The Bizarre "Morgellons Disease," Psychosis, and Exaggeration

If you are like most people, you have probably never heard of “Morgellon’s disease” or “Morgellons.” The first reason you have likely never heard if it is because it is so bizarre and uncommon. Most of what is known about it is based on rare case reports or anecdotal stories. The second reason is because it is not recognized in the medical community as a legitimate medical disease. It is a layperson’s term coined by a child’s mother (see end of entry).

People who claim to have this once mysterious condition report that all sorts of substances are excreted from their skin such as colored fibers, specks, dots, fuzzballs, worms, eggs, grainy substances, and other assorted solid materials. They report that they develop sores that are slow to heal and feel like bugs are crawling under their skin or have sensations of being bitten, stung, or experience pins and needles.

In addition to the dermatological (skin) symptoms reported, there are other non-specific symptoms reported (meaning they can have many possible causes) such as fatigue, concentration problems, memory difficulties, and depressed mood. Some of these patients have documented psychiatric disorders, some have genuine neurological conditions such as multiple sclerosis, and others have more controversial diagnoses such as fibromyalgia. Some of these patients claim to be disabled by their condition. No known medical cause has ever been discovered.

Most dermatologists consider the condition to be a psychotic disorder, which means that the person is detached from reality. Specifically, it is widely considered to be a form of delusional parasitosis, in which a person falsely believes they are infested with parasites.

Perplexed, the Centers for Disease Control and Prevention (CDC) ordered a study based on a request from Democrat Senator Dianne Feinstein due to an increasing number of people reportedly having this condition in her state of California.

A set of researchers conducted a search for patients in a managed care system with 3.3 million enrollees. 115 patients were found. The average age was 52 (range = 17-93), 77% were female, and 77% were Caucasian. 70% reported chronic fatigue. 54% reported poor health. 50% had drugs detected in hair samples. 78% reported solvent exposure. 24% had clinically significant histories of past or present drug or alcohol use.

But the most interesting part of the study was an analysis of skin samples. The most common finding was increased skin elasticity due to sunburn. Abnormal areas on the skin were most consistent with insect bites and scratched skin. There were no parasites or bacteria found. If there was something on the skin, it was usually was cotton from clothes.

When psychologicaly tested, 59% were reported as having cognitive deficits on a full battery of neuropsyhological tests in at least one area. Attention and memory were the most common areas assessed. Unfortunately, no tests were reported on that were used to confirm the reliability and validity of the cognitive test results and so one is left to wonder to what degree these poor test results are the result of poor effort to do well. This is important to consider because it is unknown how many of these patients were seeking compensation for these symptoms (e.g., litigation, disability application), which would increase the possibility of exaggeration.

Along these same lines, while a personality test known as the Personality Assessment Inventory (PAI) was administered, the authors only reported the results of the clinical scales (showing a high focus on physical symptoms). The results of scales on the test designed to measure the reliability and validity of the test results were not reported. Thus, it is unknown the degree to which some symptoms are over-reported, accurately reported, or underreported. Some of the test performance was almost certainly exaggerated, especially when one considers that of those patients with clinically significant somatic complaints on the PAI, 50% had elevated personality test scores that were at the 99.99%ile, meaning that such scores are essentially never seen in the normal population. In fact, these scores represent extreme symptom endorsement even for patient populations.  Researchers, as well as clinicians, should almost always include methods to assess whether the test performance and symptom presentation is reliable and valid.

Overall, Morgellons shares a number of features with delusional infestation beliefs and based on my read of the study, there is very likely to be an exaggerated component to the condition (at least in some people). It is interesting to note that over 75% of patient’s symptoms occurred after 2002, which was around the time that Internet postings about the topic began. This indicates that there is a suggestible or copy-cat component to Morgellons symptoms in some individuals, although some cases may truly represent psychosis (detachment from reality). The condition can also be considered a form of somatoform disorder, in which psychological distress is converted into physical symptoms that cannot be explained by a medical cause.

As to the origin of the term, it was coined in 2002 by Mary Leitao, who stated she had noticed "balls of fiber" coming out of her 2-year-old's skin prior to sores developing. She found the word "Morgellons" in a 17th century book describing an condition in which black hairs were said to appear on the backs of children in France. However, there is no evidence that the two conditions are related.

Source: Click here to read the research study.

Why Was Demi Moore Hospitalized?

Famous actress, Demi Moore, was recently hospitalized and the media has been busy trying to figure out why. It has been reported that there are three main problems: 1) substance abuse, 2) anorexia, and 3) collapsing due to a seizure.

Anorexia is excessive weight loss associated with an obsessive fear of weight gain. Pictures such as this one lend credence to the anorexia claim because she appears extremely thin.

A seizure is an overexcitable state of nerve cells in the brain. Seizures sometimes manifest as sudden, violent, involuntary contractions of a group of muscles but can also manifest as brief periods of loss of awareness and blinking. Seizures have many possible causes such as a very high fever, bleeding in the brain, drug overdose, and withdrawal from drugs, and anorexia. 

Due to alleged infidelity, Moore released a statement on 11/7/11 that she intended to divorce her much younger husband, Ashton Kutcher. Being a spouse who is the victim of infidelity, especially when placed in the public spotlight, is a very stressful experience. The same is true for divorce. Combine this with the wild Hollywood lifestyle and all of the factors are present for someone to turn to substance abuse as a maladaptive way to ease emotional pain. Anorexia involves the control of food and provides the individual with a sense of control when coping with uncontrollable events (e.g., infidelity). This is another maladaptive coping mechanism, however. Eventually, the body can no longer take the strain of such an unhealthy lifestyle (such as reported exhaustion), brain cells become desynchronized and over-excitable, and a seizure can result. Fortunately, once the underlying cause is treated in cases of substance abuse and anorexia, the person would be expected to become seizure free. She is reportedly being treated for anorexia. Treatment for anorexia involves psychological counseling, medications to reduce obsessions and increase weight, and dietary changes to increase weight gain. Substance abuse treatment primarily relies upon psychological counseling and she is reportedly receiving such treatment. 

Source: Radaronline.com article

Only .01% of the State of the Union Speech Mentioned Healthcare

Last night, President Barrack Obama delivered a 6,944 word State of the Union address to the American people. Of the speech, less than .01% was devoted to healthcare, which is remarkable considering the major changes in healthcare that are on the horizon if Obamacare survives a challenge in an upcoming U.S. Supreme Court case. During the speech, there were only three sentences that mentioned healthcare. The first was this…

“I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage, or charge women differently from men.”
 
While the President is correct that nobody likes when an insurance company cancels their policy, denies you coverage, or charges women differently from men, there are sometimes legitimate business reasons why this happens. I will use a personal example to explain this. Recently, I applied for a long-term disability policy. The insurance company paid the costs for me to have a physical exam and have routine blood tests. After a few weeks, they sent me a letter saying that they would give me the insurance, but that they would not pay me for any type of disability related to my back since I have a history of low back pain. On the one hand, I was disappointed because I would have preferred a policy without any conditions like this.

On the other hand, I understood the insurance company’s perspective. That is, the insurance company realized that I was at increased risk to claim disability per their statistics because I have a history of low back pain. Low back pain is one of the main reasons people claim disability in the U.S., and many of the cases are exaggerated or malingered. Insurance works when most people paying into the system can reasonably be expected to be healthy because those funds are needed to pay for those who become disabled. If the number of disabled patients outweighs those paying the insurance premium, then the insurance company will lose money. Thus, they seek to identify those at risk before granting coverage and add exceptions to the contract.

In my case, I decided not to accept the deal. It is a free market and I can shop around for different policies. I realize that if I find that an insurance company that is willing to give me a disability policy without any conditions attached that it will cost me more money for the insurance. The reason is because the extra costs helps partly cover the added potential cost that to the insurance company, which is taking a greater risk. Sure, I could demand the government pass a law preventing the insurance company from making such exclusions but if that happened, one needs to realize that the insurance company will likely go out of business one day and people will be left with government run healthcare (see statement three below). While some people think that this is good, it is important to remember that many doctors refuse to take patients with Medicare or Medicaid coverage because the reimbursement is so poor, the system is filled with beaurocracy, and they do not want to take the risk of making an innocent billing mistake yet find themselves charged with fraud. To be fair, many healthcare providers have also begun to refuse to take private insurance because of poor reimbursement, denials, and tedious paperwork, although this is less common. 

While it may feel like insurance companies have unchecked power, they actually do not. For example, many people do not realize that when they have a dispute with an insurance company and feel that they have been treated unfairly, they can call their state insurance agency, file a complaint, and unfair decisions and practices can be penalized and/or reversed. The state’s Attorney General’s Office also has the power to investigate insurance companies and apply sanctions against them. On the federal level, The Health and Human Services Department and the Justice Department are another check and balance on insurance companies that can and has been used many times in the past.

The second healthcare statement is the State of the Union speech was:

“Today, the discoveries taking place in our federally-financed labs and universities could lead to new treatments that kill cancer cells but leave healthy ones untouched.”

While this is a true statement, it leaves out that privately financed labs and universities also lead to new treatments to fighting cancer in this manner and in many other ways.

