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This week's questions:
1:23 The infant formula milk industry is a multi-billion dollar industry. You cannot turn on the television without at least watching an advertisement hailing the mental and physical benefits of X baby formula. Since then, there is a prevailing belief that parents MUST purchase this or that brand of baby formula otherwise their child will be at a disadvantage. Your opinion on this?
3:17 The Food and Drug Administration said there are serious and sometimes disabling side effects from the commonly used class of antibiotics called fluoroquinolones. Is this just another FDA overreaction or do the risks outweigh the benefits?
4:30 Folate during Pregnancies causes autism? Are we being trolled?
8:30 Is there a difference in regulation between herbalsupplements and vitamin supplements? I take magnesium oxide (which comes from behind the pharmacy counter) to prevent migraines.
8:50 Why don't we use male birth control?
10:27 IGG food intolerances and Leaky Gut?
11:40 Is there a way to lessen tolerance to dexamphetamines. I've been prescribed them for the last 7 years (I'm 19 now).
12:22 What diseases often produce false positive tests?
13:47 What causes visual snow and why do some people see it all the time? Is there reason to be concerned about it?

 (00:00) to (02:00)


I feel like I should like, start all these episodes looking surprised, like you just showed up, like, like Mr. Rogers--although now I'm dating myself.  Does anyone even know Mr. Rogers?  Okay, good, good, good.  I thought I would be like, you know.  Anyway, he'd always come home and he'd be like, surprised to see you were there and he put the sweater on and anyway.  Welcome to Healthcare Triage Live!  

We are late.  Late, late, late.  Not my fault.  So we're just gonna jump right in.  First, oh, by the way, it seems that all the questions people put in the comments last week somehow miraculously disappeared.  I don't know why, neither does anybody else.  We're not ignoring you, please just put the question back.  If you have a question and I didn't answer it, put it back.  We will re-add it to the list.  I don't know, we lost it, sorry.  

Anyway, "The infant formula milk industry,"--ahh, the milk industrial complex, "the milk industry is a multibillion dollar industry.  You can't turn on the TV without at least watching an advertisement hailing the mental and physical benefits of X baby formula.  Since then, there's a prevailing belief that parents must purchase this or that brand of baby formula or their child will be at a disadvantage.  You're a pediatrician,"  Yes, I am.  

You would honestly like to hear my opinion on these alleged medical claims.  Okay.  First of all, you know, first of all, you could breastfeed and not have to do the formula thing at all, so feel free.  Secondly, formula is like, you know, only up until one year, so at that point, you're turning to milk and when you're in the formula, it's like, you know, the vast majority of formulas are just fine.  

 (02:00) to (04:00)

They're just fine.  They're normal formulas.  It's like, once you read sort of the basic components, they're all the same.  Now, you can--if you go, there's a million on the shelf 'cause there's the soy based one, there'll be the, like, you know, super fat one, there'll be the low-iron one, there will be the one that's like, more easily digestible, there'll be the hypoallergenic one.  The vast, vast, vast majority of children need the basic formula and then everything above that is sort of like, uh, bonus or whatever.  Useless, I could say, for many, many people, useless.

Now, the idea that now we need the, like, super formula, 'cause that's gonna lead to a better brain--no.  No.  That's like, something in a lab or cooked up.  There's no randomized controlled trials or any trials that say that kids that get this or that formula are smarter, do better, develop better, you know, physically better, mentally--none, none, none.  That's all like, maybe.  It's almost the supplement industry.  It is just not based on actual research, so my kids were breastfed.  When Aimee was done with that, they were formula-fed.  It was the basic whatever (?~3:10) formula was available.  I can't even remember which company it was, 'cause I didn't care and for the most, most, most, most people, neither should you.  You just shouldn't.  

Next question from ak11234, "The Food and Drug Administration said there are serious and sometimes disabling side effects from the commonly used class of antibiotics called fluoroquinolones.  Is this just another FDA overreaction or do the risks outweigh the benefits?"  

Is this an--okay, what, now I'm like questioning, is this a new thing? 'Cause I mean, fluoroquinolones for all, for a while, like, you know, they were sort, we don't like to give them to young kids.  It can stain their teeth.  It can have some other issues.  We use them very commonly--I have not heard of any new serious or disabling side effect.  If it is a new thing, I don't know about it yet, which disturbs me because I should.  To be honest with you, I rarely prescribe fluoroquinolones.  I'm a primary care pediatrician.  Almost all the prescriptions that I give for antibiotics are amoxicillin.  

 (04:00) to (06:00)

Once in a while, augmented.

