Aaron: I have been assured [laughing] that we are now live. We've been flying by the seat of our pants here. We're doing major construction on the office. As you can see, I'm broadcasting from a hallway because the sets, which used to be way back there, are now turning into offices, and the new sets are being built on another floor, and so things are not what they seem. And, like, this is next to a refrigerator and a microwave, and you can't see, but, like, Mark is sitting on the floor over there and Stan is working behind me, as if we were like on the Morning Joe set. And that's it. So we'll try this again, and for those of you who have been paying attention on Twitter, we actually tried to go live a few minutes ago and I launched into the first five minutes of this, and so now that was practice and we'll try again.

Anyway, let's do some housekeeping first. You should check out facebook.com/healthcaretriage. Lots of people at the Faebook site, we're posting links, we're posting posters, lots of other great information that you can get. Great community. You should go check it out -- link's down below. Also patreon.com/healthcaretraige, can't thank you enough for your support, it's making a real difference in what we can do. We're building a new set! We are, downstairs, and you'll get to see at least a preview of it on Heallthcare Triage News on Friday, and you'll see it in upcoming episodes as we fine-tune it and get it really going. But things like that are only possible, really, with the support we get through things like patreon.com, so thank you to all the people who have become patrons. patreon.com/healthcaretriage. 

We've been off for a few weeks. People have been traveling, people have been to VidCon, things like that, but we hope to get back on normal schedule now. We should be doing Wednesday live shows for at least the next few weeks consistently. Healthcare Triage News is starting up again on Friday, and should be consistent, and Healathcare Triage has been runnin on Mondays without any breaks at all, because we're that prepared. Anyway, let's launch into it. Hopefully this time it's real and people are actually here.

First question, "Dave K," and now I should be really good at this because I've done it before. "Previously you rejected quarterly testing of blood, saying we don't have the context to make the results personally relevant. Wouldn't years of previous results give you the context you need?"

No. No, they shouldn't, and you should go watch the whole episode on this topic, because it'll give you much more detail than I'm going to right now. But the problem isn't thinking that, you know, the levels of the things that we can see on a blood test are very consistent. Um, there's a huge range of what we consider normal. You know, big discrepancies - 4-5-6-7-8-9-10 - sells per high-power field for a white blood cell test, and there's no difference clinically between a four and a 10, there just isn't.

And so, you're four, and then you're nine, and then you're six, and you're six, and you're two, and eight, and ten, and then one day you're 11 - it provides me no extra information to know where you've been over the last few years. 11 is still meaningless unless I can place it in clinical context with the pre-test probability of understanding how sick did I think you were already.

And so, all of that information just doesn't mean anything to a doctor, it just doesn't. If you've been all over the map and then you're suddenly 50, or you've been tight and suddenly you're 50, they're the same thing - we gotta judge 50 because that's all we know how to measure.

That's how the tests were created: That's how the sensitivity and the specificity and the cut-values and what we call the area under the curve and all the test characteristics - they were decided for a specific population, and that's of people who are ill. Not for people who are healthy.

The test for people who are healthy has no value. You should go watch the whole video because it's going to provide you much more information, I'll give you the math, we'll talk about positive predictive value and negative predictive value, and why tests are totally dependent on the population in which they're being drawn, and why it's so important that we consider that and we not try to get in healthy people because it just doesn't have meaning.

If you want to start drawing all those blood values because you want to make a bank or data that we can use for future research, I'm all for that. That's great. But I can't tell me anything about your health at the moment to get all of those extra test; that's why we don't do it.

Second question - "Alan Why - I recently saw an article that robotic surgery has been connected to 144 deaths in the US since 2000 due to various "malfunctions." This equates less than 10/yr, I imagine the humans fare much worse, what are your thoughts?"

I would actually need to see that article because we have to understand some of these in more detail. To say that "robotic surgery has been connected to 144 deaths in the United States in 2000" - does that mean that robotic surgery was found to be the CAUSE of those 144 deaths? Or does that mean robotic surgery was occurring DURING those 144 deaths. Because I believe it's more likely that it's the latter that 144 deaths occurred while people were doing robotic surgery.