The third statement on healthcare in the State of the Union address last night was:

“That’s why our health care law relies on a reformed private market, not a Government program.”

This was the statement that I found to be most controversial. While it is true that there would be reforms in the private market with Obamacare, these reforms are not unrelated to a government healthcare program. Specifically, under Obamacare millions of citizens would be placed on government-run healthcare. To pay for the system, people who are not insured but refuse to take government-run healthcare will be fined, as will companies who do not provide the government-run healthcare option to their employees. While privately funded healthcare insurances are focused on making a profit (which some see as a bad thing), government run healthcare has no such constraints (although this can also be a bad thing). At a certain point, if a privately run healthcare system runs out of funds to support its beneficiaries, it will need close. For any insurance company to work properly there simply must be more funds coming in than going out. Private insurances cannot continue to function by simply requesting more money from Congress, much like government run healthcare can. This can be viewed as an unfair advantage that government run healthcare has over private insurances. As a result, many private healthcare companies can shut down, resulting in most people being forced to go on government run healthcare.

No matter where you stand on healthcare, expect to see this topic debated significantly during the next election.

Man Shoots 3 Inch Nail Into His Brain and Lives

This is something you will hopefully never see on the next episode of This Old House, but in Oak Lawn, Illinois, a man accidentally shot a 3.25-inch nail into his head and lived to tell about it. The interesting thing is that he did not even know he had done this and thought he had just cut himself with the nail gun.


The man went to the hospital to get checked out, received an x-ray, and doctors showed him the above picture. He thought they were joking. The reason he did not realize what he had done is because the brain does not have any pain receptors. Many people do not know this but it is true. The pain receptors in the head are in the skull. The man did not even go to the hospital that day. In fact, he continued to do some snow plowing that day. The next day he awoke, felt nauseous, and went to the hospital.

Fortunately doctors were able to remove the nail after a two hour procedure in which they drilled two burr holes in his skull, later replacing the skull pieces with titanium mesh. He apparently did not suffer any serious effects of the injury or the surgery. Injuries to the brain like this are referred to as penetrating brain injuries. The more common example is a gunshot wound to head, but bullets are more dangerous because they break into multiple pieces once they enter the brain and also fracture the skull significantly. A good example of this was the case of Gabrielle Giffords who is permanently brain damaged and recently had to resign from Congress after being shot in the head by Jared Loughner. Nails on the other hand, have a smaller sharp tip and usually a shorter trajectory than bullets, so one would not break apart when entering the brain. I am glad this man got through this ok. Moral of the story is that if you use a nail gun, keep it away from your head!

Reference: The Associated Press

Why Sports Leagues Need to Pay Attention to Malingering

One of the most fascinating areas in medicine and psychology is the study of symptom exaggeration and malingering. Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs (APA,1994).

FEATURED BOOK: Mild Traumatic Brain Injury and Malingering

In a prior blog entry, I discussed why physicians need to pay attention to malingering, but sports organizations need to pay attention to this as well. In sports, players are often routinely administered a battery of tests designed to measure thinking abilities (e.g., memory, thinking speed) before the seasons begins (known as baseline testing) to be used as a comparison point after an injury during season. The purpose is to use the follow-up testing to determine if the person is recovered after the injury, although there are numerous problems with this approach. One such problem is that some players intentionally perform poorly during the baseline testing so that future test results obtained after an injury will not look to be as low as they actually are.

Famous NFL quarterback, Peyton Manning admitted to doing this when he said: "They have these new (brain) tests we have to take. Before the season, you have to look at 20 pictures and turn the paper over and then try to draw those 20 pictures. And they do it with words, too. Twenty words, you flip it over, and try to write those 20 words. Then, after a concussion, you take the same test and if you do worse than you did on the first test, you can't play. So I just try to do badly on the first test."

Another area where faking is happening in sports is in college and professional football. The technique is used to slow down the other team’s momentum in the hopes of gaining an advantage that can be used to increase the chances of winning the game. Winning games in college and professional football increases the chances of fame, fortune, and other external incentives.

Here is an example from a New York Giants Game earlier this year.



And here is an example from a recent college football game.



Here are several other examples in college football.

And here is yet another example from the NBA playoffs of malingered head injury (watch how the player's head never hits the ground). He was fined $5,000 by the NBA for faking this injury, which an NBA official described as "...a gross over-embellishment and was inconsistent with the degree of contact received on the play."

But what I found most fascinating was a panel discussion about this on television in reaction to the Giant players faking injuries because it echoed the debates that often take place on this topic in the fields of medicine and psychology. That is, on one side you have people who are upset that this is taking place, believe that authorities should do something to stop it, and that there should be stiff penalties for faking. On the other hand, the player (akin to the malingering patient) acknowledges that faking takes place but tries to excuse it as a tactical maneuver (and not cheating), advises that one should do this in a way to avoid getting caught, and brazenly states that attempts to stop it will never work because he believes it cannot be proven. The debate also raised the topic of false positives (the problem of saying someone is faking when they are not) and other issues.
Fortunately, there are reliable and valid methods that health care professionals can use to assess malingering that greatly minimize false positives. Behavioral observations, including video evidence (e.g., surveillance), can also play an important role in assessing malingering and appears to be the main tool that NFL and college football leagues will have to assess the apparent faking demonstrated in the videos above. If these leagues begin to crack down on this issue, my prediction is that more sophisticated attempts at deception will emerge rather than some of the unsophisticated measures used above.

Disclosure: The author of this blog in the co-editor of the book, Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering.

Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th ed. Washington, DC: American Psychiatric Association; 1994.

New York Neuropsychologists Leave State Psychological Association

Neuropsychologist members of the New York State Psychological Association (NYSPA) resigned from the organization en masse in December 2011 after years of conflict within NYSPA regarding the state’s ban on the use of neuropsychology technicians.


The resignations included current and past presidents of NYSPA’s Neuropsychology Division, which led to a vote to formally close the division and to place NYSPA in a position where it no longer represents the voice of neuropsychology in New York State. Many of the neuropsychologists who left are national leaders in the field leaving a gaping hole in the association.

For over 50 years, neuropsychologists in New York, as in the rest of the country, utilized trained technicians to assist with testing services performed under their direct supervision. The tests can be administered by technicians (also known as psychometrists) who work under the licensed psychologist and are trained to strictly adhere to manualized test administration procedures with clear and easy to follow instructions. The licensed psychologist always determines the treatment plan including all selection of tests, interpretation of results, report writing consultation with other professionals, and feedback regarding evaluation results. Thus, the technician’s job is purely mechanical, much like a technician who assists in running an X-ray machine. The radiologist does not actually run the x-ray machine but interprets the results.

Technician practice is critical in the access and delivery of health care. If medical doctors were required to collect all of the data necessary for diagnostic evaluations, our health care system would be overly burdened by cost and it would be impossible for patients to access quality care. Unfortunately, this is the current situation in New York State for psychologists trained to practice neuropsychology.

The practice of psychology pertaining to the use of technicians in New York changed in 2003 following passage of the state’s psychology scope of practice law. Despite a documented legislative intent stating that no such change would occur, an idiosyncratic and rigid interpretation of the law by the State Education Department’s (SED) led to a complete restriction on the use of technicians for psychologists throughout the state. Essentially, a parenthetical phrase was included in the scope of practice law stating the practice of psychology includes neuropsychological testing. This was then interpreted to mean that anyone besides a psychologist performing neuropsychological testing was practicing psychology without a license and that any psychologist facilitating this was aiding and abetting criminal behavior. In this way, the new interpretation essentially made it illegal for psychologists to use technicians to assist with testing services.

New York State licensed psychologists trained in the specialty of neuropsychology banded together following the 2003 interpretation with the goal of obtaining a reversal of the SED’s interpretation that would allow a return to the lawful use of neuropsychology technicians. Most initial efforts were made at fighting opposition within NYSPA, particularly from its School Psychology and Clinical Psychology divisions as well as the State Psychology Board, who generally supported the ban imposed by their department. These groups continued to oppose technician use despite being presented with statements from multiple state and national professional organizations, including Division 40 (Neuropsychology) of the American Psychological Association (APA), the National Academy of Neuropsychology, the American Academy of Clinical Neuropsychology, the American Board of Professional Neuropsychology, and the APA Practice Directorate. These groups routinely noted that use of technicians is a standard practice in neuropsychology throughout the country with functions that are recognized and reimbursable under existing national billing codes such as 96119 (neuropsychological testing by a technician).

After years of continued discussion and conflict, neuropsychologists within NYSPA reached a tentative agreement with opposing psychologists and obtained support from the NYSPA Council of Representatives in 2007 to move ahead toward an administrative solution to further clarify SED’s interpretation so that it was more flexible with regard to technician use. In order to reach the 2007 accord with a NYSPA committee tasked to address the issue, neuropsychologists made a major concession towards school psychology that technicians would not be allowed to administer full intelligence tests and would not work in school systems. This concession was made even though technician use in assessment had never been problematic to school psychologists during the lengthy period prior to 2003 when it was legal.

