I often say that if my surname was Rubin I wouldn’t be able to resist calling my son Billy. I am sure the joke would be lost on 90% of people & certainly on my poor child who might never forgive me but never on me – I get a giggle every time 🙂 Recently, I’ve been reading a lot of scientific literature on bilirubin, previously regarded as simply the end waste product of haem, it’s now attracting huge interest as a biomarker of oxidative stress. There’s still lots of ongoing debate & contradictory research findings but here’s the general consensus so far…bilirubin is an antioxidant (particularly protective against peroxyl radicals & lipid oxidation although the latter is still being hotly debated). Not surprisingly then, several studies have shown that smokers for example, consistently have lower total bilirubin blood values, indicative of their greater oxidative stress & yes, smoking cessation leads to partial correction of this (O’Malley et al. 2014 Smoking Cessation Is Followed by Increases in Serum Bilirubin, an Endogenous Antioxidant Associated With Lower Risk of Lung Cancer and Cardiovascular Disease) A recent study also found a positive correlation between higher flavonoid rich fruit & vegetable intake and total bilirubin (Laprinzi & Mahoney 2014 Association Between Flavonoid-Rich Fruit and Vegetable Consumption and Total Serum Bilirubin).
On top of this, there is a wave of epidemiological research to currently surf, suggesting inverse relationships between total bilirubin levels and several diseases: hypertension & CVD, T2DM, metabolic syndrome, MS, renal disease, IBD, lung cancer and the list goes on. The sort of cut-off point being talked about is a result < 10 µmol/L being associated with the highest risk. What remains unclear is whether lower bilirubin levels are actually risk-promoting or whether they are just a signal of the individual’s oxidative stress.
Total bilirubin (aka Indirect or Unconjugated bilirubin) values are typically included in most pathology company’s basic general chemistry or E/LFT panels which means most of your patients already have had this test performed in the previous 12 months. So next time you’re looking at patient results check out their bilirubin values and if they have bilirubin levels consistently <10µmol/Lconsider how you might better support your patient manage their oxidative burden to reduce risk of future disease and if you’re hitting the mark the bilirubin level should rise 🙂
Want to know more about Bilirubin and Pathology interpretation in general – Rachel is collaborating with Dr. Michael Hayter to present an online Master Class in Diagnostics starting this week. For more information check out Health Masters Live https://www.healthmasterslive.com/product/clinical-diagnostics-masterclass/?mc_cid=cfd82dd367&mc_eid=014c831228
I briefly mentioned in a previous post Dr. Robyn Cosford’s inspiring opening speech at this year’s MINDD conference. A key point she made was the growing gap between what’s regarded as normal and what is actually healthy.
Having worked in general practice for decades, Robyn provided us with one illustration after another – Type 2 diabetes, previously called adult-onset diabetes, now not infrequently diagnosed in primary school aged children; delayed speech and learning difficulties in male toddlers which many increasingly regard as ‘normal’; precocious puberty in girls; escalating rates of depression and anxiety in children and adolescents…Robyn asked us as practitioners to be vigilant about helping patients to distinguish between what has become perceived as ‘normal’ and what is actually healthy.
In my MINDD presentation this year I talked about the mental health challenges faced by young men and I expressed a similar concern: that when we witness extensive aberrant behaviour in young men we are prone to rationalise it. Are we mistakenly attributing these signs of dis-ease in males as simply being an initiation into Australian culture? When you hear of young men exhibiting binge drinking behaviour, does it set off the same alarms as it would if your patient was female and if not….why not?
As part of a broader discussion of the issues, I presented two cases of young men with mental health problems – both from very different sides of the tracks, one gifted and the other a struggler but one of the features they shared included the way their use of alcohol & other substances had passively been condoned by society instead of being seen as a call for help. We can help these young men but only once we’ve acknowledged there’s a problem. So now I’m extending Robyn’s plea and ask you to be vigilant in making the distinction between ‘normal’ and healthy… when mothers relay stories of their son’s ‘antics’, when brothers, cousins & uncles temporarily ‘go off the rails’, when young men reluctantly present for a quick fix…
If you missed the presentation and are interested in the full recording check out https://rachelarthur.com.au/product/new-young-white-men-mental-health-challengers-face-mindd-conference1hr-total-50/
Many of you would now be aware of the shift from culture (stool MCS) to gene-based stool testing (stool PCR) which has now become available under Medicare subsidy. While this has been an exciting development that promised greater accuracy for the detection of parasites in our patients, there remains limitations. One of the biggest is the fact that the PCR test is based on just one stool sample compared to the 3 day samples used in the culture test.
