Wednesday, May 30, 2007

Common Medical Questions

Patients often ask common and straight forward questions,and physicians try to give answers that are sound. But often we don't have scientific evidence for answering questions. I always look for studies and proof that what I am doing and saying to patients, has basis in up-to-date facts. Here are some common questions where we DO have science to back up the answers.

Q: Are Statin drugs safe for treatment of high cholesterol (hyperlipidemia)?

A: When scientists looked at Statin drugs alone (not in combination with other drugs) they were as safe as placebo except for causing increased liver enzymes. The same number of patients stopped the Statin drug for side-effects as did the placebo group. (Statin drugs: Lipitor, Mevacor, Crestor, Pravachol, Zocor)

Keep in mind that these studies did not look at drug-drug interactions and most of the patients in the studies were younger, but we have good evidence that Statin drugs are safe for prolonged use and we know they are effective in reducing heart attacks and strokes.

Q:Do herbal supplements relieve hot flashes and night sweats in women during menopause?
A: Herbal supplements (Black cohosh, botanical supplements, soy, Chinese herbs and red clover) did not relieve symptoms of menopause in women any better than placebo. The women studied were between 45-55 years old and the best relief of symptoms was from estrogen replacement therapy.

Q: What are the latest recommendations for ovarian cancer screening tests?
A: Unfortunately, there are no effective reliable screening tests for ovarian cancer. Most women who develop ovarian cancer have no known risk factors. A women with a mother or grandmother with ovarian cancer is considered at higher risk. For these women there are two tests which can be helpful in early detection.
1. Ca-125 blood test -unfortunately it is not specific for ovarian cancer and is usually used to track response to treatment.
2. Trans vaginal ultrasound - this tests visualizes the ovaries to look for tumors, but when they screened 1048 high risk women, only 6 of 13 who had cancer showed up on ultrasound.

As you can see, when your doctor says there are no good screening tests at this time, she is accurate. Hopefully, time and research will help develop such a test.

Tuesday, May 29, 2007

Recall on Contact Lens Solution

Advanced Medical Optics has recalled its Complete MoisturePlus contact lens solution because of an association with Acanthamoeba keratitis (AK). (This is an amoeba infection!)

The Center for Disease Control (CDC) described two case-control analyses showing an elevated risk for AK among users of the solution. AK, which is caused by a common waterborne amoeba, can result in vision loss or blindness if not treated.

The CDC recommends that soft contact lens wearers who have used the solution should discard it, along with their current lenses and storage containers, and see a healthcare provider if they have any signs of eye infection, such as eye pain or redness, blurred vision, sensitivity to light, a sensation of something in the eye, or excessive tearing. Clinicians and labs can report cases by calling 1-770-488-7775.

Saturday, May 26, 2007

Old age - it happens

The physician writer, Atul Gawande, has written a great article on how we age in The New Yorker. Let's face it, we are all going in the same direction..every one of us! Here are a few tidbits from Dr. Gawande's article:
* The average life span in developed countries is 80 years. (At the time of the Roman Empire, the life expectancy was 28 years!)
* Only six percent of longevity is inherited from your parents. By contrast, up to 90% of how tall you are is explained by your parents' height.
* By the age of 50, half of the average person's hairs have turned gray. This happens because the stem-cell reservoir that replaces the scalp's pigment cells gets used up.
* The amount of light reaching the retina of a healthy 60 year old is one third that of a 20 year old.
* There is no single, common cellular mechanism to the aging process. The process is gradual and unrelenting.
* In 1950 people over 80 were 1% of the U.S. population. In 30 years, there will be as many people over eighty as there are under 5.
* People are putting aside less in savings for old age now than they have since the Great Depression.
* The risk of a fatal car crash with a driver who is 85 or older is more than three times higher than with a teenage driver.
* The biggest health risk for elderly people is falls. The three primary risk factors for falling are poor balance, taking more than 4 prescription meds and muscle weakness.
* The U.S. is not prepared for an aging population. We look for new medical gizmos (joints, stents,pacemakers, pet scans, organs)to feed our fantasy that we can be ageless. Medicare, the insurer for the elderly, does not cover the cost of geriatrics and scores of medical centers across the country have shrunk or closed their geriatrics units.
* Applications to medical training programs in adult primary care medicine and geriatrics are plummeting.