In spite of the concessions by the NYSPA Neuropsychology Division, members of the School Psychology and Clinical Psychology divisions continued to lobby against NYSPA’s support and sought further restrictions for technicians, including attempts to prevent them from working with individuals less than 21 years of age and from administering most existing tests to individuals from any age group. These restrictions were sought by the opposing psychologists without any supporting evidence to back their claim technicians would be harmful to the public. The opposition continued despite clear documented evidence sent to SED (including documentation from an independently appointed advisor to SED to study the issue) that there was a restricted access to care in the state for receiving neuropsychological services. This led to long waiting lists that significantly affected the elderly (i.e., delaying a dementia or depression differential diagnosis which would lead to different treatments) and ethnic minorities, particularly those who spoke another language because there was no longer the ability to employ technicians who spoke the necessary languages to administer the tests.

The issue that eventually led to the recent mass resignations was that, after making concessions and reaching an initial agreement within NYSPA, the organization’s council of representatives returned to the issue four years later and voted against the use of technicians on administering even parts (subtests) of IQ tests, a critical element of almost all neuropsychological assessments. Neuropsychologists use these subtests due to their robust norms and to aid with the diagnostic process.

If neuropsychologists would have accepted the results of the vote, it would eliminate the way the vast number of neuropsychologists practice. This was considered totally unacceptable to neuropsychologists, who concluded that the organization was out of step with national practice standards and that neuropsychology could not have their interests represented by a group composed of so many disparate fractions who do not understand the intricacies of neuropsychological practice, some of whom were actively communicating with SED in an attempt to create further division, opposition, and prevention of a reasonable resolution. Although there were some members of NYSPA who were supportive, including the last three NYSPA presidents, the opposition by the School and Clinical Psychology Divisions led the day.  Mass resignations from NYSPA resulted and the Neuropsychology Division ceased to exist.

Neuropsychologists in New York are fortunate to have another organization to turn to after leaving NYSPA. In 2006, neuropsychologists in the state formed the New York State Association of Neuropsychology (NYSAN). This organization was initially formed on the recommendation of the APA Practice Directorate to establish a professional entity that could receive funding to hire a professional lobbyist to work at overturning the technician ban. Over the years, NYSAN has been supported generously by APA Neuropsychology Division and the other organizations mentioned above to continue its lobbying efforts. However, NYSAN has also branched into other areas of activity including development of an active Professional Affairs Committee (PAC), which has now become a major force within the state for representing neuropsychologists’ interests in negotiations with third party payers. Neuropsychologists in the state are urged to join NYSAN and help it develop as the only voice for neuropsychology in New York State and to continue its fight against opposing factions in Albany and within NYSPA. Neuropsychologists from across the country will surely be watching.

Disclaimer: Dr. Carone is a neuropsychologist who was President of NYSAN for 3.5 years.

Does More Information Lead to Healthier Life Choices?

The following is a guest blog entry.

One thing we are not in want of these days is information. Through the internet you can find out just about anything about everything – so long as you know where to look. When it comes to public health awareness such technology couldn't be more priceless. The ability for individuals to research health and medical topics is groundbreaking in that while doctors and other medical professionals are as necessary as ever, they decreasingly need to be tasked with answering questions and can instead focus more on finding the most appropriate cure. Meanwhile, members of the public can spend less money on reassurances that they are in fact not dying of cancer, at least not anytime soon.

But when it comes to such knowledge playing a part in preventive measures and thus improving the quality of life for people, it does not seem as though access to health information makes much of a difference. Amidst the advent of the Internet, this country has only seen easily-preventable illnesses skyrocket and easily-treatable afflictions increasingly be left untreated due to rising costs. Take diabetes for example. Despite type 1 diabetes news and updates, as well as more than enough information covering type 2, the symptoms of the former are more commonly being ignored due to rising healthcare costs while the latter is occurring in record numbers because individuals do not see the writing on the wall about their own health. On the surface, online sources of information such as DiabeticConnect.com don't seem to work as ideally as they ought to be.

Yet ask medical experts and researchers what the problem is when it comes to American healthcare and they'll likely tell you that it's a lack of public awareness regarding health information. Such is the reason why the majority of 2010 healthcare reform law was written as to assign the government a stronger role in public health awareness. The theory goes that once people are able to have enhanced access to health and medical information, they'll be less likely to wait till their maladies become costly before getting help and much more likely to prevent such health problems altogether.

Medical professionals across the country are eager to see such long-awaited awareness efforts put into action on a governmental scale. But aren't we forgetting the fact that the overwhelming majority of Americans have had immediate home-based access to health knowledge for years? We've had the information right in front of us thanks to the web, yet we seem to carry on living the unhealthy lives that we do until the day comes when our bad habits transform into a $70,000 emergency surgery.

With that said, the entirety of health related information that can be found online is not exactly vetted by the medical community. For every WebMD there are millions of quack sites that hand out health information that is either outdated, out-of-sync with the majority medical opinion, or outright false. While finding the safe sources of health and medical information is quite easy, a decade of such fraudulent webpages finding their way to the top of search engine results has established a distrust of health-related information online by the majority of the public.

So are we simply waiting for trustworthy information to improve our health with? Or is it that no matter how much preventive awareness is thrown our way we'll still behave as though today's health choices are not going to affect tomorrow? Such are the questions medical professionals have been asking themselves for quite sometime, and it's unlikely we'll get the answer anytime soon.

So Just How Dangerous are Cruise Ships?

As the world continues to watch a large cruise ship submerged off the coast of Italy, everyone watching this must have wondered what it would have been like if they found themselves in that scenario. Those who are averse to cruises found an additional reason never to go on a cruise, despite the fact that cars are a far more dangerous method of transportation, at least in terms of crash rates. Although sinking ships are rare, more common is the risk of contacting an infectious disease due to being in close quarters for extended periods with many strangers. However, another risk factor that does not get much attention is the risk of injury from falling in cruise ships.

A few years ago, researchers the University of San Diego studied this topic more closely and found that about two patients a year fell on major cruise ships from 2002 to 2005 and that the rate rose to 8 in 2006. All but one patient was female. Three of the eight patients had other significant medical problems. All eight of these patients were injured from falls, five of which happened in stairwells. The most common injury was concussion (mild traumatic brain injury). Five patients were discharged home, two needed care in extended rehabilitation facilities, and another died. In the case series studied by the authors, falls were the sole cause of major injury among cruise ship passengers. So while you can be pretty confident that if you go on a cruise that it will not sink, take common sense safety precautions to avoid falls of cruise ships.

Reference:
Am J Prev Med. 2007 Sep;33(3):219-21.
Significant injury in cruise ship passengers a case series.
Bansal V, Fortlage D, Lee JG, Hill LL, Potenza B, Coimbra R.

Do Old People Really Like the Nintendo Wii Fit?

Today, I dusted off the Nintendo Wii Fit exercise board that had collected a layer dust under my TV stand. It is winter in Syracuse and I wanted to get moving and have a little family fun along the way. It was a fun time and afterwards I went online and started catching up on some of the exercise programs on the Wii. While searching, one image I kept coming across were senior citizens seemingly having a blast playing with the Wii. It’s fun, don’t get me wrong, but does this image really reflect reality? It may be a stereotype, and I know there are exceptions, but most older people I know do not seem very excited to embrace new technology.

So, I did a scientific literature search and lo and behold, I came across an interesting study from Australia that examined this issue. The researchers studied 21 older hospitalized people prior to and after using the Wii Fit during physical therapy. However, when therapy was completed, most preferred traditional physical therapy as opposed to physical therapy programs that used the Wii Fit.

The authors of the study concluded that “Mainstream media portrayals of the popularity of the Wii Fit with older people may not reflect the true acceptability in the older hospitalized population.” Unfortunately, the researchers did not study why the patient’s had this preference. Nevertheless, if you are thinking of getting the Wii Fit for grandma or grandpa, you may want to take the above study into account before making your decision. You can read the full article here.

Write Your Own Funny Caption #1

I figured I would start a new feature on the MedFriendly Blog called Write Your Own Caption. Basically, just look at the picture above, sign into the blog (it is free and quick to register) and post a comment with a caption that you think is a funny way to describe the picture. All replies are moderated an no obscenities or patently offensive humor will be published. Look forward to seeing what you all come up with.

Is 27 Really a Dangerous Age for Musicians?

Famous singer, Amy Winehouse, died on 7/23/11 of alcohol poisoning. She was 27-years-old.

Famous singer, Kurt Kobain, committed suicide and died in 1994. He was 27-years-old.

Famous singer, Brian Jones, died from a drug and alcohol overdose. He was 27-years-old.

The list goes on and on.

Many famous singers have died at age 27 and belong to what has become known as The 27 Club, Club 27, the Curse of 27, or the Forever 27 Club. Other famous members include Jimi Hendrix, Janis Joplin, and Jim Morrison. So, is there a real risk associated with dying at age 27 (among musicians or the general population) or are these deaths just a coincidence? Could treatment programs for alcoholism anywhere have made a difference? A group of researchers (mostly statisticians) set out to answer the first question. The researchers studied all solo artists and band members between 1956 and 2007 who had a number one album in England. This led to 1046 musicians.