Then it would be important to see what were the rates of death for robotic surgery, like, how many deaths is that per surgeries performed, and how does that measure or compare to rates of human deaths - how many humans were doing surgery that caused deaths or that led to deaths, I should say. Or were connected to deaths. Because if the rates are similar, then we don't care. If the rates are skewed one way or the other, that might give us some information. It's also possible that robotic surgery was used in more or less precarious operations, and therefore, that might account for the differences.

The only thing that would make me freak out right away is if you can say to me that it CAUSED 144 deaths that otherwise would not have occurred. And in that case, even then, you have to get back-, it's not just the robot - someone's controlling the robot. Robotic surgery isn't C-3P0s operating on you; robotic surgery is a human is using controls over here and [points Off Screen(OS)] that's controlling a robot over there is operating - it's very still user-dependent. And we'd still need to do further research to say, "Were all 144 of those deaths one person operating? Or were they spread out, or how was it done?"

So, at its face-value, unfortunately, this doesn't tell us much. It's the kind of thing that it's a number that sounds scary in context, and people can write articles to make you freak out about it, but you would need to know much, much more information before you could make any decisions. It may turn out that 144 deaths is phenomenal and so much better than humans would be - we just can't tell.

"Lisa Jones" asks, "Thoughts on baby-led weaning vs. feeding puréed foods? What does the research say?" I'm not exactly sure, Lisa, what you're asking.

So, "baby-led weaning" - I'm assuming what you mean is that the baby is giving you cues that it's sort of done with breastfeeding or perhaps even bottle feeding and ready to start eating solids. I'll assume that's what you mean. And then, "feeding puréed foods" is feeding puréed foods.

So, most pediatricians these days start to advocate for the introduction of solid foods at certain ages - usually somewhere between four and six months - and then we have specific rules about how you do it, which ones to start first, and then to introduce sort of one new food every couple days, you can actually see if there's an allergy and know which food you're doing. And we start with puréed foods because that's what babies are best at; they don't have teeth, they don't know how to chew. You don't want them choking.

But every baby is different. Some babies will advance quickly, some babies will advance slowly, and there ongoing research all the time about whether feeding babies early leads to more bad outcomes or fewer bad outcomes. It used to be that we though if we introduced foods too early it led to allergies. Now it seems that the body of research is now leaning towards the opposite idea - that keeping babies from getting exposed to certain things can lead to significant allergies later.

And so, where's truth? We're not positive. I think the later research seems to have a bit more credibility, but usually I think we're hedging and we're saying introduction in four to six months. But every baby is different, as I said before. Our first child [chuckling], I feel like if I remember, I feel like he was eating steak at an incredibly young age.

And so, getting them on solids, you have to sort of contextualize and figure out what your baby is ready for, and you need to make sure that everything is sort of age appropriate. And certainly don't give them stuff before they have teeth and before they know what they're doing before they can swallow. But usually we start introducing those things at certain ages; we don't necessarily wait for babies to tell us or look for cues, because I'm not even sure that we necessarily train or know what those are these days, at least in many developed countries.

But that doesn't mean that people haven't been surviving for generations and generations, if not hundreds of thousands of years, without pediatricians telling them when to start putting solid foods. And there certainly weren't these puréed baby foods on the market for everyone to eat, and lo - the human race is still here, and we've all survived. So, perhaps everything that I've just said is somewhat overkill. I'm not exactly sure what the best answer would be on this, but I think that certainly most experts would say introduction of solid foods in four to six months and starting with sort of cereals and/or puréed baby foods and moving forward from there.

Next question comes from "Olga Starcher - Are there any good studies on whether the use of probiotics helps with the treatment/management of IBS?" I'm going to assume you mean "irritable bowel syndrome" and not "inflammatory bowel syndrome," which are both IBS. But I haven't seen probiotics for inflammatory bowel syndrome as much; most of it is for irritable bowel syndrome.

So, this is one of those things where there is some evidence that probiotics can help with the symptoms, and it's not the greatest, and it is somewhat contradictory in the sense that some of the studies are not perfect. They use different-, you know, not all probiotics are the same. They're not all the exact same... germ? I can't think of the word I'm looking for here. The same exact compound in the probiotic, and so saying "probiotics" with an "s" and just talking about then en mass is not meaningful, because some studies show results, some studies don't.