Gee, as I read these facts, I must admit it looks rather depressing. The good news is we are living longer and healthier. Even with the unrelenting aging process, the majority of senior citizens are active, involved, and some, like in the video, are proudly singing that great "Who" song My Generation

Friday, May 25, 2007

Obesity - all in the genes?

A new article published in Science has pointed to a common variant of a gene that may predispose some individuals to obesity. There is one particular position in the human DNA sequence that was found to increase an individuals risk of obesity by 67%. This variant is present in over half of the population and one sixth of the population has 2 copies of the gene....which explains why some individuals are heavier than others.

The variant resides within the FTO gene on chromosome 16 and the role is still a mystery. This new finding may show scientists a pathway that can be disrupted and have profound effects on fat development, weight regulation, obesity and type 2 diabetes risk.

Although research into FTO's role is in its early stages, it is hoped target therapy can be developed that will help us get a grip on the obesity epidemic.

We should keep in mind that having a genetic trait does not mean lifestyle changes are ineffective for weight control. Each of us has different traits that we must deal with and the fat gene just explains why some people can eat and still stay thin while others seem to fight the battle of the bulge all their life. Many of us are urging these researchers on to find a quick and easy fix for loosing weight. I vote for more funding for fat research!

Tuesday, May 22, 2007

For Everythinghealth- we need better leaders

The most inspiring article from The New York Times shows us that true leadership is what the world needs to get us back on track. Each of us has a responsibility to be our own leader, as well as make sure we stay informed and hold business accountable for doing the right thing. Read about this corporate giant. He leads the pack!

Sunday, May 20, 2007

Jack London---the cure worse than the disease?

I love medical history and marvel at the fact that future generations will look back on our medical treatments and see them as backward and primitive. America's famous author Jack London (Call of the Wild, White Fang,The Seawolf) died at age 40 in 1916. A writer, explorer,rancher and social activist, he traveled extensively and visited the South Pacific in 1907. It was there that he contracted a common infectious disease called "yaws". We now know it is from a spirochete bacteria pertenue, which is a subspecies of Treponema pallidum, the cause of syphilis. Yaws has been almost eradicated with the discovery of Penicillin.

But Jack London had the misfortune of living at a time when these infections were treated with mercury. Physicians at the time knew mercury was a poison but desperate diseases require desperate remedies. Epidemics of mercury toxicity include "mad hatter" syndrome from mercury-soaked fabrics in the felt hat industry and "pink disease" from calomel teething powder, whose active ingredient is mercuric chloride.

Jack London self-administered mercuric chloride when he was aboard the sailing vessel, Snark, in the South Pacific. By applying mercury topically on his Yaws lesions, he developed severe dermatitis and swelling of his hands, feet, cheeks and nose. He described this in his book The Cruise of the Snark, "On occasion my hands were twice their natural size, with seven dead and dying skins peeling off at the same time. There were times when my toe-nails, in twenty-four hours, grew as thick as they were long." The topical mercury was absorbed in large amounts systemically and over time he developed irreversible kidney failure and died.

The cure for Yaws was, in Jack London's case, worse than the disease and lead to his early death.

(History obtained from The American Journal of Medicine, 2007)

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Wednesday, May 16, 2007

Aspirin- the Wonder Drug

Despite the new pharmacologic and technologic discoveries that are being introduced to treat disease, the humble aspirin (acetylsalicytic acid) remains the true wonder drug. If I were stuck on a desert island with one drug, I would want it to be aspirin. It works for fever, pain, inflammation and topically as a wart remover!

More than 50 million Americans take aspirin daily to prevent heart attack and stroke. Aspirin works by inhibiting platelet thromboxane production and this prevents blood clots. Strokes, myocardial infarction, deep venous thrombosis (DVT) all occur when the cells are "sticky" and clump together. Of course clotting involves a very complicated biochemical cascade in the body but the lowly aspirin has quite an effect.

A new study in JAMA this week shows that the low dose aspirin (75-81mg) is effective and the best dose for preventing cardiovascular disease. The standard size aspirin is 325 mg and there is no further effectiveness with this dose but there is a higher risk of gastrointestinal side effects.

It is easy to find 81mg generic aspirin and one of the quality measures hospitals adhere to is giving every heart attack patient an aspirin as soon as they arrive in the ER.

It's nice to know some of the older, cheaper pharmacologic remedies work just fine!

