The Microbiome of the Gut: Medicine's Final Frontier?

I have been fascinated by a new school of technology that has revealed itself to us in the last few years presented by Suzanne Devkota, PhD, at the recent ASBP Conference. There are 100 trillion bacterial cells in our bodies (more than the number of cells that make up our body). Recently bacterial 16s ribosomal genes have been identified that give us a very fast, specific and quantitative identification of the bacteria in the stomach and gut.  It gives us a new gene map of the gastrointestinal system. This identification process not only allows us to look at the current bacteria in the gut, but lets us look at bacteria present in the guts of our ancestors.  It also gives us insight into how we metabolize food and how these bacteria can be helpful in the treatment of disease.

There are thousands of bacteria in our bodies that live symbiotically with us of which we were never aware. Landmark papers have been released about these bacteria and their effects begining in 2001.  Most of these papers have focused on how these bacteria affect obesity. There are three very interesting benefits I found important.

1. The spectrum of bacteria in our gut affects how we metabolize and break down different foods in our diet. It also influences our health. 

2. Mothers transfer the microbiomes early on through the method of birth.  There are very specific bacteria that confer specific beneficial or harmful immunity to a person's body.

3. These bacteria have the ability to perform Lateral Gene Transfer. Bacteria have the ability to share genes "laterally," to their neighbor, that confer antibiotic resistance, immunity or action. 

What is also important is that these microbes can process dietary fibers more effectively leading to increased formation of glucose and free fatty acids and triglycerides.  This can be the reasons that some people gain weight from the same fiber intake that others don't. These bacteria can also increases Lipoprotien Lipase, the enzyme in the body that stimulates increased fat storage. 

Another fascinating piece of information relating to this field of study reveals that certain bacteria found in patient's with type II diabetes causes a "gut leakiness  that arises predisposing many to various forms of bowel inflammation. 

The types of fat we eat actually have an effect on the bacteria colonies and upon the degree of "leakiness" in the GI system.  This may be why so many patient feel like they have "gluten" intolerance or gastrointestinal inflammation.

Omega 3 fatty acids have been found to help protect the bacteria and the "leakiness" in the GI system.  

We still have much to learn in this area and much to gain as we apply what we are learning. 

Stay tuned . . .

The Real ....

More Bacon Please . . .

Imperfect People

Great Thatcherisms . . .

An amazing lady passed away yesterday, the former research chemist turned barrister and then later, British Prime Minister serving from 1979 to 1990. She was nick-named the "Iron Lady" because of her uncompromising political views and leadership style.  In honor of the passing of the great Iron Lady, Margaret Thatcher, here are 16 of the best Thatcherisms:

"ON GETTING THINGS DONE:


“If you want something said, ask a man. If you want something done, ask a woman.”

“If you just set out to be liked, you would be prepared to compromise on anything at any time, and yu would achieve nothing.”

“I’m extraordinarily patient provided I get my own way in the end.”

"AN IRON PRIME MINISTER:


“Where there is discord, may we bring harmony. Where there is error, may we bring truth. Where there is doubt, may we bring faith. And where there is despair, may we bring hope.”

“I am in politics because of the conflict between good and evil, and I believe that in the end good will triumph.”

“Do you think you would ever have heard of Christianity if the Apostles had gone out and said, ‘I believe in consensus?’”

“Standing in the middle of the road is very dangerous; you get knocked down by the traffic from both sides.”

"ON HER CRITICS:


“If my critics saw me walking over the Thames they would say it was because I couldn’t swim.”

"ON THE START OF THE FALKLAND WARS:


“Defeat? I do not recognize the meaning of the word.”

"ON GOVERNMENT:


“We want a society where people are free to make choices, to make mistakes, to be generous and compassionate. This is what we mean by a moral society; not a society where the state is responsible for everything, and no one is responsible for the state.”

"ON HUMANITY, SOCIETY, & FEMINISM:


“The woman’s mission is not to enhance the masculine spirit, but to express the feminine; hers is not to preserve a man-made world, but to create a human world by the infusion of the feminine element into all of its activities.”

