On Vacation

Dear readers,
I will be rafting the rapids on the Colorado River for the next week. Stay healthy, wear lots of sunscreen and visit EverythingHealth again in about a week.
TB

Common Drug Interactions

Did you know that a lack of acid in the stomach significantly affects the body's ability to absorb thyroid hormone? That is just one of many facts that patients often don't know. Here are a few others:


* Proton Pump Inhibitors (PPI's like Prilosec, Aciphex, Protonics, Nexium) reduce calcium absorption. If you are on these pills,(and millions of people are) you will need extra Calcium.

* Warfarin (Coumadin) levels are increased if you take Prednisone also. The list of drugs that interacts with warfarin is long so make sure you ask your physician for the list and monitor all of the meds you take.

* Thyroid hormone (Synthroid, Levoxyl)will not be absorbed if taken with Iron,PPI's, Antacids or Calcium. Make sure your doctor knows if you take any of these with Thyroid pills.

* Antifungals (Nizoral, Sporanox)also depend upon acid for absorbtion. PPI's block acid in the stomach so these expensive pills that treat fungal infections will not work if you take acid-blockers also.

*Statins (Mevacor,Lipitor,Crestor,Pravachol)have increased toxicity risk if used with Niacin, Erythromycin or Biaxin, Verapamil or protease inhibitors.

These are just a few of the interactions we see with commonly used medications. The amount of medical knowledge a doctor must keep in his/her head has outstripped brain neurons. Electronic Health Records will help us all because they have decision support that alerts a physician when drug interactions are likely. But under 18% of doctors have this type of EHR tool, so until that time...make sure you keep an up to date medication list in your wallet and pull it out at every doctor visit. Visit my prior post on medication errors for more tips.

Chatty Doctors

Wow, I read an article in the New York Times on "Chatty Doctors" and had to gulp and wonder if I have ever done that. It seems researchers videotaped 100 primary care doctor-patient interactions and they found the doctors talked about themselves in 1/3 of the visits. This wouldn't be so bad except they never circled back to the patient's issues and wasted a lot of the precious visit time chatting about their own issues.

For instance, one doctor talked about his vacation in Italy and another about his own struggle with loosing weight. Far from being a "connection", it seems the physician's self disclosure didn't really tie back to the patient issues. Four out of five times the doctor never resumed the topic they were discussing before the interruption.

Of course, I had to think back on a recent patient visit where my patient had just returned from a safari in Africa. Since that is a trip I would like to take, I certainly peppered him with travel questions and we spent a great deal of time talking about the best locations. My only saving grace is that I was quite aware of this being "his" time and I assured him that he was my last patient and we would have lots of time for the exam and his issues. Did I justify my chattiness? I guess I better check back with him and make sure.

Osteoarthritis vs. Osteoporosis

Patients often confuse Osteoarthritis and Osteoporosis. They are two very different conditions. The following is a quick comparison:




Osteoarthritis
(Degeneration of cartilage at joints)
o Painful
o Cause unknown but occurs with aging, prior trauma and genetics
o Mainly joints of hands, knees, hips and spine
o Worse in obese people
o Calcium does not help
o Swelling and stiffness of affected joints common.

Treatment includes acetaminophen or NSAIDS (non-steroidal anti-inflammatory drugs like ibuprofen, aspirin, celebrex), joint replacement in severe cases.


Osteoporosis
(Loss of skeletal bone mineral and calcium)
o Usually painless - unless fractures occur
o Caused by lack of estrogen, smoking, corticosteroids, genetics
o Affects all skeletal bones including jaw, spine, hips. Doesn’t affect joints.
o More common in skinny people
o Intake of Calcium and Vitamin D important.
o No joint swelling involved

Treatment includes bisphosphonate drugs, calcium, weight bearing exercises, estrogen.

Hope this quick comparison helps with the confusion.

Medical Tests - think twice

An article in the New York Times struck home with me today. It has to do with excess radiation exposure from CT scans, X-rays and other ionizing radiation from medical tests.

Many patients think more is better when it comes to diagnostic testing. They request scans for headaches, backaches, new knee pain and screening total body scans "just to make sure I'm ok". Despite warnings that body scans often pick up slight abnormalities that are not significant but need to be followed up on with biopsies and more invasive tests, many patients believe it is worth it if the test can find that 1/10,000 early cancer.