Of the musicians, 71 had died, which is 7%. About one musician died for every 200 musicians at age 27. However, near identical death rates were seen for musicians at age 25 and 32. There was no increased risk of death among musicians at age 27. However, musicians are more likely to die in their 20s and 30s compared to the general UK population, but that is likely due to lifestyle choices (e.g., drugs and alcohol). The latter is my own personal interpretation. However, the authors concluded that the 27 club is unlikely to be real and that an increased risk of early death among musicians is not limited to age 27. Another myth taken down by evidence-based data. The full article can be read here.

The Most MedFriendly Popular Blog Entries of 2011

Although the MedFriendly Blog made its official daily return in September 2011, I decided it would be interesting to see what entries were the most popular last year. The top 5 most popular entries are listed below. One theme is that people clearly like the entries with extreme body parts and images. Will a 4th entry be coming in 2012? I may just have to come up with one given how popular this topic is. The ADHD critique was likely popular as it concerns my profession of neuropsychology and because the entry was featured on KevinMD.com. People also like consumer oriented stories, which is likely why the give ways to evaluated suspicious medical treatment claims article was popular. Without further ado, here are links to the top 5 entries in 2011...

1. Amazing Images of EXTREME Body Parts: Almost cracking 1000 page views, this one comes in number one at 954 page views.

2. New ADHD Guidelines and the Omission of Neuropsychology:  541 page views.

3. More EXTREME Body Parts: This was the follow-up to the first article and comes in at 508 page views. This sequel does not disappoint.

4.  Five Ways to Evaluate Suspicious Medical Treatment Claims: 478 page views

5. Even More and More Extreme Body Images...: 294 page views

Have You Seen the MedFriendly Message Board?

As the New MedFriendly redesign is in full swing, I want to take a moment to alert people to a MedFriendly feature they may not be aware of and are thus not taking advantage of. On the top of every new redesigned page, you will see a link at the top to the MedFriendly Message Board. It is the largest medical message board in the world where just about every conceivable healthcare topic has a home. And if you happen to think of a healthcare area that there is no topic for, just send in an email and the topic will be created. In a message board you get your own customizable screen name, picture/image, and you can ask questions and have discussions on just about any healthcare topic. Please give the message board a look, sign up (it’s fast and free), ask your friends and family to sign up too, and start some discussions. Looking forward to seeing your posts soon!

Guest Blog Entry: How the SpeechTrans Language Translator Can Enhance Communication in Healthcare

Before Medfriendly.com, understanding the meaning of complex medical terms was a daunting task. But what do you do if you speak a foreign language or are are in a foreign country, where others do not speak your langauge?

SpeechTrans is the Universal Language Translator from Star Trek brought to reality. It allows people who speak different languages the ability to communicate without the need for an interpreter.  SpeechTrans’ Automatic Speech Recognition Engine is powered by Nuance Communications, Inc. the maker of the popular Dragon Medical software used by Doctors worldwide to accurately transcribe patient information.  SpeechTrans can recognize and translate over 300,000 words including complex Medical Terms. SpeechTrans currently recognizes the following languages, with more being added as free updates- English, Spanish, German, Italian, French, Portuguese, Polish, Russian, Finnish, Swedish, Danish, Chinese- Cantonese, Chinese-Mandarin, Japanese, Korean and Taiwanese.

Doctors, Nurses and Medical Staff can now communicate with their patients and patient’s family with 100% confidence that language barriers will not be an issue. Here are a few testimonials:

“Your app saved my patient's life.  When Maryland Firefighter/ Medic was treating a Spanish speaking patient suffering from a Diabetic Coma, SpeechTrans came to the rescue.  Unable to get an interpreter on Dispatch, Alex used SpeechTrans to communicate.  He was able to determine the patient’s medical History using SpeechTrans, thereby avoiding the standard treatment which would have resulted in a Fatal Allergic Reaction." -- Alex Hamburger

"I can say for one, that the Landstuhl Army Regional Medical Center as well as the Heidelberg Medical Center here in Germany, would love a chance to play with this App. We are piloting the use of iPads within the Army hospitals here next month.  This App would be ideal for all the local German Nationals we get.  I make a site visit to Heidelberg on Wednesday, those guys are gonna go nuts for this." -- Ron

The next time you have a medical emergency, let SpeechTrans help you.  Now, if they only made the Medical Tri-Corder. To learn more about SpeechTrans, please visit their website at www.speechtrans.com 

This guest Blog entry was written by John Frei Co-Founder and CEO of SpeechTrans Inc.

Fastfood Wars: Final Pizza Results Are In

When the MedFriendly Fast Food Wars began, I decided to analyze the nutritional information from the top pizza chains in the United States to help people make healthier selections. Originally, I planned to analyze the four mega pizza chains (Pizza Hut, Domino’s Pizza, Papa Johns Pizza, and Little Caesars) as well as Pizzeria Uno (Uno Chicago Grill) and Sbarro’s. While I was able to do the analyses on the first five pizza restaurants, I was very disappointed to find out that Sbarro’s has no nutritional information that it provides about its products on their website or in their stores. I called Sbarro’s headquarters and was informed that their foods are being re-tested and that they would not release old nutritional information because it would be misleading. Unfortunately, they've been saying this for over a year.

As a reminder, the analyses conducted below are based on a formula I created called the UHI (UnHealthy Index). The UHI is calculated by taking the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), adding them together, and dividing by six. Higher UHI scores reflect unhealthier foods and scores closer to zero (i.e., water) reflect healthier foods. Also, please keep in mind that the serving sizes designated by the pizza chains were what I used to compare the products. Since Domino’s Pizza products were only analyzed for large pizzas, I did not analyze extra-large pizzas from other pizza chains for the comparisons in these articles. Desserts were not included in these analyses since Chicago Uno has a dessert menu that is in a different category than any of the other pizza chains. Without further ado, here are the results of the pizza analysis.

UNHEALTHIEST FOOD OVERALL:

The unhealthiest food in all five pizza chains is…

Pizza Hut’s 9" Personal PANormous™ Pizza, Meat Lover’s version. It contains pepperoni, beef topping, mild sausage, ham, Italian sausage, bacon bits and mozzarella cheese. The serving size for analysis is the entire pie, which is appropriate because it is a personal pizza. This bad boy has 1470 calories, 30 grams of saturated fat, 1.5 grams of trans fat, 175 mg of cholesterol, a whopping 3670 mg of salt (!), and 123 grams of carbohydrates. Total UHI score: 911.58. This is the only product reviewed across the five pizza chains with a UHI in the 800 range of higher.

The 9" Personal PANormous™ Pizzas are among the unhealthiest products across the major pizza chains. Four of them are in the 700 UHI range, all of which can found on the Pizza Hut comparison page, four are in the 600 UHI range, and three are in the 500 UHI range. If you had to buy one, the healthiest one would be the Veggie Lovers, with a UHI of 576.9.

UNHEALTHIEST ITEMS BY NUTRITIONAL CATEGORY:

Highest calories: 1470 (Pizza Hut’s 9" Personal PANormous™ Pizza Meat Lover’s version)
Highest saturated fat: 30 grams (Pizza Hut’s 9" Personal PANormous™ Pizza Meat Lover’s version)
Highest trans fat: 2 grams (Pizza Hut’s Fried Cheese sticks, 4 pieces)
Highest cholesterol: 175 mg (Pizza Hut’s 9" Personal PANormous™ Pizza Meat Lover’s version)
Highest sodium: 3670 mg (Pizza Hut’s 9" Personal PANormous™ Pizza Meat Lover’s version).
Highest carbohydrates: 129 grams (Pizza Hut’s 9" Personal PANormous™ Pizza Meat Lover’s version)

TRANS FAT AWARDS

MedFriendly congratulates Little Caesers and Papa Johns for not having trans fats in any of their food products.

UNHEALTHIEST APPETIZER OR SIDE ITEMS (includes bread, chicken wings, and salads):

Chicago Uno’s Chi Town Tasting Plate Contains buffalo wings, avocado egg roll, chicken thumbs, crispy cheese dippers, and French fries. Total calories = 470, saturated fat = 6 grams, trans fat = 0 grams, cholesterol = 85 grams, sodium = 1030 mg, carbohydrates = 28 grams. Total UHI = 269.83. Serving size = 5. Keep in mind that these values are only for one serving size and that you would need to multiply these numbers by 5 to calculate the values for the entire plate.

UNHEALTHIEST DIPPING CUP/SAUCES:

With the exception of Pizza Hut, the other pizza chains all provide nutritional information for dipping cups and causes. The unhealthiest of these is the:

Domino’s Pizza Hot sauce. It as 150 calories, 0.5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, a whopping 1480 mg of sodium, and 3 grams of carbohydrates. Total UHI: 272.25.
And now that we’ve dealt with the unhealthiest foods, here is some information on the healthiest overall food choices. These analyses for healthiest foods overall does not include dipping cups, sauces, or beverages.