“I owe nothing to Women’s Lib.”

“Being powerful is like being a lady. If you have to tell people you are, you aren’t.”

"ON AMERICA:


“Europe will never be like America. Europe is a product of history. America is a product of philosophy.”

"ON SOCIALISM:


“Socialist governments traditionally do make a financial mess. They always run out of other people’s money. It’s quite characteristic of them.”

“And what a prize we have to fight for: no less than the chance to banish from our land the dark divisive clouds of Marxist socialism."

(taken from the article by Becket Adams on TheBlaze.com)

Family Physician Burnout . . .

A national survey published in the Archives of Family Medicine in 2012 reported that US physicians suffer more burnout than other American workers.[1] Some 45.8% of physicians were experiencing at least 1 symptom of burnout: loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.
Medscape conducted a survey and family physicians were given the same criteria. The response was discouraging: 43% responded that they were burned out. The 2 specialties with the highest percentage of burnout were those that dealt with severely ill patients: emergency medicine and critical care. Family physicians were in third place.



What is causing the burnout? Following table lists the causes found in the study.



In the Archives article,[1] the authors sum up the very challenging problem of physician burnout: "Collectively, the findings...indicate that (1) the prevalence of burnout among US physicians is at an alarming level, (2) physicians in specialties at the front line of care access (emergency medicine, general Family Medicine, and family medicine) are at greatest risk, (3) physicians work longer hours and have greater struggles with work-life integration than other US workers, and (4) after adjusting for hours worked per week, higher levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine (MD or DO) increases the risk. These results suggest that the experience of burnout among physicians does not simply mirror larger societal trends."

What to do? The finding suggest that physicians should participate in and advocate for changes in work that give them more control over there ability to help and interact with patients. They should become involved in advocating for health reforms that will return a greater level of control to physicians and their patients. These would include payment for value and greater patient participation in decision-making about care. Reorganizing primary care practices to allow more time for complex patients and recognition by insurers that excessive hassle is bad for patients and physician are also vital. These changes should lead to more satisfied patients and physicians and less burnout,[3] .

References:
1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physician relative to the general US population. Arch Intern Med. 2012;172:1377-1385. http://archinte.jamanetwork.com/article.aspx?articleid=1351351 Accessed February 7, 2013.
2.http://www.medscape.com/features/slideshow/lifestyle/2013/family-medicine?src=wnl_edit_specol#2
3. Centor RM, Morrow RW, Poses RM, et al. Doc burnout -- worse than other workers'. Medscape Roundtable in Primary Care. November 13, 2012. http://www.medscape.com/viewarticle/774013 Accessed February 20, 2013.

Where Do You Get Your Advice?

I DO ALL MY OWN STUNTS!

I've determined that life is not a journey to the grave with the intention of arriving safely in a dainty and well-preserved condition. But, my life's journey is, rather, to be fully enjoyed, thoroughly used up, totally worn out and I intend to be found skidding broadsided into heaven and when landing I will proclaim, "WOW, WHAT A RIDE!"

My orthopedic surgeon, just grinned and recommended I avoid bungee jumping or hang gliding . . .

Confidence

One of the greatest success in life is the confidence that comes from understanding shared in sincere conversation between two people.

My Friend The Doctor . . .

My sister (an up and coming author), Robyn Oler, recently published a wonderful children's book entitled "My Friend the Doctor", published by Tate Publishing.  She admits the book is based on my medical office and the experiences of her daughter in the doctor's office.  She has done another fabulous job!

The new book is a wonderful addition to any children's book library and, in my biased opinion, I highly recommend you buy your copy today.  You can order it online here.

Keep up the good work, Robyn!

Today's Thoughts . . .

Patriotism is easy to understand in America: it means looking out for yourself when looking out for your country. - Calvin Coolidge

He who floats with the current, who does not guide himself according to higher principles, who has no ideal, no convictions-such a man is a mere article of the world's furniture - a thing moved, instead of a living and moving being - an echo, not a voice.