Monday, May 14, 2007

What is Torture? Archives of General Psychiatry weighs in

Following all the reports of human rights abuses by the US military in Guantanamo Bay, Iraq, and Afghanistan, a report in Archives of General Psychiatry has studied various forms of ill treatment during captivity in terms of their relative psychological impact. They found that psychological manipulations, humiliating treatment and forced stress positions cause the same severity of mental suffering as physical torture. The researchers concluded that these procedures do amount to torture, thereby lending support to their prohibition by international law.

When we heard those awful reports, didn't we already know this? I am glad this study was published in a distinguished medical journal, but wouldn't any real American already come to that conclusion?

Sunday, May 13, 2007


They say the only time your child is really all yours is when they are in the womb. At the time of birth, they begin their own life journey and you are there as a guide. For a few years you are guiding all the time and their journey is mapped out by you. It doesn't take long to realize that you can set the course but the child will take their own path that has nothing to do with where you thought she was going.

18 years go by in a flash. You don't even realize that Mommy and Me at Gymboree has ended. The wonderful spirituality of breastfeeding is over. That first lost tooth led to others and then there were no more. Those endless pageants and recitals just ended. You clutched your heart hoping he wouldn't miss the fly ball, and then he began catching them all and then there was no more little league. The piano lessons faded into science projects and they faded into SAT practice. The weird music and clothes and text messaging that was "oh so secret" just seemed to fade away and're alone with the memories. Our little ones are launched and all we can do is hope all of the stories, bedtime tuck-ins, advise, school project help and prayers will be enough to sustain that sweet child into adulthood.

"The Mother-child relationship is paradoxical and, in a sense, tragic. It requires the most intense love on the mother's side, yet this very love must help the child grow away from the mother and to become fully independent."
- Erich Fromm

At the end of the day, all we can do is give our best love to our children as they grow and enjoy the love that returns to us on Mothers Day. Happy Mothers Day to all of you!

Thursday, May 10, 2007

Oral Contraceptive Use and Ability to Get Pregnant

There is a common thought among women that use of oral contraceptives (birth control pills) might affect the ability to get pregnant in the future. Now a definitive study has shown that use of oral contraceptives has no affect on a woman's ability to conceive after she stops the pill.

A large study reported in Obstet gynecol looked at 60,000 new pill users. They followed the women who stopped the pill to get pregnant. The researchers found that 21.2% of women conceived within the first month of stopping the pill. This was comparable to women who had never been on the pill. One year after stopping the pill, 79.4% were pregnant! The median time to conception for all women was 3 months.

Pregnancy also did not differ for women over the age of 35 compared to women who had never been on the pill.
About 70-80% of women between age 25-34 became pregnant within 12 cycles of stopping birth control pills. After 2 years, 90% of the women conceived. Among women 35 or older 62% became pregnant by 1 year and 77.5% were pregnant at 2 years. These rates were statistically the same as for women who had never taken the pill.

This study debunked old myths that the birth control pill affects future pregnancy.

Monday, May 7, 2007

More Omega 3 FFA's

A few days ago I wrote about the benefits of Omega 3 supplements and I now find YET ANOTHER study that supports this cheap and amazing supplement. The Lancet reported on a large study of 19,000 Japanese patients with hypercholesterolemia. The patients who were given 1800mg/day of Omega 3(EPA) capsules in addition to low dose Statins (Pravachol and Mevacor,) had a 19% lower incidence of non-fatal coronary events like heart attack or unstable angina needing stents or bypass surgery.

Omega 3 FFA supplements are easy and inexpensive and should be used by people with cardiac risk factors, especially hyperlipemia. The benefit was on top of the benefits of Statin drugs and is thought to be from additional biologic effects of Omega 3's.

"Compared with drugs, invasive procedures, and devices, modest dietary changes are low risk, inexpensive, and widely available," writes Dr. Mozaffarian from Harvard Medical School, in an accompanying Lancet editorial, "We must curb our infatuation with downstream risk factors and treatments, and focus on the fundamental risk factors for cardiovascular disease: dietary habits, smoking, and physical activity. If the millions of heart attacks occurring each year were not a clarion call, the obesity epidemic certainly should be."

Omega 3's rule!