HEALTHIEST FOOD OVERALL:

Domino’s Pizza’s Garden Fresh Salad. Each half-bowl has only 70 calories, 2.5 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 80 mg of salt, and 5 grams of carbohydrates. Total UHI score: 27.92. Serving size = half-bowl.

HEALTHIEST OVERALL PIZZA (REGULAR CRUST):

Remember, that for fair comparisons, values were calculated for a large (14”) pizza only.
Little Caeser’s 14" Round HOT-N-READY Pizza, Just Cheese. Each slice has only 240 calories, 4.5 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 410 mg of salt, and 30 grams of carbohydrates. Total UHI: 117.42.

HEALTHIEST APPETIZER/SIDE ITEM:.

These analyses exclude salads, which has already been documented above to be the healthiest item on one of the menus. When performing the analyses, it became clear that the healthiest items were in the chicken wing category but that some places used a serving size as two wings and Little Caeser’s used a serving size of one wing. Therefore, calculations were performed for TWO wings for each restaurant. Results showed that the healthiest appetizer across the five pizza chains is:
Dominos Pizza’s Buffalo Chicken Kickers . Every two wings has only 100 calories, 1 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 280 mg of salt, and 7 grams of carbohydrates. Total UHI: 68. Keep in mind that this is without adding any additional sauce.

HEALTHIEST DIPPING CUP/SAUCE:.

Papa John’s Cheese Sause. Each cup (28g) of cheese has only 40 calories, 1 grams of saturated fat, 0 grams of trans fat, 5 mg of cholesterol, 160 mg of salt, and 1 grams of carbohydrates. Total UHI: 34.

REFERENCES FOR MEDFRIENDLY’S PIZZA CHAIN FOOD ANALYSES:

•    Dominos Pizza
•    Little Caesers
•    Papa John’s
•    Pizza Hut
•    Uno Chicago Grill (Pizzeria Uno)

The Myth that Mouthguards Prevent Concussions

A popular myth amongst the public, athletes, and some health care providers is that use of a mouthguard reduces the chance of sustaining a concussion (aka mild traumatic brain injury). As this article will demonstrate, however, the claim is often cited without reference to any empirical evidence or when evidence is cited, a review of the cited studies shows that a significant overstatement has been made based on available data.

An example of a claim that mouthguards reduce concussions that can be found in the popular press was the following statement by Ron Wilson, head coach of the Toronto Maple Leafs: "We're trying to get all our players to wear mouthguards. If you get hit and you're wearing a proper mouthguard, it lessens the chance of a concussion." The theory is that a mouth guard prevents concussions after a blow to the jaw (in which forces are thought to move upwards to the base of the brain) by positioning the jaw in such a manner that it absorbs the impact forces instead of the brain. Now let us examine what the data shows in terms of whether mouthguards actually reduce concussion.

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Review of the evidence

The most comprehensive scientific review on the topic of mouthguards and concussions was conducted by Knapik et al. (2007). Their conclusion was as follows: "However, the evidence that mouth guards protect against concussion was inconsistent, and no conclusion regarding the effectiveness of mouth guards in preventing concussion can be drawn at present.” (p. 118). Note that all underlined sections in this article are emphasized by myself and not the original authors. The authors also discuss “…a lack of evidence for concussion prevention (regarding mouth guards).  The inconsistency among studies is problematic and makes it impossible to determine conclusively whether mouthguards reduce concussion risk at present.” (p. 139). In fact, the authors even cite some evidence that concussion rates are higher among mouth guard users than non-mouth guard users. Lastly, the authors state, “There is currently insufficient evidence to determine whether mouthguards offer protection against concussion injury, and more work of good methodological quality is needed.” (p.140).

Review of specific studies

Here are some reviews of articles on the topic of mouthguards and concussions that were found during a literature search on PubMed, and what these articles say on the topic.

BARBIC ET AL. (2005).  These authors performed a multicenter randomized controlled study and concluded that, “In this study, concussion rates were not significantly different for varsity football and rugby players who wore the WIPSS Brain-Pad mouth guard compared with other types of mouth guards.” (p. 94). The American Academy of Neurology’s (AAN’s) definition of concussion was used. The based on observations by trained health care professionals, not a survey.

BLIGNAUT ET Al. (1987). The authors performed a cross-sectional study of 321 college rugby players who did or did not use mouthguards. The authors stated, “We conclude that injuries sustained at rugby in this study were not associated with the use or non-use of mouthguards.” (p. 5). These injuries included concussion. The study, however, is flawed because it is based on survey data and does not provide a definition of concussion.

GARON ET AL. (1986).  This study is based on survey data from 754 male football players who were asked about mouthguard use and history of various injuries, including concussion. The study is flawed because it is based on survey data and does not provide a definition of concussion. The authors found 15 concussions reported in the mouthguard use group and 14 reported in the non-mouthguard use group. This is not a significant difference and does not provide any evidence of mouthguard effectiveness for concussion reduction.

LABELLA ET AL. (2002).  In this study of male Division I college basketball players (also flawed due to survey data and not clearly defining concussion in the article) the authors concluded, “Custom-fitted mouthguards do not significantly affect rates of concussions or oral soft tissue injuries, but can significantly reduce the morbidity and expense resulting from dental injuries in men’s Division I college basketball.” (p. 41).

MARSHALL ET AL (2005).  This was a study of rugby players assessed weekly for injuries based on whether they did or did not wear mouthguards. The authors found that, “The risk of concussion was not lessened by the use of padded headgear (RR = 1.13, 95% CI: 0.40–3.16) or mouthguards (RR = 1.62, 95% CI: 0.51–5.11)”  (p. 113).  Unfortunately, no definition of concussion was provided by the authors and information was based on self-report only.

MIHALIK ET AL. (2007). These authors found that mouthguard use does not decrease the severity of concussion and that neurocognitive deficits after concussion did not differ between athletes who used mouthguards compared to those who did not. The study involved 180 athletes who were followed prospectively after a baseline cognitive assessment was performed. Unfortunately, the definition of concussion used in this study was not described. It was also not specified how a concussion was identified beyond having athlete’s complete self-report questionnaires.

TAKEDA ET AL. (2005). These authors performed experiments in which they struck an artificial skull model with a pendulum. They found that use of a mouthguard significantly decreased distortion of the mandibular bone and acceleration of the head. Based on this, the authors theorized that mouthguards may have the potential to reduce concussions. However, this is speculative and is not data that allows one to make any firm conclusions about this topic in living human beings.

WISNIEWSKI ET AL. (2004).  The authors studied 87 Division I College football teams and found no advantage of wearing a custom made mouthguard over a boil-and-bite mouthguard to reduce the risk of concussion. Concussions were recorded by athletic trainers but the definition of concussion was not described.

Why the Myth Continues

The main reason why the mouthguard myth continues is because people misread (or do not read) peer reviewed research articles, authors make misleading statements, and/or because authors cite flawed studies to support their claims without noting the caveats. An example can be found in the study by Kemp et al. (2008). If one were to just review the abstract of the paper, one would see the following statement: “Mouthguard and headgear usage was associated with a reduced incidence of concussive injury.” (p.227). However, it is not until one reads the actual manuscript where it is found that this statement is misleading. Specifically, the manuscript states, “The incidence of concussions sustained by players not wearing mouthguards was higher than those wearing mouthguards, but it did not reach statistical significance; the average severity of concussions was similar for wearers and nonwearers.” (p. 229). In science, if a difference is not statistically significant, there is no real difference between the two groups. In fact, the authors later go on to state the following: “Similarly, research to date indicates that the wearing of mouthguards does not reduce the incidence of concussion in rugby.” (p. 232-233).

It should not come as a surprise to anyone keeping up with the research literature on this topic that there is no conclusive evidence that mouthguards prevent concussions since McCrory addressed this very topic in 2001. In that paper, McCrory noted that, “The ability of mouthguards to protect against head and spinal injuries in sport falls into the realm of ‘neuromythology’ rather than hard science.” McCrory shows how two often cited papers have been used to perpetuate this myth.
The first paper often cited was by Stenger et al. in 1964. In this study, the authors reported their observations of a season of Notre Dame University football. They anecdotally reported one case in which they felt that mouthguard use abolished the symptoms of repeat concussion. The case includes the implausible claim that the patient could not recall a game or scrimmage dating back to highschool in which he had not either partly or completely lost consciousness. Despite this claim of losing consciousness every game and scrimmage, the patient made his way onto a Division I football team as an All-American. In the Stenger paper, there were 10 cases of concussion during the entire season, which did not provide enough data to perform statistical analysis of a protective effect. In addition, all of their data was speculative. The most the authors could do was speculate that mouthguards may reduce concussions since mouthguards alter the position of the mandible.

The second paper often cited is by Hickey et al. (1967). This study did not even examine living people, but instead used mouthguards fitted to cadavers (also known as dead people). The author showed that mouthguards could reduce forces applied to the head after a blow to the jaw. This was then used by later authors as evidence that mouthguards reduce concussion risk in living people, although Hickey et al. never made such a claim. The problem is that this is obviously a huge generalization which does not provide any direct proof of reduced concussion risk in living humans. In addition, the degree to which a cadaver’s skull responds to trauma is different from how the skull of a living human would respond.