But there have been some studies that show that some probiotics do reduce some of the symptoms. But as we talk about in Healthcare Triage all the time, a lot of this is weighing the risk and the benefit, and the risk of probiotic is incredibly slow: a lot of them are not expensive, there's very little downside, and if your symptoms of irritable bowel syndrome are incredibly large - why not? Go for it.

Talk to your doctor, of course, and ALWAYS talk to a medical professional before you do anything; do not take anything I'm saying here to be telling you to treat or use any drugs or to use any therapies - you always need to talk to your own healthcare professional. But there seems to be-, it seems that the potential upside for using a probiotic for your irritable bowel syndrome might be greater than the potential downside, in which case, it's certainly worth talking to your physician about.

"Daniel Hawkson - How strong is the link between statin use and the risk of developing diabetes? How should that link affect the calculation/decision to start a patient on a statin?" So, it depends which study you look at and how you follow it out.

There are people that will argue that the number needed to harm for a statin to get diabetes is shockingly low on the order of 50 or so; there are some people that'll say it's much higher. I think both sides have a point in the sense that even the number we have that's sort of scary looks at a certain number of years, but they look at the years of benefit much further out, and you assume that as you keep people on statins for longer and longer periods of time, the risk of getting diabetes goes higher and higher.

I don't think it should be ignored, but it's one of those where it's not exactly well known. So, certainly if you have a really bad disease, and your doctor really thinks that you need a statin because you're at very, very, high risk for bad outcomes, well then that person, the benefit of a statin may outweigh the risk.

If, however, you're one of the many, many people who seems to have a very low risk, but because of the widening criteria that we use to technically decide people might benefit from statin so your risk/benefit may be very low, your risk of getting diabetes is exactly the same. Because, of course, while the benefit you might see from the drug changes based up on your profile, the harm you might see from the drug - it causing diabetes - absolutely doesn't change whether or not you're at high or low risk for cardiovascular disease. So, the benefit may outweigh risk if you are at high risk for cardiovascular outcomes/bad outcomes. But the profile-, the harms may definitely outweigh the benefits if you're at very low risk.

So, my cholesterol is slightly elevated; my doctor and I had a discussion, I did not want to go on statins, I take red yeast rice. There are some small randomized controlled trials that showed that red yeast rice has some benefit for people with my risk profile, which is pretty low, and I don't want to take the risks of some of the medications - the higher intensive medications - because I just don't think I'm at that high a risk for cardiovascular outcomes given my history, age, diet, and everything else that's involved in my life, and my cholesterol level isn't that high.

So, some people should have this-, everyone should have this conversation with their doctor. But I imagine with some people the risks of developing a side effect of the drug are greater than the benefits they might see, and for some people, the opposite will be true. And this is why medicine is not cookbook, and this is why we still need to have discussions and make individual decisions about what kinds of drugs ad therapies we want to be on.

"Sarah Melnick" asks, "Do antibiotic ointments (Neosporin, bacitracin, bactroban, etc) contribute to antibiotic resistance? If so, is the benefit of their use on small wounds sufficient to outweigh the cost?"

So, when people use these things - unlike taking broad-spectrum antibiotics or putting it on all the stuff - it's pretty concentrated an local. You're using a very tiny amount on a very small amount of your body, so it's not the kind of thing where-, you're not creating resistance in the sense of, like, it's not getting into the water supply really, it's not like it's treating your entire body over a period of time and allowing tons and tons of bacteria - it is very small.

Having said that, these are pretty broad-spectrum antibiotics, but they're also antibiotics that have been around forever; they're not the newest antibiotics that we're worried about, like new-found resistance creating super-bugs. And so, I don't think that most researchers and physicians are worried about the ointments like this being the major culprit of antibiotic resistance.

There's no question that randomized controlled trials show that using ointments like this help wounds heal better and faster, but so do other ointments that keep things moist and covered. And that's what you want to do with the wound - moist and covered. Letting them dry out - huge myth, huge waste of time. That does not work. What works best is really sort of keeping it moist and clean and covered, and that Neosporin is often-, or bacitracin or bactroban are often good ways to do that.

