Taking Too Much Vitamins May Even Cause Cancer

Image by David Richfield from Wikipedia

Too much of anything can be harmful... even vitamins which people seem to consider benign regardless of how much is taken. In fact, taking regular large doses of vitamins  (greater than 150% of what is recommended per day) actually INCREASES the risk of cancer.

To be clear, vitamins and supplements are great, but only when taking the recommended daily amount in a normal, healthy individual. Supplements may be necessary only if there's a deficiency, but not when you are a healthy individual.

The New York Times wrote a nice expose regarding this issue along with why the FDA doesn't say anything about it (vitamin lobbyists passed a law in 1976 prohibiting the FDA from saying anything).

So, let's take a look at the studies mentioned in the NYT documenting the adverse affects of too much vitamins:

The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. N Engl J Med. 1994 Apr 14;330(15):1029-35.

"Unexpectedly, we observed a higher incidence of lung cancer among the men who received beta carotene than among those who did not (change in incidence, 18 percent; 95 percent confidence interval, 3 to 36 percent)... more deaths from hemorrhagic stroke were observed among the men who received this supplement than among those who did not. Total mortality was 8 percent higher (95 percent confidence interval, 1 to 16 percent) among the participants who received beta carotene than among those who did not, primarily because there were more deaths from lung cancer and ischemic heart disease."

Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. N Engl J Med. 1996 May 2;334(18):1150-5.

"After an average of four years of supplementation, the combination of beta carotene and vitamin A had no benefit and may have had an adverse effect on the incidence of lung cancer and on the risk of death from lung cancer, cardiovascular disease."

Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med. 2005 Jan 4;142(1):37-46. Epub 2004 Nov 10.

A dose-response analysis showed a statistically significant relationship between vitamin E dosage and all-cause mortality, with increased risk of dosages greater than 150 IU/d.

Antioxidant supplements for preventing gastrointestinal cancers. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004183.

We could not find evidence that antioxidant supplements prevent gastrointestinal cancers. On the contrary, they seem to increase overall mortality.

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. 2012 Mar 14;3:CD007176. doi: 10.1002/14651858.CD007176.pub2.

We found no evidence to support antioxidant supplements for primary or secondary prevention. Beta-carotene and vitamin E seem to increase mortality, and so may higher doses of vitamin A. Antioxidant supplements need to be considered as medicinal products and should undergo sufficient evaluation before marketing.

There are many more studies that show the adverse affects of taking mega-vitamins as well as additional studies that show that taking mega-vitamins makes absolutely no difference. Of course, with any medical issue, there are also studies that support the consumption of mega-vitamins, but the studies are not as rigorous nor as conclusive.

What to do?

I would suggest taking a regular multi-vitamin daily which contains enough vitamins to supplement any deficiencies that may occur from insufficient dietary intake... Otherwise, additional vitamin supplementation is not necessary unless a known deficiency is present.

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Hospital Charges vs Surgeon Charges

Some of the most bitter complaints I get from patients are their hospital bills. Apparently, this complaint is not unique to me given numerous media articles about perceived outrageous hospital charges for seemingly simple procedures (article #1 and article #2).

The healthcare system as it currently stands establishes 2 separate charges (surgeon and hospital) with any type of procedure performed in a hospital (even if not in an operating room). There is even a 3rd charge if anesthesia is provided.

The ONLY charge a surgeon has any control over is the surgeon's charge which often is the least expensive of the 3 charges. A common misconception is that the surgeon also has control over hospital and even anesthesia charges which is patently false.

Indeed, the surgeon is not even informed what the hospital or anesthesia charges are for any procedures performed. The surgeon also has no influence, say, or authority over what the hospital or anesthesia charges as well.

As such, if knowledge of total costs is desired with any type of procedure performed in the hospital, it is best to speak with a hospital representative of what the anticipated charges will be... not the surgeon because we actually do not know.

I should also mention that hospital charges are often 10 times or more greater than the surgeon's fees.

Read more about surgical fees.

Even for the SAME exact procedure, the charges vary greatly from one hospital to another.

In May 2013, the federal government released information on how a given hospital ranks in their charges for a given diagnosis or procedure (specifically Medicare, but all insurance base their charges on Medicare rates).

