Dr Colin KopesKerr Evidence for Lifestyle & Health

Reliable Quick Answers to Medical Questions on the Web

2012-02-17T14:37:00.000-08:00

A VIEW FROM THE OFFICE

RELIABLE QUICK ANSWERS TO MEDICAL QUESTIONS ON THE WEB:

WELCOME TO HEALTHTAP!

Two weeks ago I read in the Sunday New York Times an article about a web-based consumer information service called "HealthTap." It invites both consumers and physicians to join. Consumers ask the questions. Volunteer physicians provide the answer. HealthTap started its Web site last May. It has signed up more than 9,000 physicians and is adding 100 a day. The site does not carry advertising. "Users can follow particular doctors and topics of interest; new answers related to these are displayed in an “activity feed” shown when users log on to the site. The site offers a peer-based reputation system of its own devising. Next to each answer, users see the number of doctors who agree; with a click, they can see who the approving doctors are, as well as something that HealthTap calls a “reputation level,” which is built by accumulating HealthTap awards, “Agrees” from fellow physicians and other measurable activities at the site."

Here is a screenshot from the patient side of the website:

Here is a screenshot from my physician side of HealthTap.

Probably the strongest feature about this site for consumers is the ability to "follow" the opinions of certain physicians who give precise, clear, practical answer. [Some of the answers are indeed too brief to be helpful.] You will be notified of new responses for the physicians that you follow. [You are certainly welcome to follow me.]
For the physicians it is an excellent opportunity to reach out to patients outside of the office and to do good for the community (in fact, a very big community--the whole internet!). It can also sharpen physician skills in communication. Trying to be helpful, succinct, and clear in only 400 characters [the limit for each answer] is a good mind-sharpening challenge. I find it an excellent way to both learn something and be useful in the few minutes between patients in the office. It is always informative to see the kinds of things that patients are concerned about but may not bring to the office. Some of the questions are distinctly challenging and send me to do online research so that we can both be educated at the same time. In my opinion, any way that a doctor can make more contact with the community is a good thing.
HealthTap offers a very sociable and time-efficient way of getting in touch with a treasure trove of physicians. Try it!

A NOTE TO MY FRIENDS IN PLUMAS COUNTY: I will be returning to do a Saturday morning clinic on March 3rd at the Portola Clinic. The plan is for me to come back for a clinic session on the first Saturday of each month. I look forward to seeing you there.

Dr. Colin Kopes-Kerr, MD

ARE THE TESTS YOU ARE GETTING WORTHWHILE?

2012-02-09T14:27:00.000-08:00

A VIEW FROM THE OFFICE

ARE THE TESTS YOU ARE GETTING WORTHWHILE?

An important new article in the Annals of Internal Medicine urges physicians (and ultimately their patients) to limit a lot of common testing based on the value to the patient (Will the test actually improve the patient's outcome?) and the cost to the system, which in the end we all pay.

They have selected 34 tests as appropriate targets for reduced use. Here I will comment on the tests that I have seen most often used in Plumas County with little or no benefit to either the physician or the patient.

1. Bone Mineral Density Testing: The national guideline from the United States Preventive Services Task Force does not call for routine DEXA scanning of average risk women until age 65. As I have explained in a recent post here, new evidence shows that for average risk women with normal DEXA scans at age 65, they do not need another one for 15 years! I have seen many women who have been coming in for one every year or every other year.

Even for women at high-risk or who have abnormal scans at baseline, there is little evidence to suggest any benefit to repeating the scans in less than 5 years.

2. Lipid panel testing. Many people come in for a lipid panel every year or sometimes even more often. The recommendation for asymptomatic health persons is to have this done every 5 years starting at age 30. If you're not on any treatment, there is no need to repeat more often than this. Even if you are on treatment, a British Study (The British Heart Study) has shown that once you select the treatment and just continue the medication, as long as there are no side effects, you don't need to recheck the lipid panel or adjust the dose (ever). You can still get exactly the same 33% reduction of all-cause mortality and cardiac events that you do when you get all the extra tests and medication adjustments. Why go through all that extra trouble and expense?

3. Pre-operative testing: Many surgeons, almost all, in fact, want patients to get an elaborate set of blood tests, urinalysis, chest x-rays, and ECGs before they have any kind of elective surgery. I recently had occasion to undergo an upper GI endoscopy twice. When I had it done here, the Portola hospital did not require any specific testing, but when I need to have the endoscopy repeated at Saint Mary's they routinely threw in a requirement for blood counts, chemistry panel, coagulation tests, urinalysis, chest x-ray, and ECG. This was more than a little irksome since they did not inform me of this in advance, and because I knew it was ultimately pointless. All tests were in fact normal, and I lost both time and money. This report strongly advises against all forms of routine preoperative testing for average risk adults before any general elective surgery.

COMMENT: Of course, this is usually not a decision you make yourself. Your surgeon makes it. But you can, and should, ask why. And don't be afraid to bring them a copy of this article and the reference supplied below to encourage them to think twice about ordering unnecessary tests.

4. Colon cancer screening: This group also takes a strong stand against any routine colon cancer screening after the age of 75. You can get it, if you really want it, but there is no evidence of systematic benefit at this age.

5. Cervical cancer screening: There is no reason that a healthy 65 year old woman needs additional Pap smears as long as she has had regular screening up to age 65 (every 3 years) and they have all been negative over the last 10 years.

6. Prostate cancer screening: This group takes only the position that men over age 75 should not be screening for prostate cancer with the PSA test. I encourage the more straight forward recommendation of the United States Preventive Services Task Force--that no man, at any age, should be routinely screened for prostate cancer with a PSA test.