According to a new study, the dose of ionizing radiation from clinical imaging exams in the U.S. increased almost 600% from 1980 to 2006. CT scans,nuclear medicine exams and cardiac studies deliver the most radiation. X-rays have been classified as carcinogens by the World Health Organization and the Centers for Disease Control and Prevention and excess exposure causes leukemia, thyroid, breast and lung cancer.

The American College of Radiology says mammograms deliver only 0.7mSv radiation and a bone density scan is only 0.01mSv. Compare that to a single CT scan that can expose a patient to 10mSv. The new multislice scanners deliver even more radiation.

We are blessed to live in an age with technology that can help us diagnose illness, treat disease and extend our lives far beyond our grandparents. But new technology comes with a cost, both in health care dollars and in exposure to radiation. The smart patient will ask "Is this test necessary?" The smart patient will avoid total body scans unless it is for a specific diagnostic question.

Brits Got Talent - A Star Is Born

British Idol - just believe in yourself

Greetings by your Doctor- how do you like it?

The Archives of Internal Medicine had an interesting article about patient preferences for how a doctor greets them. Over 78% of patients want the physician to shake their hand. (I hardly ever shake hands with a patient! Why pass those germs?)

Over 50% want the doctor to greet them with their first name and 56.4% want the doctor to introduce his/her self using first and last name. (I always do this).

The study videotaped patient-doctor interactions and in over 50% of initial encounters the doctor did not mention the patient's name at all.

I found this interesting. I was always trained that unless instructed otherwise, patients should be greeted as Mr. or Ms. I train my staff to speak to patients in a formal manner unless the patient says "Oh, please call me Susan". Of course after a long relationship, everyone is on a first name basis. We are like family!

Other studies I have read said patients like to see the physician in a white lab coat and they like name badges. I have a white coat with my name embroidered above the pocket and I couldn't function without the many pockets a coat provides for my pens, booklets, hammers, stethoscope, measures, palm pilot and other tools of the trade.

So, did the study get it right? What is your preference in greeting and dress code from your doctor?

Green Tea - maybe very very good for you

Green tea, like black and oolong tea, comes from the Camellia senesis plant. For green tea, the plant leaves are steamed and parched after picking to prevent oxidation of the compounds present in the leaf. Green tea extracts have been used in traditional Chinese medicine for centuries but now conventional medicine practitioners are beginning to explore the health-promoting benefits of green tea derivatives.

The most common compound found in green tea is called EGCG (epigallocatechin-3-gallate ).
EGCG is a complex molecule with many potential anticarcinogenic functions. It acts as an antioxidant and neutralizes free radicals in the body. It also blocks angiogenesis, the process by which new blood vessels are formed and can block tumors from getting nutrients needed for growth. It inhibits cell cycles and has antibacterial properties. It can also protect against potential carcinogenic agents such as UV radiation and smoking by increasing the catabolism of these carcinogens.


Mayo Clinic Proceedings recently reviewed 400 studies on green tea and EGCG. They found only 15% of US adults drink green tea on any day. Therefore, most studies examining an association between green tea and lowered cancer risk have been conducted abroad, mainly in Asia. No prospective studies of green tea consumption and cancer risk have been reported from European or American subject populations and the studies reviewed had varied results. Unfortunately, differences in the methods used to assess green tea consumption make it difficult to derive any firm conclusions.

Although the study designs were variable, there were a number that did show green tea and EGCG may have potential as prevention or treatment for cancer and the biologic mechanisms of the compound make these findings compelling.

I am not aware of any prospective trials underway on green tea and that is a shame. We need trials that determine how the active ingredients in green tea interact with environmental and genetic factors. Although we have no proof... since it is readily available and non-toxic and it tastes good, maybe we should all be drinking a cup daily.

Liquid Skin

When my daughter was young and I told her to get out of the sun or it would ruin her skin she would reply "Oh, it's OK, when I grow up there will be liquid skin. I will just rub it on and all the sun damage will be gone". I laughed at her silliness as I slathered sunscreen on her. Now there is a recent study from the Archives of Dermatology that shows there is hope for the wrinkles of aging.