Speech . . .

There are many things I believe . . . that I shall never say; however, I shall never say the things that I do not believe.

What Do You Want To Do . . . ?

You can master anything you love doing  . . .

Camouflage . . .

The plumbing under my sink exploded just before we had some company coming over.  I raced over to the Home Depot and found the parts and found myself under my sink. Memories of my father fixing my mother's sink crossed my mind as I removed the old corroded seals and replaced the piping.
This was not something I wanted to do in front of my visitors, however, we could not finish cooking dinner.  You never realize how much the kitchen sink is used until the pipes explode.
Anyway, the pipes are flowing again, my wife is happy, and dinner went well.  No Plumber's Camouflage was needed.

Arizona Entitlements...To Expand or Not to Expand?

I had the wonderful pleasure of visiting the Arizona State Capital yesterday and meeting with a number of our state senators and representatives.  The big "hula-ballou" was that Governor Jan Brewer was also holding a press conference about her proposal for Medicaid, Arizona Health Care Cost Containment System (AHCCCS), expansion for our state. This has had a significant amount of media coverage, as Gov. Brewer a fiscal conservative, has decided to expand Arizona's entitlements by leveraging federal funds. Her press conference was held on the same morning the Arizona Osteopathic Medical Association (AOMA) was meeting with our state legislative representatives.  I was interviewed by News Channel 3's Dennis Welch, but only three seconds of my three minute interview was aired and it was taken completely out of context.
Here is what I tried to explain and my position on the issue. At first appearance, it seems that Gov. Brewer sprouted "progressive" tendencies and has given in to the Affordable Care Act ("ObamaCare") to which she has been historically and strongly opposed.  However, this is a very sticky problem, and it is important to understand the back ground on this issue to understand why this proposal has arisen.
It started in1982 when Arizona voted to enter the Medicaid program.  Arizona was the last state in the union to enter into Medicaid.  This brought on a number of budgetary challenges, and to solve this problem, the state "privatized" Medicaid, allowing a number of insurance companies to compete for and oversee the distribution of the care and funding in 1987 called the Arizona Health Care Cost Containment System (AHCCCS) and lovingly termed "access."  This allowed for tighter control and efficient use of the Medicaid funds.

Bigger challenges arose with the voter passage of Proposition 204 in 1995 and then re-voted upon in 2000, amending the Arizona constitution to mandate state health coverage of those residents up to 100% of the federal poverty level.  This means that no matter what, Arizona is constitutionally required to pay for and participate in Medicaid.  Part of the health care dollars have been paid for by an Arizona Sales Tax which was set to expire on December 31, 2013.  The renew of the sales tax was voted down at the end of 2012 and these funds will no longer be available.
Currently, the federal government matches Arizona's contribution to Medicaid at a 2:1 ratio. Because of budgetary AHCCCS enrollment freezes, childless adults that will not be covered, mandated changes to the plan required by the ACA, and the loss of revenue from the sales tax, AHCCCS will cost Arizona an additional $450 million dollars per year that will be required to come from the State's general fund.  This makes it impossible to balance the state's budget in 2014.
Because Medicaid coverage at a minimum of 100% of the federal poverty level is required by the state constitution, Governor Brewer is stuck with a difficult problem.  Services have already been notably reduced and reimbursement to providers has already been cut by 10% over the last few years.  Further cuts would cause providers and hospitals to drop the program like a rock.
The proposal, therefore, is to accept the Federal 9:1 match of funds by expanding Medicaid to 133% of the federal poverty level. This would actually allow coverage of an additional 60,000 Arizonians and would save the state $325 million dollars per year.
From the perspective of Health Care Policy, it is important to look at any policy in regards to cost, quality and access.  Governor Brewers proposal will allow her to balance the budget much easier, however, this proposal will not improved quality and only partially improves access.  The liberal side of the community is excited about the expansion of entitlements; however, the strong conservative side of the community is concerned that we are adding to the federal debt to balance the state's budget and strapping our children with today's burdens.  Because of increased access to services (modest as they may be), most physician and health care organizations have thrown their support behind Governor Brewer.
Will federal income tax increase in the future because of this?  Will the federal government actually have the funds to move the ACA forward? If the federal government fails with it's commitment, will that leave Arizona in a financial bind?  Does this affect our states sovereignty? These are questions that have not been answered.
I agree that something must be done, but is there another way to balance Arizona's budget without increasing  our state's dependence upon federal funds?