While this is rationalised, both by the pathology companies and some doctors, by higher test sensitivity and specificity, it flies in the face of our understanding about the irregular shedding of parasites i.e. the presence of the parasite in an infected individual’s stool can vary from nothing to severe, just day to day, therefore diagnosis must be based on several days of stool collection to account for this.
A practitioner I mentor, faced with several patients with negative PCR results but a clinical picture and other pathology results (raised eosinophils, impaired iron levels etc.) that strongly suggested the presence of parasites has been debating this with her shared care providers trying to encourage them to still refer patients for the stool PCR but performed over several samples.
She came across this article as a nice piece of supportive evidence Irregular shedding of Blastocystis hominis (Venilla et al 1999): ncbi.nlm.nih.gov/pubmed/9934969
While there are numerous other studies confirming the irregular shedding of most parasites this is a handy paper perhaps to use to strengthen the case for PCR stool tests performed over 3 days rather than 1. Let’s face it – it’s a big enough ask to get our patients to collect stool – we should really ensure we have optimised their chances of getting an accurate result!
As most of you know, I’m a big fan of establishing good communication with the other practitioners (GPs, psychologists, osteopaths, specialists etc.) also caring for my patients and what began as occasional letters that I found exasperatingly difficult & time consuming to write has become second nature. That’s not to say every letter I write now hits the spot & evokes the desired response but I think I’ve got a pretty good run rate. So I put together some tips that I thought might help you either get started or get SMARRRTer at it!
- S – Service
- M – Medical language & conventions
- A – Accuracy
- R – Reasonable
- R – Rationale
- R – Respectful
- T – Time-conscious
- A summary of the most important medical aspects of the case is a great time saver for other health professionals & assists them in making better informed clinical decisions
- Summarise key points of reference
- e.g. Betty Smith (BMI 36kg/m2, Waist 92cm)
- e.g. Depression (diagnosed 2010, Zoloft 100mg/d)
- Pick out the salient features of the case
- What are the absolute must-knows in the case?
Medical language & conventions
- Only use medically accepted terms & diagnoses
- e.g. avoid naturopathic speak such as dysbiosis, adrenal fatigue etc.
- Quantify EVERYTHING relevant
- e.g. weight loss/gain (7kg in 3mo), DASS scores, stool Bristol type & frequency
- Include all units of measurement
- e.g. 4.6 mmol/L, 129/84 mmHg
- Summarise medical hx in table form for easy reference
- Clarify which details you have first-hand Vs second hand – be careful not to be part of Chinese whispers
- e.g. patient reports being diagnosed with lactose intolerance
- When including patients’ own words – use quotation marks
- e.g. patient reports feeling “dizzy & vague with brain fog most days”
- Clarify if some things have been self-prescribed – otherwise the assumption will be that you gave/recommended it to them
- Don’t use a scatter gun approach when suggesting investigations
- Try not to ask for subsidised testing that the GP is simply unable to do under subsidy
- e.g. Full thyroid function test can’t be subsidised without a prior diagnosis of thyroid disease or TSH outside of reference range…WEIRD BUT TRUE
- Present a brief, clear justification for any requests
- e.g. Iron studies (vegetarian diet)
- Include appropriate references when the justification is likely to be beyond expected knowledge
- e.g. as a deficiency of this vitamin has Vitamin D – both 25 (OH)D & 1,25(OH)2 D, been implicated in a large number of autoimmune conditions assessment of both forms is recommended (Smieth et al. Vitamin D in Autoimmunity. Am J Clin Nutr. 2013)
- Ask for their assistance/insight/review/guidance
- Don’t forget – you want & need it!
- Keep in mind also how the relationship your patient shares with this practitioner may be positively or negatively impacted by the respect & tone of your letter
- How far in advance should the GP receive your letter in order to give him/her adequate time to read & digest the content?