I really just don't get that deep into the weeds about the resistance because I just don't see it, so it is possible that something new has come down the path about fluoroquinolones and I don't know about it, but I'm going to look into it because you've made me nervous.  Until that moment, if there is anything new, then there weren't any crazy, disabling side effects that I've known in the past that would have prevented us from using them. Unless it was some kind of drug-drug interaction which is of course would be a concern. Bottom line, I'm going to look into this for you.

 Folate during Pregnancies causes autism? Are we being trolled? (4:33)

Folate during Pregnancies causes autism? Are we being trolled?

Aww, you're not being trolled, but here's where we went off the rails on this one. Alright, first of all, this was not a published, peer-reviewed study. Even though it was covered more than almost any other news story in the last two weeks that I know of in health and kids.

Except for the swaddling thing.

This was a presentation of an abstract at a meeting which means that truly all I know about is like this much (4:58) because that's all you can see. There is no peer-reviewed publication.

There's no vetted science. I don't know what the results were. It was a presentation at a meeting that a limited number of people heard, and yet it was covered as if it was the leading story in Science or Nature or the New England Journal of Medicine.  It's not the case.

In fact, one of the good studies that's been done on what should we think about abstracts was done by me.  When I was a fellow, back in the long ago, this is probably like 2001-ish or 2002-ish, I had a randomized controlled trial rejected from our pediatric meeting and it irked me so badly, because so much crap is often presented at those meetings, that we did a study to see what happens to abstracts that are presented at meeting. And the first thing we found is that this meeting, that I went to, something like 87% of abstracts that are submitted are accepted for presentation. So own up right off the bat. The litmus test for getting your stuff presented at a meeting, I'm sorry, the bar for getting your stuff presented at a meeting is low.

 (06:00) to (08:00)

The vast majority of stuff submitted was accepted so being presented at a meeting does not mean it's truth.

The second thing is only less than half, or about half, of stuff presented at the meeting ever made it into the peer reviewed literature. So half the stuff presented at meetings never gets published.

Which means it didn't pan out. So it's like you can't trust that stuff. And even then we did studies looking at whether poster-presentation, or platform-presentation, or poster-symposia had any bearing on the quality of the journal, how fast it gets published, all those other things.

And the answer is no. Being presented at a meeting is not necessarily linked to later being published or to being right. The peer review process is much less rigorous, because of course, they only have a tiny abstract as compared to the same thing.

It is not the same, and yet the press often covers it like it is the same thing, which is why I, as a policy, will never speak about any of my presentations at meetings before they are published. And so when a meeting says "We'd like to add your paper or your -I'm sorry- your abstract to the list of things we're going to publize about the meetings", I say "no". I'm not alone in that, although I would say most people probably take the press, but I'm very concerned about the fact that stuff that's presented at meetings is not of the same rigor as stuff that is actually published in the peer reviewed literature.

And so that's what that Folate study was. Now that Folate study was not the first study that looks at Folate. Other studies have found that Folate is protective in association against autism.

Other studies don't find the same findings, so it could be that it's an outlier. It could be that it's not as rigorous. It could be that there's a-  I don't know any of that.

I don't know until it actually gets published. Um- We do know that Folate is really good for other things, like presenting neural tube defects, which is why we take- we give it to pregnant women, so um there's lots of proven benefits. I don't know about this.

This has not been published yet.

 (08:00) to (10:00)

It probably shouldn't have been covered to the extent it was, but the- the health media can't help themselves. They just can't. And uh, neither can people for, you know, being hungry for that kind of stuff, so yeahhh.

I won't even cover it in healthcare triage news, this is the thing, is that people have said "will you cover this?" and my answer is NO. There's no study. I can't even comment. I don't know about it yet. So, um, we have to wait unfortunately, until it gets published. But I would tell you, until that moment, no one should get panicked, really. 

(?~8:31) asks, "is there a difference in regulation between herbal supplements and vitamin supplements?" No, no there's not. "I take magnesium oxide, which comes from behind the pharmacy counter, to prevent migraines." Yeah, no, no difference between regulation. Supplements are supplements are supplements. You have no idea if you're getting what you think.And there's so many healthcare triage episodes on that. I'm gonna send you to those. 

Olivesolives says "why don't we use male birth control? I've read some articles about the RISUG, which is the reverse of inhibition of sperm under guidance, and I don't get why it wouldn't be viable. It seems a lot less harmful than the pill". 

Well, we don't, I- It's not that this stuff can't get studied. It's that we don't really have them available. You know, people would- I think a lot of people would argue that male birth control is like condoms. If you're talking about taking a pill, they just haven't really been studied.