Just Return To The Basics

My son I recently completed our open water SCUBA dive training.  We signed up and took the course through a wonderful near-by diving shop with some trustworthy diving instructors, George & Pete, and a group of master divers that we quickly came to admire. I have always want to SCUBA dive, however, living in landlocked Arizona makes this hard, and when the opportunity presented itself for my son and I to get trained, we jumped at the chance.

It was a wonderful experience. I came away with a sense of awe and the realization that there is an entirely new world below the surface yet unseen by most.  My son and I made a pact to begin discovering this new world. I look forward to some time with my son in this adventure.

I learned something else. Just like most things in life, safe SCUBA diving requires that you master and frequently return to the basics.  We spend about 30-45 minutes in the water with each dive and most of the time was spent reviewing and refreshing simple techniques of breathing, regulator recovery, mask clearing, following the buddy system, preparing for emergencies.

On our last dive, we descended to 45 feet and demonstrated that if we lost our mask, or our air regulator, we could recover or assist our buddy in these emergencies. You don't realize how easy panic can set in when you loose your air supply 45 feet under water. 

While demonstrating that I could safely remove my regulator by dropping it to my side,  I had to lean over and reach behind myself to find it.  It the process, my mask filled with water and I ended up getting water up my nose.  This caused me to cough and empty my lungs.  I was still searching for my regulator during this experience and panic set in.  My first instinct was to dart to the surface, however, I recognized this is a bad idea as we were below 33 feet and I was now at 2 atmospheres of pressure. A shot to the surface could easily rupture a lung or cause decompression sickness.  I've treated those problems in other patients before, and it isn't pretty. 

So, with a little concentration, back to the basics.  I located my regulator, cleared it with the purge button, took a deeply desired breath, and cleared my nose.  I then followed the techniques I was taught to clear my masks and within a few seconds, life was good again.  I gave my instructor the "OK" sign and we moved on to our last few skills checks.  

This little experience drove home the message about how important it is to just return to the basics. Life is like that.  Weather in SCUBA diving, medicine, relationships, marriage, weight loss, driving, sports or any other life experiences, when all goes south, just fall back on the basics and get yourself grounded.

Action . . . The Measuring Stick

I came across an interesting quotation by Francis Bacon.  In thinking about the message here, I thought of myself, as well as those that currently lead our state and our country.  It is advise that acts as a good measuring stick.

"He that gives good advice builds with one hand; 

he that gives good counsel and example builds with both; 

but he that gives good admonition and bad example 

builds with one hand and pulls down with the other."

Either way, anyone named after one of the most delicious breakfast foods on the planet, should be paid some attention.

Thanks, Francis!

Had Enough Yet?!

Just so you know, I Second the First!

We The People . . .

I seem to recall that the Declaration of Independence starts with the phrase "We the people . . ." not "We the elites . . .," "We your leaders...," or "We your congress..."  The Declaration of Independence asserts, as a matter of Natural Law, the ability of a people to assume and maintain political independence and that the grounds for such independence must be reasonable and therefore explicable. 
We the people came together and established a body of government to protect OUR God given rights of Life, Liberty and the Pursuit of Happiness by the consent of the governed.  I don't recall consenting to have the freedoms and rights to protect my family, home and community removed.  The arrogance of superiority of many of our leaders demonstrates that they do not understand or account for the principle that we have granted them power, we pay daily to protect them, and our politicians are only as powerful as we the people allow them to be . . .


May each of us have the courage to stand for and defend the life and liberty for which our fathers spilled their innocent blood.