- e.g. too close to consult – GP might understandably feel ambushed/rushed/unprepared
- How much time does a GP or other professional have to spend with each patient?
- In summary the less words the better – look for ways to reduce your word count, cut to the chase and ideally get most letters down to 1 page
In the Byron shire we have a fabulous local comedian called Mandy Nolan who makes a lot of fun of the health and food fads that regularly sweep this area and one of her favourite catch-cries is “I’m gluten intolerant-intolerant, if I meet another person who tells me they’re gluten intolerant I’m going to scream!” Although I take genuine gluten reactions very seriously I do get where she’s coming from and it stems primarily from pervasive misunderstandings & misuse of terms in the community. The problems with this are multiple: firstly those people who are walking around with an exaggerated sense of their problem will unnecessarily limit their diet (and perhaps the diets of their loved ones) at significant financial, nutritional & even psychological cost and then we have people who have the most extreme gluten reactions not receiving the serious attention that they absolutely need in all sorts of settings like restaurants, childcare centres and schools…because seemingly everyone has some sort of ‘gluten issue’ & therefore it has become dangerously ‘normalised’.
So let’s just recap the possibilities and try to clear the confusion. When people walk through our door and tell us they ‘can’t eat bread’ or ‘pasta makes them bloat’ or ‘I don’t think wheat agrees with me’, that’s where our work just begins in terms of needing to clarify what the nature of their reaction is. Putting them immediately on a gluten free diet is a mistake because it doesn’t tell us which one of the below issues is at play and therefore fails to give us clear guidance about what is an appropriate course of treatment & dietary intervention.
- Coeliac disease – while there are a multitude of testing options for CD the first place to start is the genotype. If you don’t have the gene it is extremely unlikely that you have CD. If you have the gene then there’s about a 1/3 chance you might & specific tailored antibody testing or jejunal investigations are necessary.
- A genuine wheat allergy (not CD) is rare but is more common in infants & toddlers. It can be diagnosed by blood antibody tests (IgE RAST) or skin prick testing (SPT) for wheat
- Non-coeliac disease gluten sensitivity – may not involve the immune system at all, however, raised anti-gliadin antibodies are frequently seen in these patients
- FODMAPS – is not an allergy but a type of intolerance due to impaired digestion of the fructans found in wheat. We must rule this out as a possible explanation for someone’s reaction and I would start with a good checklist of other FODMAP foods to check tolerance e.g. soy, dairy, increased fruit intake and check for other conditions that can lead to this via disruption or destruction of the small intestinal brush border
- Carbohydrate digestion issues other than (or in addition to) FODMAPs i.e. underfunctioning of the pancreas
- Red herring! And don’t forget this old pearl… it could of course be a total red herring. Perhaps the reaction is due to another component in bread (yeasts, preservatives etc.), or the other foods they always eat with the pasta (tomato etc.) or their general poor diet quality and speed of eating, lack of relaxation around meals etc. etc.
My one exception would be in children diagnosed on the spectrum for autism. I think going gluten free where possible is appropriate from the get-go in ASD. For everyone else, a correct diagnosis is the essential first step to effective & proportionate treatment so keep your wits about you my fabulous fellow diet detectives!
We’ve all heard about the higher incidence of mood disorders (depression, anxiety etc.) in women and chances are we’ve all seen this reflected in the dominance of female clients who present seeking help but what’s this really telling us? Many of us are aware that men are more likely to ‘self-medicate’ with alcohol and other substances, as a maladaptive way of dealing with the psychological stressors, however, the lesser talked about fact is that substance induced (i.e. cannabis etc.) psychotic disorders are significantly more prevalent in men and occur at younger ages than women (Bogren et al 2010) and substance use & abuse is commonly not sufficiently explored or adequately diagnosed in general practice amongst male patients. Oh dear…what else do we need to know?
The results of a large English survey on mental health and help-seeking behaviour published in 2005 found that men were less likely than women to say that they would seek help (OR=0.78, 95% CI 0.72–0.88,P<0.001). The preferred reported source of help was friends or relatives with 63.1% saying they would seek help from this source. In addition to this and somewhat, more alarmingly, the WHO reports that “doctors are more likely to diagnose depression in women compared with men, even when they have similar scores on standardised measures of depression or present with identical symptoms.” https://www.who.int/mental_health/prevention/genderwomen/en/ So even when males do finally present for help, often, the mental health problem is being overlooked or missed.