Check to see how your hospital ranks compared with other hospitals with respect to how high their charges are. The New York Times created a handy dandy map that illustrates hospitals which are "expensive" and those that are below average in terms of hospital charges.

I should mention that Fauquier Hospital where I have privileges charges at less than the US average.

Let's take an example to see how hospital charges can significantly influence how much you pay for the same exact procedure depending on which hospital you go.

Let's say you have health insurance with a 10% coinsurance and a $1000 deductible (meaning, before insurance pays for anything, you must pay at least $1000 and than an additional 10% of all remaining charges).

Let's say you decide to proceed with a tonsillectomy.

At hospital A, the surgeon's fee is $500, hospital charges are $5000, and anesthesia charges are $1000 for a grand total of $6500.

At hospital B, the surgeon's fee is $500, hospital charges are $10,000, and anesthesia charges are $5000 for a grand total of $15,500.

Clearly, whether you go to hospital A or B, you will pay $1000 deductible first.

So, at hospital A, the total charges (minus your deductible) billed to insurance will be $5,500 and at hospital B that cost will be $14,500.

Insurance pays 90% of these charges and you pay the remaining 10% (the 10% coinsurance as per the policy you have).

As such, having a tonsillectomy at hospital A will cost an additional $550 whereas at hospital B, you will have to pay an additional $1,450.

Now, it may seem the charge differences are extreme in the example, but sadly, hospital charges can truly be that dramatically different. Read this New York Times article for more information.

Of course, do keep in mind that the above example is over-simplified as reality does include things like fee schedules, allowable charges, etc.

Source:
Hospital Billing Varies Wildly, Government Data Shows. NYT 5/8/13

How Much Hospitals Charge For the Same Procedures. NYT 5/8/13

As Hospital Prices Soar, a Stitch Tops $500. NYT 12/2/13

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Surgeries on a Weekend Have More Complications

The New York Times published an interesting story regarding how patients with ulcerative colitis suffered significantly more surgical complications when performed on a weekend compared to a weekday. Just how much worse?

The cited research reported that the most common post-operative complication was post-operative infections (Weekend 30% vs. Weekday 20%). However, there was also an increased risk of need for repeat laparotomy, mechanical wound complications, and pulmonary complications. Of note, there was no difference in disease severity between weekend and weekday groups.

Oddly, this increase in complications did not occur with Crohn's disease patients.

Although these findings can not and should not generalize to other surgical procedures, the following logistical issues ARE present when decision for urgent surgery is made after hours or on weekends.

The following issues are probably what prompts this type of research to occur in the first place.

During such off-periods, there are no surgical support staff present in the hospital. They need to be called in from home. As such, there may be a slightly higher time delay before surgery begins. Furthermore, the surgical tech that assists the surgeon may be unfamiliar with the surgery as well as instruments used leading to a surgical procedure that may be "inefficiently" performed.

For example, if I need to take a child back to the OR who is suffering from excessive bleeding after a tonsillectomy, the surgical technician who may be assisting me may be an orthopedic technician unfamiliar with ENT instruments as well as unfamiliar with how the procedure is performed.

Although one may like to select who assists in the surgery, unfortunately, the patient nor the surgeon gets to choose who their surgical support staff is. It is whoever happens to be on-call when the need for urgent surgery arises. You get who you get...

However, during the weekday, the surgical support staff helping with the surgery is the team that does that particular surgery all the time... the "A" team so to speak.

The other factor is the surgeon himself. During the weekday, the patient will most likely have surgery performed by "their" surgeon who knows and is already familiar with the patient.

After-hours or on the weekend, the patient may or may not get the surgeon who knows the patient personally. It would be whoever the on-call surgeon is.

So now you know...

Now to be fair, there have been studies that both support as well as refute the assertion that weekend surgeries/admissions place patients at elevated risk of complications.

Source:
Weekends Worse for Surgery. New York Times. 3/22/13

Reference:
Weekend hospitalisations and post-operative complications following urgent surgery for ulcerative colitis and Crohn's disease. AP&T Article first published online: 4 MAR 2013. DOI: 10.1111/apt.12272

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Sinus Mass Chance Finding (Incidentaloma)

The New York Times published a great story on the dreaded incidentaloma on Jan 17, 2013. An incidentaloma is essentially a chance finding of a mass most likely benign, that was incidentally discovered on a CT or MRI scan ordered for a completely different reason.