In 1998, a review by Chalmers (1998) stated, “Moreover, there is evidence that mouthguards are effective in protecting against concussion and injuries to the cervical spine.” (p. 339). He cites numerous studies as evidence to support his statement. These studies are Clegg (1969), Fricker (1983), Kerr (1986), Jagger and Milward (1995), Johnsen and Winters (1991), Powers et al. (1984), Stenger at al. (1964), and Chapman (1985). Let us examine these studies one by one.

CHAPMAN (1985a): The author states that “The use of mouthguards should be encouraged in all contact sports as the most important value of the mouthguard is the concussion saving effect following impact to the mandible. This fact alone should make the wearing of mouthguards compulsory in all contact sports.” (p. 27). The problem is that no references are listed to support the claim. However, earlier in the article, the authors reference the Hickey et al. study (see above for discussion) as support for wearing a mouthguard in sports.

CLEGG (1969): Regarding mouthguards, the author states, ”It reduces the incidence of concussion caused by blows from under the chin.” (p. 341). No references were cited by Clegg to support the statement.

FRICKER (1983): Not a single mention of concussion or brain injury is made in the article.

JAGGER (1995): The author states that, “The increased separation between the head of the glenoid fossa that occurs at the increased vertical dimension should also decrease the transmission of force from the mandible to the cranial base and thus reduce the risk of concussion.” (p. 31). The reference was Chapman (1985b). Chapman (1985b) stated: “Thus, standard mouthguards protect against orofacial injuries (dental injuries, intraoral and circumoral lacerations and jaw fractures) and concussion.” (p. 25). The references cited were Clegg (1969; see above), Davis and Knott (1984) and Chapman (1985c). Davis and Knott (1984) is a dental article with no mention of concussion. Chapman (1985c) states that mouthguards result in reduced injury to facial regions and “…a reduction in the concussion force from a blow to the mandible.” (p. 34). The references were Clegg (1969; see above), Upson (1982) and Davies et al. (1977).  The articles by Davies and Upson (1982) make no mention of mouthguards reducing concussions.

JOHNSEN & WINTERS (1991): The authors state that, “The use of mouthguards reduces the likelihood of concusssions, cerebral hemorrhage, unconsciousness (“knock-out“), or other serious central nervous system injuries and even death.“ (p. 658). Three references were cited, a) Hickey et al. (see above), b) Stenger et al. (see above), and c) Godwin et al. (1968). The reference to Godwin is odd because it is a dental article that does not contain a single mention of concussions or any other type of central nervous system problem.

KERR (1986): The author states that mouthguards “…prevents fractures, dislocations, and concussions.” (p. 417). The author references Hickey et al. (see above) and Cathcart (1959). Note that the reference in the text is to Cathcart (1959) yet the biography lists Cathcart (1952) and that the actual reference is really from 1951. The Cathcart article does not make a single mention of concussions.

POWERS ET AL. (1984): The authors state that, “The mouth protector reduces forces that may cause concussions, neck injuries, and jaw fractures.” (p.84).  The reference? You guessed it. Hickey et al. yet again (see above).  A few sentences later the authors state: “According to some observers, an additional benefit was a reduction in the number of concussions and neck injuries occurring among football players.” (p. 84). The reference was Stenger et al. (see above) and News of Dentistry (1972).  The News of Dentistry reference discussed the 1971 University of Connecticut football program. It stated that no players wearing a mouthguard suffered a concussion but two players who wore a mouthguard did not. This was what was offered as support for “key protection” when the reality is that the numbers are too small to make any sweeping generalizations about a protective effect.

STENGER ET AL. (1964): See above.

Conclusions

As this article has demonstrated, there is no strong scientific evidence that mouthguards prevent or reduce concussive injuries. Despite this, a myth continues to exist in the media, among coaches, the public, and some health care providers that mouthguards prevent or reduce concussions. As was detailed above, this belief owes its historical roots to the citation of articles that do not support the claim. Many of the cited articles contain no mention of concussions or refer back to two articles from the 1960s based on one living person and one dead person. This article highlights the need for statements to be based on evidence and for people to check the sources of information and critically analyze them before believing a particular claim. Mouthguards do play a role in reducing dental and oral-facial injuries and are recommended by many physicians for this express purpose.

References

Barbic et al. (2005). Comparison of Mouth Guard Designs and Concussion
Prevention in Contact Sports. A Multicenter Randomized Controlled Trial. Clin J Sport Med, 15, 294-298.

Blignaut et al. (1987). Injuries Sustained in Rugby by Wearers and Non-Wearers of Mouthguards. Brit.J.Sports Med., 21, 5-7.

Cathcart, J. (1951). Mouth protectors for contact sports. Dental Digest, 57, 346-348.

Chalmers, D. (1998). Mouthguards Protection for the Mouth in Rugby Union. Sports Med, 25, 339-349.

Chapman PJ. (1985a). Concussion in contact sports and importance of mouthguards in protection. Aust J Sci Med Sport, 17, 23-7.

Chapman (1985b). The bimaxillary mouthguard. Increased protection against orofacial and head injuries in sport. Australian Journal of Science and Medicine in Sport, 17, 25-28.

Chapman (1985c). Orofacial injuries and the use of mouthguards by the 1984 Great Britain Rugby League Touring Team. British Journal of Sports Medicine, 19, 34-36.

Clegg JH (1969). Mouth protection for the rugby football player. Br Dent J,127, 341-3.

Davies et al. (1977). The prevalence of dental injuries in rugby players and their attitudes to mouthguards. British Journal of Sports Medicine, 11, 72-4.

Davis and Knott (1984). Dental trauma in Australia. Australian Dental Journal, 29, 217-21.

Fricker JP. (1983) Mouthguards. Aust J Sports Med Exerc Sci, 15, 22-3.

Garon et al. (1986). Mouth protectors and oral trauma: a study of adolescent football players. J Am Dent Assoc, 74, 112, 663-665.

Godwin, W. (1968). Stress transmitted through mouth protectors. J Am Dent Assoc. 77, 1316-20.

Hickey J. et al (1967). The relation of mouth protectors to cranial pressure and deformation. J Am Dent Assoc, 74, 735–40.

Jagger RJ, Milward PJ.(1995). The bimaxillary mouthguard. Br Dent J., 178, 31-2

Johnsen DC and Winters JE. (1991). Prevention of intraoral trauma in sports. Dent Clin North Am, 35, 657-66

Kemp et al. (2008). The Epidemiology of Head Injuries in English Professional Rugby Union. Clin J Sport Med ,18, 227-234.

Kerr IJ. (1986). Mouthguards for the prevention of injuries in contact sports. Sports Med, 3: 415-27.

Knapik et al (2007). Mouthguards in Sport Activities History, Physical Properties and Injury Prevention Effectiveness. Sports Med, 37, 117-144.

Labella et al (2002). Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc., 34, 41-4.

Marshall et al. (2005). Evaluation of protective equipment for prevention of injuries in rugby union. International Journal of Epidemiology, 34, 113–118.

McCrory (2001). Do mouthguards prevent concussion? Br J Sports Med, 35:81–82.

Mihalik et al. (2007). Effectiveness of mouthguards in reducing neurognitive deficits following sports-related cerebral concussion. Dental Traumatology, 23, 14-20.

News of Dentistry (1972). Fitted mouthguards afford key protection, Journal of the American Dental Association, 84, 531..

Powers et al. (1984). Mouth protectors and sports team dentists. Bureau of Health Education and Audiovisual Services, Council on Dental Materials, Instruments, and Equipment. J Am Dent Assoc, 109, 84-7.

Stenger et al. 91964) Mouthguards: protection against shock to head, neck and teeth. J Am Dent Assoc, 69: 273-81.

Takeda et al. (2007). Can mouthguards prevent mandibular bone fractures and concussions? A laboratory model with an artificial skull model. Dental Traumatology, 21, 134-140.

Upson, N. (1982).  Dental injuries and the attitudes of rugby players to mouthguards. British Journal of Sports Medicine, 16, 241-44.

Wisniewski et al. (2004). Incidence of cerebral concussions associated with type of mouthguard used in college football. Dental Traumatology, 20, 143-49. 

Fast Food Wars: Uno Chicago Grill

Uno Chicago Grill (formerly known as Pizzeria Uno) is the fifth and last pizza restaurant to be subjected to analysis in the Fast Food Wars. I decided to enter them into the competition because it is a place where many people across the U.S. go for pizza, despite the fact that they do not deliver. Of all the pizza restaurants that will be analyzed in the Great Pizza Battle, Uno Chicago Grill is the one that most typifies a standard sit-in dining restaurant with a broad menu. To keep the analyses fair and on the same level with the traditional pizza chains reviewed, the analyses listed below are limited to all pizzas (deep dish and thin crust pizza), appetizers, and deserts.
As a reminder, the analyses conducted below are based on a formula I created called the UHI (UnHealthy Index). The UHI is calculated by taking the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), adding them together, and dividing by six. Higher UHI scores reflect unhealthier foods and scores closer to zero (i.e., water) reflect healthier foods.