One theme that keeps coming up in research is the ongoing associated stigma for men with mental health issues. A study published in 2008, conducted by two National Institute of Mental Health postdoctoral fellows in mental health care policy at Harvard Medical School, investigated the effect of gender, race and socioeconomic status on psychosocial barriers to mental health care and found that white males were most likely to mistrust the mental health care system and were also likely to perceive mental illness as a stigma and therefore avoid formal mental health care https://www.sciencedaily.com/releases/2008/09/080908125123.htm
In my practice we actually have a high proportion of males presenting with mental health concerns, admittedly, our practice specialises in this area so that may be a key reason for this and in many instances the appointment has been instigated or driven by a concerned mother, a wife etc. Regardless, I’ve found that many men really struggle & it’s made somewhat more complicated by the role they are expected to play in society. I think the key message is not to reinforce gender based stereotypes on our patients, have the confidence to explore mental health with male patients, their vulnerabilities, concerns etc. as much as you would your female patients. Make sure you thoroughly assess their substance use and take heart there is a lot we can do for these individuals, the first step is recognising there’s a problem.
Rachel will be speaking on Young White Men & the Mental Health Challenges They Face at the MINDD International Forum in Sydney June 14-15th. For more information and bookings check out: https://mindd.org/forum/mind2014.html
Be warned…whinge ahead! One of the things I’m asked most often by naturopaths is about my experiences & interactions with doctors regarding shared care of patients. The question typically arises because they’ve been on the receiving end of less than ideal situations. We’ve probably all been there at some point. My usual optimism tells me that if we keep building the bridge by ensuring our communication is professional, accurate, respectful and always in the patients best interests, eventually we’ll bring the detractors around and those who make it clear they’ll never come around reveal themselves to be ill-equipped for shared care. Over this last week I’ve had a nasty reminder of the latter!
Here’s the scenario: I recently started seeing a female patient in her late 50s who has had unresolving diarrhoea for 3 months. Multiple trips to the GP and investigations revealed no explanation, however, the diarrhoea was severe, unprecedented and deeply concerning to my patient. After much discussion I organised a CDSA for her, the results of which confirmed extensive infection with Dientamoeba fragilis. This parasite is a well-known established cause of diarrhoea and its eradication is associated with resolution of these issues. There were also high levels of two gram negative bacteria which can be commensals (non-pathogenic, not infrequently found in human GIT), however, their population should be kept in check: Klebsiella pneumonia & Citrobacter freundii. As both of these bacteria are notorious for developing antibiotic resistance I did what I thought was best and communicated the findings of these results (plus copies) as well as a review paper from a mainstream scientific journal on Dientamoeba fragilis to her doctor in case we needed to pursue medical treatment of the parasite. Now this is where the drama begins. Did I mention this patient also suffers from anxiety? Upon receiving my communication, her doctor wildly informs her that Klebsiella pneumonia is lethal! Potentially true if found in your respiratory system, however, absolutely not in the GIT. He says has no idea about what I’m talking about (true!), with the suggestion that I don’t either & refuses to treat her. Understandably, I receive frantic calls from a very upset patient concerned about the lethal bit! What do you say? Here’s what I said: Unfortunately this GP has simply demonstrated his ignorance about GIT microflora. K. pneumonia is nasty in other parts of your body but quite common in the gut. I can send you some information about this to reassure you. In the meantime let’s get you in to see someone who actually knows something about GIT pathogens.
A week later after the same patient sees the GP I referred her to (who received the same referral letter and information) I receive an email from him saying essentially: Thanks for sending this patient and the information. According to the Centre for Digestive Diseases I think we can treat the parasite if necessary without risking resistance with the gram negative bacteria, however, right now she seems to be doing really well on the herbal anti-microbials you’ve prescribed so let’s delay any medical intervention unless really necessary. I’ll see her again in 3 weeks and keep you posted.