With such incidentalomas, it leads to patient anxiety causing physicians and surgeons to order even more tests and procedures (which themselves may lead to other incidentalomas). The vast majority of such incidentalomas are "nothings" without any significance, but hard to persuade patients otherwise at times.

In the ENT world, incidentalomas are very common when CT and MRI scans are performed of the head for a headache, stroke, eye pain, dizziness, or some other non-sinus related complaint.

In the report, there is the statement of:

"There is an opacified mass inside the right maxillary sinus cavity [or some other sinus cavity] two centimeters [or larger] in size."

Compare the above CT scan (red arrow pointing to the mass) with a normal CT scan of the sinuses below:

IF symptoms are localized to the corresponding mass on the CT/MRI scan, than further management which may include surgery can be pursued.

However, the vast majority of patients have absolutely NO symptoms localized to the corresponding abnormality. Radiologists and ENTs report that such a mass is most likely a benign mucosal inclusion cyst for which there is no significance and nothing more needs to be done.

However, some patients due to cancer concerns, even insist on having surgery to get it removed, even in spite of the risks associated with surgery including brain fluid leakage, eye damage, etc.

I personally usually insist a patient get a 2nd opinion prior to any surgical intervention for an incidentaloma if I'm pressured to "do something" when my gut feeling is to "do nothing."

Source:
The Fallout of a Chance Medical Finding. New York Times 1/17/13

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How to "Grow" Clean Air

The New York Times published a story regarding how common houseplants can purify the air of chemicals like benzene and formaldehyde.

This claim is based on NASA research performed in the 1980s when the agency was trying to figure out ways to keep the air quality as clean as possible within enclosed habitats (like a space station).

Of course, you can read the 27 page report... or read a mom-friendly book that summarizes the findings in an easy-to-understand language from Amazon.com.

"How to Grow Fresh Air" by Dr. BC Wolverton


The book reviews 50 common houseplants' ability to clean the air inside the home or office. Depending on the plant, chemicals that can be removed include benzene, formaldehyde, xylene, toulene, trichlorethylene, chloroform, ammonia, acetone, and alcohols. Such chemicals are emitted from electronics, drywall, adhesives, upholstery, carpet, paint, cosmetics, etc.

It is suspected that such chemicals may be the cause of "sick building syndrome" that induces symptoms of upper respiratory irritation, fatigue, headache, and congestion when afflicted individuals enter certain buildings.

My personal favorite plants are the fern and peace lilly, both which have a high rate of chemical vapor removal, easy to grow and maintain, and fairly resistant to insect infestation. Does the job and easy to care for.

BEWARE!!!

Now before running to the nearest greenhouse and buying numerous plants to keep inside the home, consider that though such plants remove chemicals from the air, the plants themselves may exacerbate allergies in sensitive individuals.

Why? Plants can increase dust (accumulated on the leaves) and mold allergens (in the soil).


Source:
Really? Some Plants Can Filter Airborne Chemicals. NYT 9/3/12

Reference:
Interior Landscape Plants Indoor Air Pollution Abatement. NASA 9/15/89

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Waking Up to NOT Just Major Colonoscopy Bills...

The New York Times published an article on May 28, 2012 regarding the high anesthesia charges associated with colonoscopy.

What people need to realize is that anesthesia charges apply not just to colonoscopy, but ANY procedure that requires general anesthesia... tonsillectomy, appendectomy, gallbladder surgery, ear tube placement in kids, etc.

With any procedure requiring general anesthesia, a patient is going to receive THREE bills... not just one which is what most reasonable people think.

1) A bill from the surgeon

2) A bill from anesthesia

3) A bill from the hospital

Sometimes the hospital and anesthesia charges are bundled into a single bill.

Often, patients mistakenly focus on the surgeon's charges thinking that's where their largest out-of-pocket cost is going to lie. However, the surgeon's fee is almost always the lowest of the charges.

Let's take a look at the New York Time's article...

The GI doctors actually performing the colonoscopy procedure got paid around $200. The anesthesia charges were around $2000 or 10x more (note that insurance coverage was an issue in this article and IF insurance did cover, out-of-pocket charges would have been significantly lower).

And than... if the procedure is done in the hospital, the hospital charges will often be around $5000 or 25x more.