First, a word about pizza serving sizes at Uno Chicago Grill, which can be confusing if you examine the nutritional menu. The serving sizes for deep dish pizzas state Ind: 3 or Reg: 6. “Ind” means individual and “Reg” means regular. An individual pizza is 7 inches and a regular pizza is 10 inches. Each is sliced into 6 pieces. Thus, the serving size for an individual pizza is 2 slices and for a general pizza is 1 slice. For thin crust pizzas, the serving size is two slices.

UNHEALTHIEST FOODS OVERALL:

First, let’s start with the five foods on the Uno Chicago Grill menu with the highest UHI scores. The unhealthiest food you can purchase at Uno Chicago Grill in the above categories is the...

1. Chicago Classic Deep Dish Pizza. This is a pizza that contains sausage and pork. Each serving has 770 calories, 18 grams of saturated fat, 0 grams of trans fat, 75 mg of cholesterol, 1640 mg of salt, and 40 grams of carbohydrates. Total UHI score: 423.83

2. Numero Uno Deep Dish Pizza. This pizza contains sausage, pepperoni, pork, and brick. Total calories: = 640, saturated fat = 12 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 1200 mg, carbohydrates = 41 grams. Total UHI = 323.

3. Lobster BLT Thin Crust Pizza. Total calories = 510, saturated fat = 10 grams, trans fat = 0 grams, cholesterol = 85 grams, sodium = 1160 mg, carbohydrates = 33 grams. Total UHI = 299.66.

4. Prima Pepperoni Deep Dish Pizza. Total calories = 610, saturated fat = 12 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 1040 mg, carbohydrates = 39 grams. Total UHI = 290.16.

5. The Chi Town Tasting Plate. Contains buffalo wings, avocado egg roll, chicken thumbs, crispy cheese dippers, and French fries. Total calories = 470, saturated fat = 6 grams, trans fat = 0 grams, cholesterol = 85 grams, sodium = 1030 mg, carbohydrates = 28 grams. Total UHI = 269.83. Serving size = 5.

WORST ITEMS BY NUTRITIONAL CATEGORY:

Highest calories: 770 (Chicago Classic Deep Dish Pizza)

Highest saturated fat: 18 grams (Chicago Classic Deep Dish Pizza; Uno Deep Dish Sundae [serving size = 2]; Banana’s Foster [serving size = 1; Mega Sized Deep Dish Sundae [serving size = 5])

Highest trans fat: 0.5 grams (Cheeseburger Deep Dish Pizza). All other items analyzed in the above categories have no reported trans fat.

Highest cholesterol: 145 mg (Bread Pudding with caramel sauce, serving size = 2)

Highest sodium: 1640 mg (Chicago Classic Deep Dish Pizza)

Highest carbohydrates: 96 grams (Mini White Chocolate Chunk Deep Dish Sundae, serving size = 1)

UNHEALTHIEST APPETIZERS:

1. The Chi Town Tasting Plate. Contains buffalo wings, avocado egg roll, chicken thumbs, crispy cheese dippers, and French fries. Total calories = 470, saturated fat = 6 grams, trans fat = 0 grams, cholesterol = 85 grams, sodium = 1030 mg, carbohydrates = 28 grams. Total UHI = 269.83. Serving size = 5.

2. Three Way Buffalo Wings. Total calories = 430, saturated fat = 8 grams, trans fat = 0 grams, cholesterol = 135 grams, sodium = 970 mg, carbohydrates = 3 grams. Total UHI = 257.66. Serving size = 3.

3. Three Way Buffalo Bites. Total calories = 320, saturated fat = 2 grams, trans fat = 0 grams, cholesterol = 60 grams, sodium = 1070 mg, carbohydrates = 20 grams. Total UHI = 245.33 Serving size = 3.

4. Muchos Nachos. Total calories = 460, saturated fat = 8 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 810 mg, carbohydrates = 54 grams. Total UHI = 229.5. Serving size = 3.

5. Buffalo Chicken Quesadillas. Total calories = 350, saturated fat = 8 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 890 mg, carbohydrates = 36 grams. Total UHI = 220.66. Serving size = 3.
   
UNHEALTHIEST DESSERTS:

1. Mini White Chocolate Chunk Deep Dish Sundae. Total calories = 660, saturated fat = 14 grams, trans fat = 0 grams, cholesterol = 80 grams, sodium = 390 mg, carbohydrates = 96 grams. Total UHI = 206.67. Serving size = 1.

2. Uno Deep Dish Sundae. Total calories = 700, saturated fat = 18 grams, trans fat = 0 grams, cholesterol = 70 grams, sodium = 310 mg, carbohydrates = 95 grams. Total UHI = 198.83 Serving size = 2.

3. Mega Sized Deep Dish Sundae. Total calories = 700, saturated fat = 18 grams, trans fat = 0 grams, cholesterol = 70 grams, sodium = 310 mg, carbohydrates = 95 grams. Total UHI = 198.83 Serving size = 4.

4. Bananas Foster. Total calories = 640, saturated fat = 18 grams, trans fat = 0 grams, cholesterol = 90 grams, sodium = 260 mg, carbohydrates = 82 grams. Total UHI = 181.66. Serving size = 1.

5. Bread Pudding with Caramel Sauce. Total calories = 450, saturated fat = 16 grams, trans fat = 0 grams, cholesterol = 145 grams, sodium = 330 mg, carbohydrates = 46 grams. Total UHI = 164.5. Serving size = 2.

KIDS MENU:

If you are going to get pizza from the Kids menu, the most unhealthy items is the Kids Pepperoni Pizza (UHI: 250.33) and the Kids Deep Dish Pepperoni Pizza (UHI: 249.83). The healthiest pizza on the kids menu is the Kids Cheese Pizza with a UHI of 219.83. The Kids Deep Dish Pizza comes in a close second with a UHI of 219.67.

SAUCES:

Uno Chicago Grill has eight sauces to choose from. The unhealthiest sauce is the Asian sauce, with a UHI of 139. This is because the sodium level is 710. The 2nd unhealthiest sauce is the Buffalo Garlic (UHI = 96.3) and the 3rd unhealthiest is the Buffalo Wing (UHI 88.83). The other sauces are relatively equivalent with UHIs in the 40s to 60s range. The healthiest sauce is the tamarind cashew sauce, which has a UHI of 41.66and is the only sauce with a UHI in the 40s. The serving size for the tamarind cashew sauce is 57 grams and the other sauces have a serving size of 43 grams.

HEALTHIEST FOODS OVERALL: (excluding sauces)

1. The healthiest item you can purchase at Uno Chicago Grill in the pizza, appetizers, or desert section is the

house made guacamole. It has only 235 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 230 mg of salt, and 32 grams of carbohydrates. Total UHI: 82.25. Serving size = 2.

2. Mini Bananas Foster. This dessert has 350 calories, 9 grams of saturated fat, 0 grams of trans fat, 45 mg of cholesterol, 140 mg of salt, and 46 grams of carbohydrates. Total UHI: 98.33. Serving size = 1.

3. Mini All American Apple Crumble. This dessert has 320 calories, 8 grams of saturated fat, 0 grams of trans fat, 50 mg of cholesterol, 250 mg of salt, and 44 grams of carbohydrates. Total UHI: 112. Serving size = 1.

4. Mini Hot Chocolate Brownie Sundae. This dessert has 370 calories, 8 grams of saturated fat, 0 grams of trans fat, 60 mg of cholesterol, 190 mg of salt, and 54 grams of carbohydrates. Total UHI: 113.66. Serving size = 1.

5. Avocado Egg Rolls. Each egg roll has 270 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 25 mg of cholesterol, 350 mg of salt, and 38 grams of carbohydrates. Total UHI: 114.08. Serving size = 2.

HEALTHIEST PIZZAS OVERALL:

Now that you have a sense of which appetizers and desserts to steer towards, let’s move to the pizzas. The healthiest pizzas on the menu are all in the thin crust domain. According to the Chicago Uno restaurant I called, these pizzas are about 9 inches. For these pizzas, the serving size is two out of six slices. Rankings are as follows:

1. Thin Crust Roasted Eggplant Spinach & Feta . Total calories = 290, saturated fat = 3.5 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 560 mg, carbohydrates = 38 grams. Total UHI = 151.08.

2.Thin Crust Cheese & Tomato . Total calories = 280, saturated fat = 5 grams, trans fat = 0 grams, cholesterol = 20 grams, sodium = 590 mg, carbohydrates = 33 grams. Total UHI = 154.66.

3. Thin Crust BBQ Chicken Multigrain. Total calories = 330, saturated fat = 4.5 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 550 mg, carbohydrates = 39 grams. Total UHI = 160.58.

4. Thin Crust BBQ Chicken. Total calories = 340, saturated fat = 5 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 660 mg, carbohydrates = 39 grams. Total UHI = 180.66.

5. Thin Crust Gluten Free Veggie. Total calories = 320, saturated fat = 4.5 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 710 mg, carbohydrates = 43 grams. Total UHI = 182.08.

Note: Soft drinks were not subject to analysis.