And trials show, and they do randomized controlled trials, again, both on pigs - which happen to have skin very much like humans - and on humans, where they will randomize people. [gestures] "This arm gets the treatment, this arm gets nothing," and they make wounds, "Which heals faster?" And the ones with the ointments and they get covered and moist, those heal faster. I still recommend that with my patients and my kids, and I'm not terribly concerned about that small use being the major culprit with respect to antibiotic resistance being developed in the community.

"Jason Harner" asks, "Do you have an opinion on the "worm wars"? The re-analysis of Miguel and Kremer's deworming trial?" We should probably do an episode on this because this is a big deal, and it's going to require more than I can give you in a quick answer to Live.

The gist of this is that years and years and years ago, big huge trials - I believe in Africa - showed that-. First of all, as we've talked about, parasites are ubiquitous; we did a whole month, remember, on parasites. And HUGE numbers of people are infected with worms in the world - hundreds of millions of kids - I mean, it's huge. And this can have consequences: they can miss school, they can have illness, and it might not kill them, but that doesn't mean that that doesn't affect quality of life.

And what the original studies did was they showed that not only did treating basically broad - I mean, basically everybody - benefit the people getting treated, it treated people at neighboring schools, because, of course, if these kids over here [gestures] don't have worms, then it's very likely that the kids that come into contact with them [gestures adjacent] are going to be less likely to get infected, because they're not getting exposed to kids with worms. So, not only did treating tons of kids have a benefit for them, it had a benefit for people even kilometers away. And that was a big deal, because it made the argument that huge, widespread, universal treatment of worms was massively cost-effective and massively good because it had benefit even beyond what we were doing.

Years and years and years later - like, recently - there were replication and reanalysis and review of the study where they looked at how the research was done and they reanalyzed it and they replicated some of the work that they had done, like with the reanalysis, and they republished it, and it looked like the results - they were arguing - were wrong. That it wasn't the benefit that people were seeing. And therefore, it became this HUGE argument about whether we believe the original study or we believe the reanalysis.

And it's complicated because some of it was replication in the sense they were just repeating the analysis of what had been done before, and there were some mistakes that were done, and they did affect the results a bit, but what they also did was they rethought HOW they would do the analysis, and they made some specific changes to how the analysis was going to go, and that also changed the results.

But those require some debate. In other words, in the original study, I believe, it was over two years - they analyzed the two years together as one big group, and in the redo, they said, "No, no, no. Let's analyze them as two separate years," which, of course, reduces some of the power that you might see. But I think there's an argument to be made that, "I don't know why you have to separate out the years; why can't you do it as one big thing?" We do drug trials all the time where people are entered and enrolled over years, and we analyze them as one big thing. We don't necessarily believe that something is magic about 2013 that is different about 2014, so we could debate whether that was right.

And then they said, "Oh, you know what, they looked at one kilometer and three kilometer and five kilometer circles, and we think it's better to do two kilometer, four kilometer, and six kilometer," and then that'll change the results. But that, again, is a debatable thing.

So, some of the new analysis could be argued, "That doesn't invalidate the original findings." Some of it could. And so, it's much more complicated and sophisticated than you might be. I think, still - if you're asking me on the spot - I still think that the original work holds up. And that it might not be as huge in its effect as might have been said in the original paper, but that the benefit is real, and that it is there, and then it still may be very, very cost-effective. But you know what? This is a good thing; we should probably do a whole episode on this, I think it'd be good. So, tune in later.

"E. Stewart" asks, "What's the reason for waiting 15+ minutes after applying sunscreen before going out in the sun? Everyone says to do it, but no one says why."

So, sunscreen has to be absorbed - at least the non-zinc oxide says -  it has to be absorbed into the skin, and that's what the 15 minutes are for. If I put it on immediately, and then I go out and I start sweating, I could sweat it off; I could go out in the water immediately and wash it off. You need to have some time for the stuff to get absorbed, that's what that time period is for. That's why you're supposed to put it on before you go out, and then even after you go out, you're supposed to be continually reapplying it, because you can still rub it off or lose its effectiveness. But a lot of that is because it needs to be absorbed. There you go.

