ACCRAC Podcast: Pediatric Cardiothoracic Anesthesia

There's pediatric anesthesia (they're not small adults). There's cardiothoracic anesthesia (the complex cases are very complex). 

Then there's pediatric cardiothoracic anesthesia. Mind blown. Such a fascinating extremely specialized field.

ACCRAC: The Obesity Code Book Review

This podcast episode was so good and free in knowledge, I decided to listen again and write notes to share. Jed Wolpaw decides to review a book authored by nephrologist Jason Fung. The author also manages the diet of obese patients in a special program and thus has hands-on knowledge/experience to what he's doing (along with access and reviews of various literature).

Interesting points of the author highlighted by Jed (that may or may not be true as research slowly progresses on, as nutrition is difficult to make really good strong studies and the higher authorities have a a knack of making literally wrong recommendations):

1. The low-fat, low-cholesterol, high-grain diet is unscientific and mostly just wrong. The problem is that when it's incorporated in guidelines, it takes time to reverse the wrong advice.
2. Not all calories are the same. Sugar calories are most problematic as they cause high insulin and insulin resistance, which is the crux of the problem; insulin is the main culprit
3. Exercise is important, but the diet is what counts. The body can conserve energy very well, and therefore you'll burn less calories than you think, especially at rest.
4. Persistently high insulin levels from constant eating (including even calorie free sugar substitutes) leads to eventual resistance, leading to a feed-forward spiral of higher insulin levels yet higher resistance. Apparently insulin levels determine the body's "set weight"; with higher insulin levels, the body tries to keep it's set weight higher. The key to weight loss is to keep insulin levels low to reset the set weight lower.
5. Apparently intermittent fasting lowers insulin levels, insulin resistance and thus facilitates weight loss.
6. As fructose is only metabolized by the liver, it eventually leads to fatty liver which itself leads to insulin resistance
7. The book disagrees with constant small meals due to the aforementioned persistently high insulin levels even with the same number of calories
8. Anti-diabetic drugs that increase insulin all cause weight gain, and ditto for other drugs that may have the same effect
9. Sleep deprivation (via cortisol) also causes increased insulin
10. Protective foods to lower insulin: fibers, vinegar
11. The glycemic index is misleading. For example, fructose and Stevia have lower GI's but increases insulin resistance
12. Highly processed oils except olive oil are worse than saturated fats, e.g. butter (which may actually protect than harm), and "full" food options are better than skimmed.
13. Don't skip and make breakfast optional (as the body is adapted to not eat breakfast). Studies on breakfast and mental performance need to be taken with a pinch of salt.
14. No to sweetened beverages. Reduce refined grains
15. Moderate protein intake (it does increase insulin somewhat)
16. Increase natural fats
17. Fast. Muscle is not wasted until you reach low body fats (via increased GH). Your brain can use more than just glucose (ketones too). The BMR does not fall with fasting (apparently adaptive to supply energy for food hunting in times of low food). Hunger usually abates after a few days of acclimatization. Rebound binging rarely occurs with regular fasting. With a good diet, there is no shortage of nutrients. Hypoglycemia does not occur unless in type 1 diabetics as the body adapts to the utilization of fats. Many of these points are a part of established science for anesthesia. Fasting counterintuitively causes a sense of well-being. Muslims and others who practice regular fasting may attest to it.
18. Simply cutting calories overall does not work well as it drops the BMR.
19. This does not apply well to the critically ill, who have different nutritional needs.

I'm sure that I can/should incorporate some of this into my own daily life. It's always good to talk about primary prevention rather than expensive secondary/tertiary prevention of threats to health.

Opioid Crisis Engagement from ACCRAC

It’s pretty clear listening to this podcast that doctors (at least in the states)  are among the guiltiest in the development of the opioid crisis epidemic.

1 billion excess of opioid pills per year post surgery? That’s absurd. 

Quick discharges post surgery is good, but there has to be a much better way of managing postoperative pain and more discriminate painkiller prescribing.