From the Uno Chicago Grill website:

All nutritional information is derived from a computer analysis of recipes with the help of "Genesis R&D SQL", nutrition and labeling software, from ESHA Research in Salem, Oregon and data from our suppliers. The nutrition information provided is based on standard recipes that may vary based on portion size, regional and seasonal differences in products or substitution of ingredients. This information is not to be used by individuals with special dietary needs in lieu of professional medical advice. The nutritional information is subject to change.

Fast Food Wars: Pizza Hut

Pizza Hut is the fourth pizza restaurant to be subjected to analysis in the Fast Food Wars because it was recently ranked as the pizza chain with the most stores by Pizza Magazine. In fact, I was surprised to learn that in 2008, Pizza Hut had almost twice as many stores (14,759) than Domino’s Pizza (8,641). According to the Pizza Hut Wikipedia entry, they have approximately 34,000 restaurants, delivery/carry-out locations, and kiosks in 100 countries.

As a reminder, the analyses conducted below are based on a formula I created called the UHI (UnHealthy Index). The UHI is calculated by taking the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), adding them together, and dividing by six. Higher UHI scores reflect unhealthier foods and scores closer to zero (i.e., water) reflect healthier foods.

UNHEALTHIEST FOODS OVERALL:

First, let’s start with the five foods on the Pizza Hut menu with the highest UHI scores. By far, the absolute unhealthiest food you can purchase at Pizza Hut is the...

1. 9" Personal PANormous™ Pizza Meat Lover’s version. It contains pepperoni, beef topping, mild sausage, ham, Italian sausage, bacon bits and mozzarella cheese. The serving size for analysis is the entire pie, which is appropriate because it is a personal pizza. This bad boy has 1470 calories, 30 grams of saturated fat, 1.5 grams of trans fat, 175 mg of cholesterol, a whopping 3670 mg of salt (!), and 123 grams of carbohydrates. Total UHI score: 911.58.

The remaining unhealthiest foods at Pizza Hut are also all members of the 9" Personal PANormous™ Pizza, so this is really something you want to veer away from. Here are the stats.

2. 9" Personal PANormous™ Pizza Spicy Italian version: Total calories: = 1220, saturated fat = 22 grams, trans fat = 1.5 grams, cholesterol = 115 grams, sodium = 3150 mg, carbohydrates =126 grams. Total UHI = 772.42.

3. 9" Personal PANormous™ Pizza Triple Meat Italian version: Total calories = 1280, saturated fat = 23 grams, trans fat = 1 gram, cholesterol = 135 grams, sodium = 3070 mg, carbohydrates = 123 grams. Total UHI = 772.

4. 9" Personal PANormous™ Pizza Supreme version: Total calories = 1270, saturated fat = 24 grams, trans fat = 1.5 grams, cholesterol = 130 grams, sodium = 2920 mg, carbohydrates = 125 grams. Total UHI = 745.08.

5. 9" Personal PANormous™ Pizza Dan’s Original version: Total calories = 1270, saturated fat = 23 grams, trans fat = 1 grams, cholesterol = 125 grams, sodium = 2810 mg, carbohydrates =124 grams. Total UHI = 725.5.

No other Pizza Hut menu item had a UHI in the 700 range.

UNHEALTHIEST ITEMS BY NUTRITIONAL CATEGORY:

Highest calories: 1470 (9" Personal PANormous™ Pizza Meat Lover’s version)

Highest saturated fat: 30 grams (9" Personal PANormous™ Pizza Meat Lover’s version)

Highest trans fat: 2 grams (Fried Cheese sticks, 4 pieces)

Highest cholesterol: 175 mg (9" Personal PANormous™ Pizza Meat Lover’s version)

Highest sodium: 3670 mg (9" Personal PANormous™ Pizza Meat Lover’s version)

Highest carbohydrates: 129 grams (9" Personal PANormous™ Pizza Meat Lover’s version)

UNHEALTHIEST APPETIZERS AND SIDE ITEMS (includes chicken wings and stuffed pizza rollers):

1. The unhealthiest appetizer or side item you can purchase at Pizza Hut are the cheese sticks (4 pieces). It contains 380 calories, 9 grams of saturated fat, 2 grams of trans fat, 40 mg of cholesterol, 1020 mg of salt, and 29 grams of carbohydrates. Total UHI score: 246.6.

The remaining unhealthiest appetizer of side items you can purchase at Pizza Hut are all in the Crispy Bone In Wings section. The following information is for every two chicken wings you eat.

2. Crispy Bone In Wings Buffalo Mild version: Total calories = 230, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 1040 mg, carbohydrates = 16 grams. Total UHI = 222.33.

3. Crispy Bone In Wings Buffalo Burnin Hot version: Total calories = 230, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 1020 mg, carbohydrates = 16 grams. Total UHI = 219.

4. Crispy Bone In Wings Buffalo Medium version: Total calories = 230, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 1010 mg, carbohydrates = 16 grams. Total UHI = 217.3.
   

5. Crispy Bone In Wings Spicy BBQ version: Total calories = 240, saturated fat = 2.5 grams, trans fat = 0 grams, cholesterol = 50 grams, sodium = 950 mg, carbohydrates = 19 grams. Total UHI = 210.25

DESSERTS:

Pizza Hut essentially has two desserts to choose from: Cinnamon Sticks (2 pieces) or HERSHEY'S® Chocolate Dunkers® (2 pieces). If you had to choose, the healthiest choice is the Cinnamon Sticks, which has a UHI of 66.25. The Chocolate Dunkers have a UHI of 73.3. If you add the 2 oz white icing for the cinnamon sticks or the 1.5 oz of HERSHEY'S® Chocolate Sauce®, you are adding 36 and a half UHI points for each.

HEALTHIEST FOODS OVERALL:

1. The healthiest item you can purchase at Pizza Hut (excluding beverages, dipping sauces, and small desert glazes) would be 2 pieces of Cinnamon sticks. It has only 170 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 200 mg of salt, and 26 grams of carbohydrates. Total UHI: 66.25.

2. Assuming you’re fast food hunger will not be satisfied by two cinnamon sticks, then you can move up to the second healthiest item which is the healthiest appetizer on the menu: the Traditional Wings All American version. Every two wings have only 80 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 40 mg of cholesterol, 290 mg of salt, and 0 grams of carbohydrates. Total UHI: 68.58.

3. HERSHEY'S® Chocolate Dunkers® (2 pieces). Every two pieces have 200 calories, 4 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 210 mg of salt, and 26 grams of carbohydrates. Total UHI: 73.3.

4. The apple pie side item. Every two pies have 330 calories, 5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 190 mg of salt, and 40 grams of carbohydrates. Total UHI: 94.16.

5. “BUT I CAME HERE FOR PIZZA!” you proclaim. Well, you’re in luck. The fifth healthiest item on the menu is a slice of the 12” Fit 'n Delicious® Pizza (Green Pepper, Red Onion & Diced Red Tomato version): Each slice has 150 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 400 mg of salt, and 24 grams of carbohydrates. Total UHI: 97.58.

HEALTHIEST PIZZAS OVERALL:

1. As noted above, the healthiest pizza at Pizza Hut is the 12” Fit 'n Delicious® Pizza(Green Pepper, Red Onion & Diced Red Tomato version) with a UHI of 97.58.

2. One slice of the 9” Pizza Mia Pizza, cheese only. Each slice has 200 calories, 4 grams of saturated fat, 0 grams of trans fat, 15 mg of cholesterol, 490 mg of salt, and 24 grams of carbohydrates. Total UHI score: 122.16.

The remaining most healthiest pizzas are all from the 12" Fit 'n Delicious® Pizza, so it is nice to see that it objectively lives up to its advertised name. Serving size is 1 slice.

3. 12" Fit 'n Delicious® Pizza, Chicken, Red Onion, & Green Pepper version (one slice): Total calories = 180, saturated fat = 2 grams, trans fat = 0 grams, cholesterol = 20 grams, sodium = 510 mg, carbohydrates = 23 grams. Total UHI = 122.5.

4. 12" Fit 'n Delicious® Pizza, Ham, Red Onion, & Mushroom (one slice): Total calories = 160, saturated fat = 1.5 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 550 mg, carbohydrates = 23 grams. Total UHI = 124.9.

5. 12" Fit 'n Delicious® Pizza, Ham, Pineapple, & Diced Red Tomato version (one slice): Total calories = 160, saturated fat = 1.5 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 550 mg, carbohydrates = 24 grams. Total UHI = 125.08.

Note: Soft drinks were not subject to analysis.

From the Pizza Hut website: Nutritional values not applicable to Pizza Hut products in Hawaii. Substitutions of ingredients may alter nutritional values. Menu items and hours of availability may vary at participating locations. Although this data is based on standard portion product guidelines, variations can be expected due to seasonal influences, minor differences in product assembly per restaurant and other factors. Some menu items may not be available at all Pizza Hut restaurants, and certain locations may at times offer buffet items, test products, limited-time offerings or other regional menu choices not listed here. Product data is based on current formulations as of date of posting. If you have any questions about Pizza Hut and nutrition or are particularly sensitive to specific ingredients or foods, please contact us at 1-800-948-8488.