Next question, "Johnathan Schroeder" asks, "What's your opinion on class-wide or school-wide bans on allergens nuts, etc.? Do the benefits really outweigh the costs? What about bans on alternatives (like soy-based peanut butter replacements)?"

So, most of the costs are inconvenience. You know, let's be honest, it's like when my kid's school refused to let peanuts be brought in for food coming in from the outside; that just meant that you had to make sure that the brownies that were being brought in had no peanuts, they don't need the brownies anyway. And so, it gets a little bit harder for that. The problem is that, of course, you gotta weight both sides of this:

Some of these allergies are not severe, and then maybe it's overkill. But some kids have significant and real, REAL allergies. And they need to be protected. And that sometimes means inconvenience for the other people in the room. And I know that that bothers some people, but [shrugs] this is the cost of living in the civilized world. [camera feed cuts off, sound continues] If we want to care about our fellow human beings, we have to care about our fellow human beings, and sometimes that  means bending what we do to make it easier for the other kids in the school.

Having said that, that doesn't mean that-, it sometimes doesn't go overkill [camera feed returns] just banning everything across the board. And, of course, kids can be allergic to so many things, soon you'll wind up banning food. I don't know that there have been studies that show that these policies (?~21:11) the numbers of cases of anaphylaxis, probably the number of cases of anaphylaxis are pretty small, and the likelihood of picking them up in a trial is pretty small, and so I doubt that we're going to have any kind of randomized controlled trials to prove this. But the pediatrician in me and the parent in my says as long as they're reasonable and they're trying to not go too far, you gotta sometimes bend.

Sometimes my kids invite friends over who have severe allergies, some of my best friends have kids with severe allergies, and of course we make sure that the food we serve them when they come to visit or we go there - when we're bringing dessert over - meets their needs. You want to be nice; it's part of being good. And so, you gotta do that. I understand people's aversion to the policies, and you don't want to do these policies, but until you come up with a better alternative, I don't know what else we can do.

"Caitlin Blanchard - Why are many chiropractors on bad terms with modern medicine? I enjoy the benefits I get from chiropractic care, but every chiropractor I've been to is at odds with vaccines and traditional doctors."

Well, [chuckling] I can't talk for doctors as a whole. My personal issue is that when we do the studies, and they show that it doesn't work, and people continue to do it, that's where I take issue. Because I don't favor care that doesn't work. Unless there's no harm. And with chiropractors, this isn't where I tell my friends who have-, "If you've got money and you want to spend it on chiropractic care, go ahead."

But if you start asking insurance to pay for it, then I want that care to be proven, and if you start charging people who don't have the means to pay for it, and making them spend hard-earned money that they don't really have in excess, and because you keep telling them that it's proven to work - THAT'S where I take exception of it.

And a lot of the research on chiropractic care, unfortunately, shows that it doesn't have much benefit. Sometimes that-, sometimes, SOMETIMES...that leads practitioners of the art to disdain science because it's not lining up with them. And if you start to disdain science, then you start to disdain things like vaccines and everything else. And so, you sometimes wind up being, you know, finding people who are either pro or anti-science and believing what the results of the trials show, and that can line up, and that can be an issue.

But, you know, this is interesting because this is actually, I think, my next-, one of the upcoming topics I'm writing about at the New York Times is gonna be about this dichotomy between alternative and traditional medicine or eastern versus western medicine. I think part of it is that it really should be pro or anti-science.

And western medicine and traditional medicine are just as guilty of ignoring science before. You can pull up any random Healthcare Triage and inevitably, part of the topic is going to be me railing against the fact that research shows one thing and doctors in the medical community seem to ignore it. We are just as guilty of ignoring medicine when it runs against - I mean, ignoring science - when it runs against our biases ALL the time. And everyone could do a better job of following whether or not - [waves someone to cross behind]. You see? Construction going on as we speak, here we go.

Whether or not people are following science. Everybody is guilty of that. It's just easier to see sometimes in areas where we get into alternative or complimentary medicine, but we have problems like this across the board.

"Aaron Schmidt" asks, "Can household chemicals (e.g. soaps and cleaners) be absorbed through the skin and cause problems, especially for children and pregnant women? Any specific products or ingredients we should avoid?"