These charges are similar to that found for many ENT procedures as well including tonsillectomy. (Of note, all insurances that we participate with... the anesthesia group I work with also participates with.)

On a more personal note, I recently underwent a general surgical procedure myself performed under general anesthesia in the hospital and got the following charges (3 different bills):

1) Surgeon's charge of $425 of which I owed $148.54 (difference covered by insurance)
2) Anesthesia charge of $1,400 of which I owed $140 (difference covered by insurance)
3) Hospital charge of $3,710.25 of which I owed $559.05 (difference covered by insurance)

Now if anesthesia did not participate with my insurance company, than I would have been fully responsible for anesthesia's full charge of $1,400. This situation is what the New York Time's article mainly focused on.

SO what is a cost-conscious patient to do?

Rather than focusing on the surgeon doing the procedure, the biggest cost-savings will occur negotiating with the hospital followed by anesthesia.

OR... avoid having procedures done in the hospital altogether to avoid hospital charges followed by avoid general anesthesia if at all possible and stick with local anesthesia alone. You will than ONLY have to deal with surgical charges which the surgeon should be able to inform up-front.

WHY do surgeons do procedures in the hospital rather than the office?

Beyond patient and procedural factors which may require general anesthesia, procedures may preferentially be performed in the hospital due to money. No big surprise there, but it may not be for the reasons people may suspect.

Let's take a real life example... balloon sinuplasty.

Balloon sinuplasty is an innovative minimally invasive surgical procedure to treat chronic sinusitis. Prior to 2011, this procedure was almost always performed in the operating room in the hospital though it could have been performed in the office.

Why?

The balloon used for this procedure costs around $2000 and is not reusable.

The reimbursement for the surgeon to perform this procedure was around $200+ depending on the number of sinuses addressed and insurance company.

SO... if balloon sinuplasty was performed in the office prior to 2011, the surgeon would have spent $2000 to do the procedure and than would have gotten paid only $200+ meaning a loss of ~$1800.

Why not charge the patient for the balloon device? Because it is called balance-billing and it is illegal.

So what is a surgeon to do if a patient desires balloon sinuplasty and yet the surgeon doesn't want to lose money?

You do it in the hospital... where the hospital eats the $2000 cost of purchasing the balloon device... and the surgeon still gets paid $200.

However, starting in 2012, insurance companies started reimbursing surgeons for the cost of the device which is why all of a sudden, balloon sinuplasty is now being performed in the office.

This type of financial calculation occurs all the time in medical offices.

Even a pediatrician's office where gardasil vaccination is often not offered... Why? Because the vaccine costs more than what the pediatrician will get reimbursed to give it.

Source:
Waking up to Major Colonoscopy Bills. New York Times 5/28/12

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Doctor Distraction Happens... It's Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out... But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form... and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery... and often the surgery is already over... and the nurse is still busy filling out forms.

Talk about distraction... a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR... ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations... which is true 99% of the time... but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Reference:

As Doctors Use More Devices, Potential for Distraction Grows. NYT Dec 14, 2011.

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Can What Makes a Lion Roar Help Human With a Weak Voice?

Researchers in Iowa have discovered what makes a lion or tiger roar so effectively. Apparently, there is a layer of fat within large feline vocal cords that makes the vocal cords especially prone to vibrate easily with minimal exhalation effort.

What import does this have to humans?

Well, there are patients who have a very weak voice due to vocal cord atrophy as well as vocal cord paralysis. Standard interventions include voice therapy as well as surgical procedures using an implant or injectable material in order to "bulk" up the vocal cord.

In fact... one such injectable material that has been used to inject into vocal cords is fat, typically taken from the belly of the patient!

Two points to keep in mind however...

Just like in lions and tigers, it DOES improve the vocal strength and volume to a patient who previously had a weak voice, may now have a much stronger voice after the procedure.

However, the second point is that by making the vocal cord "bulkier" you are making it thicker which can decrease the vocal pitch... just like a violin string where the thicker the string, the lower the pitch.

On another related note... human infants have fat within their vocal cords... that may be why something so small with tiny lungs can produce such a terrific loud cry!

Read a story in the NYT regarding this research here.

Reference:
Adapted to Roar: Functional Morphology of Tiger and Lion Vocal Folds. PLoS ONE 6(11): e27029. doi:10.1371/journal.pone.0027029

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