and Vitamin B12 in Relation to Diabetes Incidence Among American Young Adults: A 30-Year Follow-up Study — Diabetes Care 2020 Oct; 43(10): 2426-2434. https://doi.org/10.2337/dc20-0828

Folate is a B vitamin that occurs naturally in foods such as green leafy vegetables, citrus fruit, and beans. So eat your greens and beans. Taking a supplement can’t hurt either. My multivitamin has plenty of folate.

Quote for Today – 09.19.20

Higher education committed suicide with its dual racketeering model. First was the college loan racket, in which schools colluded with the federal government to jam too many “customers” through the pipeline who didn’t belong there, and who buried themselves under a lifetime debt obligation they could never escape. The second was the intellectual racket of creating sham fields of study that contaminated all the other “humanities” with poisonous bullshit theory, and eventually even invaded the STEM disciplines. Covid-19 screwed the pooch on all that, scotching the four-year party-hearty in-residence part of the deal. For now, who needs an online class in Contemporary Sexual Transgression ($2000-a-credit) when you can just click on Porn-hub for free? Hundreds of colleges and universities will be going out of business in the years ahead.

James Howard Kunstler — https://kunstler.com/clusterfuck-nation/things-going-by/#more-‘

Vitamin D Hypothesis – A Role in COVID-19 Mortality Rates?

Vitamin D Levels Appear to Play Role in COVID-19 Mortality Rates

By analyzing publicly available patient data from around the globe, Backman and his team discovered a strong correlation between vitamin D levels and cytokine storm — a hyperinflammatory condition caused by an overactive immune system — as well as a correlation between vitamin D deficiency and mortality.

The research is available on medRxiv, a preprint server for health sciences.

The role of vitamin D in the prevention of coronavirus disease 2019 infection and mortality

In conclusion, we found significant crude relationships between vitamin D levels and the number COVID-19 cases and especially the mortality caused by this infection. The most vulnerable group of population for COVID-19, the aging population, is also the one that has the most deficit Vitamin D levels.

Vitamin D has already been shown to protect against acute respiratory infections and it was shown to be safe. It should be advisable to perform dedicated studies about vitamin D levels in COVID-19 patients with different degrees of disease severity.

Many years ago I approached my former personal care physician and asked to have my Vitamin D level checked.

“What the hell for?”

“I would like to know my Vitamin D blood level to see if I need to take a supplement.”

“Just get outside in the sun for around 20 minutes a day.”

“Just order the test.”

And he did.  Less than a week later Doc called me back to let me know I had Vitamin D deficiency.  I’ve been taking a daily supplement since.

Vitamin D deficiency is now recognized as a pandemic. The major cause of vitamin D deficiency is the lack of appreciation that sun exposure in moderation is the major source of vitamin D for most humans. Very few foods naturally contain vitamin D, and foods that are fortified with vitamin D are often inadequate to satisfy either a child’s or an adult’s vitamin D requirement. Vitamin D deficiency causes rickets in children and will precipitate and exacerbate osteopenia, osteoporosis, and fractures in adults. Vitamin D deficiency has been associated with increased risk of common cancers, autoimmune diseases, hypertension, and infectious diseases. A circulating level of 25-hydroxyvitamin D of >75 nmol/L, or 30 ng/mL, is required to maximize vitamin D’s beneficial effects for health. In the absence of adequate sun exposure, at least 800–1000 IU vitamin D3/d may be needed to achieve this in children and adults. Vitamin D2 may be equally effective for maintaining circulating concentrations of 25-hydroxyvitamin D when given in physiologic concentrations.

The American Journal of Clinical Nutrition, Volume 87, Issue 4, April 2008, Pages 1080S–1086S, https://doi.org/10.1093/ajcn/87.4.1080S
Published: 01 April 2008

An interesting hypothesis that needs more research.

Update 05.16.20

Journal Reference:

  1. E. Laird, J. Rhodes, R.A. Kenny. Vitamin D and Inflammation: Potential Implications for Severity of Covid-19. Irish Medical Journal, 2020; 113 (5): P81 [link]

Journal Reference:

  1. Petre Cristian Ilie, Simina Stefanescu, Lee Smith. The role of vitamin D in the prevention of coronavirus disease 2019 infection and mortality. Aging Clinical and Experimental Research, 2020; DOI: 10.1007/s40520-020-01570-8