Yeah! Yeah, I mean, that's why there are warnings on stuff, like, "Don't use this if you're pregnant," or "Don't touch this and (?~24:41), don't get it into your eyes." There's too many for me to even label, but that's why the stuff - the warnings - are on the side of the bottle. Don't assume that it's safe, make sure that it's okay for pregnant women or children. I'm going to start going into the lighting round here because I think we're close to done.

"Liz Barino - Is there any truth to the rumor that banana peels will help take out splinters?" I ha - [feed cuts, returns, asks OS] - does anyone know anything about...?

OS: [unintelligible]

A: How would you a bana-, I don't even know how you'd use a banana peel to take out a splinter. I have no idea, I'll have to look that up.

"Jeffery Davis - My nephew habitually walks on his toes and doesn't seem to want/be able to walk with his heels on the ground. he's 3 yrs old. will he need physical therapy?"

You need to talk to a medical professional. Lots of kids outgrow that, some kids need some help, and sometimes therapy will help when they outgrow that. But I often, you know, a lot of those kinds of behaviors, when I see parents and parents are worrying about a particular young age, I often say, "How many adults do you see walking around entirely on their toes?" The answer is pretty much "none." So almost everybody outgrows those kinds of things, but when you outgrow it, or how best to outgrow it, or maybe whether physical therapy will help in that - talk to your medical professional.

"JackalGirl -  Is recurring edema in both feet without numbness something to be worried about? Is there any way to treat or prevent it beyond elevation exercise and sodium intake reduction?"

Talk to your medical professional! I can't diagnose you from here. I bet you HAVE talked to a medical professional because elevating your feet, sodium intake reduction are both first-line things. There are other things that they can do that require drugs and things like that. It could or could not be something to worry about - you need to talk to a doctor.

And finally, "Nora Muhammad - Is there any research on the benefits of Gluten free Casein free diet for autistic children?" I'm gonna go with "no." Is there any research? Possibly. Is there conclusive research saying that there's a benefit? Not at this time.

And often when I say that, I know I can hear the screams of advocates that I'm "ignoring research" and everything else - you've got to trust me on this. I'm a pediatrician, I'm a parent, I do research; I've done research on how we can improve the diagnosis and proper management of kids with autism - I want kids with autism to get better. I swear to you, if there's research someday that shows that a gluten-free, casein diet benefits, I will put it on Healthcare Triage, I will write about it in the New York Times, I will scream it from the rooftops. If there's something that will benefit children with autism, I want every child with autism to have it. I have no seen any conclusive evidence that these kinds of dietary changes are good for all autistic children.

Does that mean that if you change the diet of a child with autism you might not see some benefit yourself? Of course not. You might. Could be placebo-effect, it could be something. The problem is that when we do the trials, randomize them and figure it out, we can't see any increased benefit in the treatment groups above what we see in the placebo groups. And that means that it's not something we can just advocate and say, "Everyone should do this," because, of course, doing fake placebo stuff works just as well.

And sometimes these diets cost more, they're hard to do, and everything else, and I don't want to make the life of a family with autism any more difficult by trying to stick to a very difficult diet that I don't believe has any kind of benefit.

Having said that, it's your children. You're certainly welcome to feed them like you do, I'm not going to judge you for it. And if you think that it helps, by all means, that's your personal decision. Again, talk to your doctor.

Thank you for turning in to Healthcare-, TUNING into Healthcare Triage Live! Check out our facebook page - facebook.com/healthcaretriage, check out our Reddit, check out patreon.com/healthcaretriage; we appreciate any support you can give us, not that Healthcare Triage will no-, we'll ALWAYS BE FREE! But we'd love to make the show bigger and better, and not have to film outside-, inside a hallway every week, it's a sad time here for Healthcare Triage. Imagine what your contribution could do to help. I'm just kidding.

Anyway! Healthcare Triage News on Friday, Healthcare Triage Monday, catch us next week again - hopefully down in the studio - for Healthcare Triage Live at 11:30 - hopefully next week on time as well. Thank you for watching, tune in later, Mark will have all the questions lined up, all the information you'll ever want about the episode and the questions will be down below - see you next week

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