Friday, May 4, 2007

Patient Safety - Our New Focus

I attended a conference today that dealt with a good trend that is sweeping U.S. Healthcare- called the Patient Safety movement. The Institute of Medicine published a shocking report in 1999 that showed as many as 98,000 people die from serious hospital medical errors each year. It is the equivalent of a full jumbo jet crashing each day! That made everyone sit up and take notice and started us looking at how we deliver care. Believe it or not, prior to that report, we never discussed how to change our hospital systems to avoid medical errors and make sure we didn't inadvertently hurt a patient. Health professionals had a mindset that this was just the unavoidable collateral damage of the high-tech, lifesaving war we were fighting against disease.

We now know that way of thinking is unacceptable and we need to collectively change our systems of care so that no patient is given the wrong drug, or the wrong blood or organ, or operated on the wrong side, or given the wrong test, or receives the wrong treatment. Caregivers want to do the right thing for every patient, but the complexities and fragmentation of care are working against us. In the 1950's and 60's, an Internist needed to know about a handful of medications...penicillin, lasix and thyroid pills just about covered the bases. Now a General Internist actively uses over 400 medications, each with their own interactions.

Medicine grew up as a cottage industry, with each doctor running his/her own show and with extreme variations in how medicine was practiced. Whether you get a treatment or not depends as much on where the doctor trained or in what part of the county he practices as much as anything else. These variations in care are part of the problem. You wouldn't get on an airplane if each pilot wanted the cockpit panel arranged his "own way". Why should something as complicated as surgery be any different? As a patient, we deserve proven technology, delivered in a consistent way. There is nothing wrong with innovation, but if there is proof that raising the head of the bed keeps me from getting pneumonia, damn it, I want the head of the bed raised! (yes, it does)

Fortunately the Patient Centered Safety movement is teaching us all how to ensure a patient receives no harm from our actions. It is a cultural change in how we think about patient care. It requires institutions, physicians and nurses to work together as a team. It also requires us to be brutally honest as a profession, to look at each problem we identify and to use a
"systems" approach to redesigning what we do. We need to make it easy for caregivers to do the right thing (barcoding medications, electronic prescription ordering, protocols for "hand offs" of patients) and we need to be willing to tap our colleagues on the shoulder and say "Hey, shouldn't you wash your hands?"

Tuesday, May 1, 2007

Omega 3 - Why we need 'em

The medical journals are filled with study after study touting the proven health benefits of Omega 3 Free Fatty Acids (Omega 3 FFA)in our diet. These fatty acids are called "essential" because they cannot be synthesized in the body and must be obtained through diet or supplements. There are three types of Omega 3 FFA: docosahexaenoic acid (DHA), alpha-linolenic acid (AHA) and eicosapentaenoic acid (EPA). These essential FFAs are vital components of almost all cell membranes

Our Western diet changed dramatically after 1913 when refined vegetable oil (margarine, etc) came on the scene. These refined oils are a major source of Omega 6 FFA and it threw off the body's healthy balance of Omega 6 to Omega 3. What was once a ratio of 2:1 is now as high as 17:1. We stopped eating fish, wild game, nuts, seeds and green leafy vegetables and substituted corn sugar and processed foods. Our diets are severely out of whack and our health is showing the effects.

A new study released in Psychosomatic Medicine showed that older adults who had depressive symptoms, coupled with diets low in Omega 3 FFA had higher levels of inflammatory chemicals in their blood. These inflammatory cytokines have been proven to influence the onset of many serious conditions including cardiovascular disease, arthritis, alzheimers and cancer. Omega 3 FFA act as an antinflammatory and make blood less likely to form clots. Studies have also shown a connection with attention deficit hyperactivity disorder (ADHD) and low levels of Omega 3 FFA. The study's author said when it comes to how people respond to stress "diet is not just a sideline player". Depression and stress, coupled with diets high in Omega 6 and low in Omega 3, may influence how we age and what diseases we acquire.

I prescribe Omega 3 supplements to patients with arthritis and hyperlipidemia (high cholesterol and triglycerides). We all know it is better to get our nutrients from our diet but few of us have the kind of diet our hunter-gatherer forefathers had.
If we could all eat like great-grandma, coupled with the benefits of the scientific advances of the 21st century, who knows how long we could live? If you can't eat a diet high in fish oil, sunflower seeds, flax seeds, walnuts and vegetables, supplementing with Omega 3 FFA is a wise move.

See my prior post on the negative effects of chronic stress

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...