Sun exposed skin shows accelerated aging and lack of collagen. This study was done on 87 year olds, living in senior citizen facilities and they applied a combination of liquid Retinol (Vitamin A) and glycosaminoglycan, which is known to retain water and increase collagen synthesis. After 24 weeks, the treated patients had fewer visible wrinkles and biopsy of their skin showed more collagen and ability of the skin to withstand injury.
My grown daughter knows she "goofed" as liquid skin isn't here and, as usual, mom was right about sun protection. But a commercial product is patented and in development so maybe she was on to something. I guess in the future eighty-seven will be the new 40!

Health Care Reform - Myths and Facts

Finally, after almost 15 years, Health Care Reform is back in vogue. With the upcoming election, our country might be poised to actually address this issue. The California Healthcare Foundation has released some myths and facts that readers of EverythingHealth will find interesting.

MYTH - The uninsured can get care when they need it.
FACT- Almost half of uninsured individuals will not seek care when they have a medical problem, compared to 15% of patients with insurance. Uninsured patients consistently have worse health outcomes. Accident victims without insurance have 37% higher mortality rates. Uninsured patients with breast and colon cancer have 50% higher mortality rates. Because uninsured patients lack routine care, their chronic conditions are often poorly managed

MYTH-People without job-based health insurance could buy insurance if they wanted to, but they choose not to.
FACT-Consumers can be denied coverage outright, can be charged higher premiums or be offered more limited benefits based on their health status. For example, many people who have had cancer or have heart disease are denied coverage. See my prior post on one such case. Even for individuals or families who can get coverage, it may be available only at prices that are unaffordable. The individual insurance market is a viable choice for only a subset of the uninsured.

MYTH-Voluntary purchasing pools lower the cost of health insurance premiums.
FACT-Establishing a voluntary purchasing pool will not automatically reduce premiums to an affordable level. Only if the pool is structured so that its enrollment is stable, only if its target population is required to use the pool will the pool have the potential to achieve economies of scale and negotiate effectively with health plans. The California sponsored purchasing pool - Pac Advantage- recently ceased operations.

The dialog about health care in America has begun and dispelling myths is the first step toward solving complicated problems. We are the only industrialized nation without universal access to basic health care.

Cigarette Addiction -More on Nicotine

Here in the San Francisco Bay area, few people still smoke. But if you get away from the coast, you see the grip that nicotine addiction still has on people. I wrote a prior post on stopping smoking but newer studies are showing that the addictive properties of modern cigarettes are even more powerful than we thought.

Cigarette smoke contains 4000 chemical compounds, some of which also reinforce smoking behavior. This may explain why nicotine replacement therapies are often ineffective alone. Using PET (positive emission tomography)scans, researchers found smokers have 40% less of certain enzymes in their brains and other organs of the body. This may explain the increased rate of smoking in diseases like depression because these enzymes affect neurotransmitters that lead to depression. Cigarette smoking, like other addictive compounds (cocaine, methamphetamine) causes intense craving and brain imaging techniques are giving scientists a window on what happens during cravings.

It is becoming more clear that there is probably a genetic basis for addiction. As we develop treatment drugs that are selective for a persons genotype, we will be able to use therapies that are targeted and appropriate.

Until we get there, we need to use all the tools we now have to help people stop smoking. Use every opportunity you have and talk to your children about the dangers of cigarettes. Explain that Hollywood uses smoking in movies to influence the kids to start. Ask any physician...the number one most important thing you can do for your health is to Stop Smoking Today.

Recall on Imported Toothpaste

The FDA is warning consumers to throw out any Chinese toothpaste after it found a component of antifreeze in several products.

Because diethylene glycol (DEG) is not always listed in the ingredients on the package, the FDA says people should examine their toothpaste and discard any imported from China. The FDA is concerned about chronic exposure to DEG, particularly to vulnerable populations like children and people with kidney or liver disease.

The following brands are affected by the advisory: Cooldent Fluoride, Cooldent Spearmint, Cooldent ICE, Dr. Cool, Everfresh, Superdent, Clean Rite, Oralmax Extreme, Oral Bright Fresh Spearmint Flavor, Bright Max Peppermint Flavor, ShiR Fresh Mint Fluoride Paste, DentaPro, DentaKleen, and DentaKleen Junior.