Um, why? I don't know. Probably the patriarchy. I don't know. Probably because we've always said "it's the girls responsibility now". I mean I'm being facetious, but that- I got to imagine that's what it is. And that somehow, we as a society or the world or the government, that's the girl's responsibility, or the female's responsibility, and they have to be responsible for it, and they have to take care of it. And men don't do it.

So there is no pill for that. Maybe we could make one. But again, it would have to be not just decent, it would have to be all the way. Like to prevent a woman from getting pregnant, you need to just prevent that one ovulation a month. To prevent a man from- you have to kill all the sperm.

 (10:00) to (12:00)

They all gotta die, every single one, 'cause if some get through, you can get pregnant, and you need it to be, like, all, so it would have to be something which could reversibly inhibit sperm. And that's what you're saying. I don't know that they've achieved that yet. Um, and so therefore we don't have it. Why don't we put more money into looking into that? Excellent question. Talk to the NIH.

Darkdiva9- or for that matter the pharmaceutical companies too. I shouldn't just blame the governement. 

Darkdiva92, "ICG food intolerances and Leaky Gut?" What's, hmm. "If you look up online about digestive and health issues, you can find a lot on Leaky Gut, which is intestine permeability. Aparrently this causes a host of health issues. There are also companies that claim ICG food intolerance testing via small pin pricks to know if you have a certain intolerance to different foods."

I'm gonna call mmm on this. Um, Leaky Gut Syndrome is an actual thing. It's not that common. Um, it's not nearly as common as you think it is. Uh, and the idea that it's only about certain foods, I don't actually believe that's the case. Uh, the idea that you can pin prick test yourself for certain foods to tell you if that's gonna give you GI issues, you're sorta going off the reservation there, um, you're just not really focused.

Uh, because that's not well-proven. Um, plus it's like would it be classed as a foods or individual foods? This just isn't as researched as I would like it to be in order for me to actually talk about it and say something really authoritatively one way or the other. I just don't think it's there, so I would be suspicious of companies that are trying to get you to eat their food because they're making these claims. 

Connor(?~11:40), "Is there a way to lessen tolerance to dexamphetamines. I've been prescribed them for the last 7 years. You're 19 now." I'm assuming this is for something like, Attention Deficit Hyperactivity Disorder. Um, to lessen tolerance- I don't know of any. Um, on the other hand, if you've been taking it for 7 years, tolerance would happen long before then.

 (12:00) to (14:00)

Um, it wouldn't take like 7 years to get there. This is something you should probably talk to your doctor about. Uh, about whether you need to continue to take them, about whether there are alternatives, or about whether you need increased doses, exactly what's going on, whether therapy might help. At this point, I would definitely talk to your doctor. 

(?~12:22) says, "Hello! What diseases often produce false positive tests?" That's a really great question. Diseases don't produce false positive tests, tests produce false positive tests. The tests that are- the diseases that are most likely to have false positive tests, for the most part, are really rare diseases. Because if a disease is really rare, then a positive test is more likely to be not real, 'cause the disease is so rare, then unless it's a really really really perfect test.

Um, the other would be if a test is just bad, and if it's not, um I gotta get this right in my head- Oh, I'm not gonna be able to do it. I can't remember if it's sensitivity or specificity off the top of my head, but if doesn't have the right test characteristics, it might also produce too many false positive tests. But that is test dependant. Those are test characteristics, not disease characteristics. 

So first, know that that's a test, not a disease, but if you really- if you really push me, yeah, a disease that's incredibly rare is- So like, if you know, even when we used to do, well problem is we still do, HIV tests. It's rare enough that when they do the first test, a lot of the positives from the first tests are still more likely to be false positive negatives than true positives.

That's why they do the second test, 'cause one is more sensitive, one if more specific. And the one that is one way to begin with lets in more false positives. And that's why we need to rule them out with the second test. But that's not because of HIV, that's because of the tests. 

Alright, we have time for maybe one more. Kenji(?~13:48), "What causes visual snow and why do some people see it all the time like tv static/noise over all visual input? Is there a reason to be concerned about it?" I don't know what causes it. It's gotta be something either in the retina or in your nerves. Um, or in your eye. 

 (14:00) to (15:32)

I mean, like in the vitrious humour or whatnot.

If you're seeing a lot of it, I'd certainly talk to your opthamologist. I don't think it's always a sign of concern but if you're seeing a lot of it it can be sometimes an aura from migraines.

It can sometimes be, you know, I think you're tired. It can also, I think, rarely be a, you know, a harbinger of problems but regardless, it is definitely something worth talking to your eye doctor about so that they can do a full test. And then if you're fine, it's probably something just to monitor.

And I'm gonna stop there because we are actually over time. We will add the questions that are left to next week's Healthcare Triage Live. Check us out on

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