Let’s just recap…this is a regular GP with the same training as her original one the difference is he has an open mind and takes the time to keep abreast of new information in order to offer his patients the best care. In the space of one week and two GPs I’ve gone from ‘mad fish-slapping dangerous naturopath’ to a welcome & respected contributor in patient care. A good reminder that if you’ve done your best in terms of establishing good communication with doctors and other carers and they seem unable to respond in a way that has the patients best interests at heart…find another doctor! Ok – I’m done now 🙂
Seeing female patients with anxiety/depression, irregular menstrual cycles and perhaps marked PMS? How about male clients with decreased libido, low measurable testosterone and perhaps even impotence or infertility? All of these signs and symptoms could actually be the result of elevated prolactin.
Our patients are faced by more health & nutrition messages via multiple mediums than ever before yet escalating rates of obesity & lifestyle related disease highlight the failure of these. It would seem behavioural psychologists are right when they assert that information does not change behaviour in the majority of people. Therefore if we too simply add to our patients’ information overload, we’ve missed the point. One of my favourite & at the same time terrible illustrations of this was when I walked into a local café and saw a man sitting at a table by himself having just finished a cup of coffee and something sweet. On the table next to his coffee was a very recognisable ‘prescription’ from a naturopath he’d obviously just been to see.
- Reduce coffee
- Reduce sugar
- Reduce fat
- Increase exercise
Oh the power of such words!! If we spit out advice/instructions/directives at our patients, even with all the best intentions, we seem to make very little progress or only create short-term change. In contrast, if we take the time to focus in on each change we wish the patient to make, individualise the approach and solutions then we may have only given them a small fraction of the ‘advice’ we ultimately want to but at least this time it’s actually met it’s mark and created life-long healthy habits.
An understanding of the components behind successful behavioural change (readiness, empowerment, barrier identification & resolution etc.) is essential to improving patients’ health & wellbeing. If you want to hear more about how to successfully promote behavioural change in your patients follow this link https://rachelarthur.com.au/product-category/premium-audio/ to a premium audio download I recorded on this topic last February. I really believe it can make the difference between success and failure with individual patient’s treatment & the success of your practice overall. Enjoy and remember more information isn’t the answer!
Often I find practitioners are a bit mystified by the male hormonal milieu and their skills at interpreting androgen results are patchy compared with their confidence in female hormone investigation. Yet, just like in females, understanding the sex hormones is a critical part of the whole health puzzle in our male patients – leading us to a better understanding of possibly the cause of their presentation (impaired motivation and mood, subfertility or infertility & osteoporosis etc.) or perhaps the consequence of unhealthy behaviours & other health risks (e.g. obesity, excess alcohol, chronic inflammation etc.). The natural decline in androgen levels with ageing (so called andropause or PADAM) gets talked about a lot but when does it start (typically in the 4th decade), why does it happen (primarily due to reduced number, function & responsivity of testicular secretory cells) & how low does it go? Is it possible for men to age and not become hypogonadal in the process? Well the answer to the last question is emphatically, ‘Yes!’ according to Australian research. Often, however, I’m finding younger males with very low testosterone levels which require thorough investigation to determine any direct cause. When none emerge, we are left with the ‘canary in the mine’ scenario, whereby testosterone production, not considered essential for survival, will be sacrificed when the organism is ‘under threat’. To hear more about how to comprehensively assess & interpret androgens, the real causes and consequences of low testosterone and some treatment suggestions check out the following premium audio https://rachelarthur.com.au/product-category/premium-audio/
Mid-40 female presents with acute onset pain in both feet and hands. Questioning reveals that she has experienced episodic numbness in her feet over the past 2 years. Patient suspects gout but blood urate levels are normal and patient’s diet and lifestyle not ‘typical’ of the gout sufferer (high alcohol and meat intake, central adiposity etc.)
A current patient is a 20+ year old male who is trying to recover from a heroin addiction.
Having been on the methadone program for the last 7 months and only having ‘used’ once or twice during this time, he is doing well. He has managed to get down to just 25mg/d of methadone which is typically the final dose before stopping altogether.
Recently I started seeing an 8 year old girl diagnosed with ODD and ADHD as well as impaired IQ at 6yo.
Notable features include:
- She has variable bowel and bladder control – often coming home from school with wet pants and a Bristol type 1 stool in her underwear. She increasingly complains of abdominal pain and an itchy bottom in spite of being ‘wormed’. (more…)