Here I describe only a handful of the 34 tests covered in the report. But these are the most common ones. If we learn to use these tests correctly, we will solve a lot of the problem. A patient should: "Think not what these tests can do for the physician, but what these tests can really do for you!"

REFERENCE: Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Annals of Internal Medicine 2012; 156:147-9.

Who Knows What Their Blood Pressure Is?

2012-01-20T16:11:00.000-08:00

A VIEW FROM THE OFFICE

WHO KNOWS WHAT THEIR BLOOD PRESSURE IS?

Everyone knows that blood pressure is one of the most important variables in health. Uncontrolled blood pressure leads over many years to strokes, heart attacks, peripheral vascular disease, aneurysms, and heart failure.

Most people know that the recommended level of blood pressure is to have the upper number (systolic pressure) be less than 140 mm Hg, and to have the lower number (diastolic pressure) less than 90 mm Hg. The systolic number is the level of pressure achieved in the arteries when the heart contracts, and the diastolic number is the level of pressure in the arteries when the heart relaxes in between beats. Of these two numbers the upper systolic pressure number is the more important.

So, what's your blood pressure? How would one know? Most people know (if they can remember it) their blood pressure from a visit to the doctor's office. But is the number you get from the doctor's office the correct number? A large number of new studies suggests that it is not.

First, there is the factor of "white coat hypertension," which by now most of my patients seem to know about; this is when your blood pressure is transiently elevated because one may feel somewhat nervous or anxious about going to the doctor. Pain is another factor that will elevate the blood pressure in a doctor's office.

A second factor is that in the busy flow of doctors' office practice, the correct technique for measurement may not be employed. According to the experts, the proper way of measuring blood pressure is to check it after at least 5 minutes of quiet sitting waiting for the doctor. In most practices, the nurse checks it as soon as or right before leading a patient into the exam room, which is not optimal. Usual practice, however, is for the doctor to re-measure any high readings after 5 minutes has passed. If the patient has been waiting for 45 minutes to an hour for the doctor, however, the blood pressure may be elevated just due to aggravation.

The expert recommendations also call for the blood pressure to be taken while the patient is sitting upright in a chair with his/her back supported and the feet flat on the floor. Checking the patients' blood pressure while they are sitting on the exam table with their backs unsupported and their feet dangling in the air is not consistent with these standards, but it is, in fact, the most common way blood pressure is measured in the office.

Other problems that occur in doctors' office are the use of an incorrect cuff size (cuffs that are too small tend to elevated the pressure readings) due to an inexperienced staff person. Also, the blood pressure devices themselves can get banged up, dropped, or just old and no longer give accurate readings.

For all of these reasons and some others a single blood pressure measurement in a doctor's office is simply not a reliable indicator of the true blood pressure. A new study in the Annals of Internal Medicine* concludes that: "Physicians who want to have 80% or more certainty that they are correctly classifying patients' BP control should use the average of several measurements. Hypertension quality metrics based on a single clinic measurement potentially misclassify a large proportion of patients." The data from this study show clearly that patients could not be classified as having BP that was in or out of control with 80% certainty on the basis of a single clinic systolic blood pressure measurement anywhere in the range from 120 mm Hg to 157 mm Hg. The investigators recommend obtaining an average of several measurements and feel that the optimal number of readings to average is 5 to 6.

Based on several other studies it now appears that the optimal way to measure and manage patients' blood pressure is for the patients to monitor their blood pressure at home with the increasingly accurate and inexpensive automatic measuring devices that are now available. This is actually better than using the numbers obtained in the doctor's office, even if the doctor does go through the trouble to average 5-6 readings. (Most don't!)

I advise patients not to be obsessive about it. (This tends to raise your blood pressure.) There is no point in checking it several times a day; nor is there any need really to check it more than twice a week. I tell most patients that once a week is fine. Ideal management calls for patients to bring into their doctor a list or log of at least 5-6 recent measurements so that a reliable average blood pressure may be obtained. In the near future, I expect that the makers of the blood pressure devices will computerize and memorize hundreds of measurements so that a continuous average is reported automatically. Until then we'll just have to obtain an average the old fashioned way--add up all the numbers and divide by the number of readings. The improvement that should come soon to doctors' offices is that electronic medical record system will begin to automatically calculate the average of multiple physician readings.

It is certainly clear to me in my practice that blood pressures vary quite erratically for many patients, and I only make my decisions on blood pressure medication adjustment based on an average blood pressure. I recommend that all patients who have been told that they have high blood pressure get themselves a home blood pressure measuring device (now available for less than $50). If they can bring in at least 5-6 readings from home every 4 months we will really be able to do a great job of managing hypertension.

* References: (Powers BJ et al, "Measuring blood pressure for decision making and quality reporting: Where and how many measures?" 2011; 154: 781-788; editorial by Appel LJ et al., "Improving the measurement of flood pressure: Is it time for regulated standards?" 154: 836-7)

STUDY CALLS FOR REDUCED USED OF BONE MINERAL DENSITY TESTING

2012-01-19T16:36:00.000-08:00

THE VIEW FROM THE OFFICE

STUDY CALLS FOR REDUCED BONE MINERAL DENSITY TESTING FOR OSTEOPOROSIS

It is a long-standing problem that there has been little or no hard evidence to guide the decision on how to screen for and prevent osteoporosis. The United States Preventive Services Task Force has gone ahead and endorsed it despite the lack of evidence. The recent "Welcome to Medicare" guidelines will pay for it every 2 years. I have long been opposed to this test because it is expensive and because no one is sure how to use it. The vast majority of its value lies in the first screening with a bone density test technique, and, simply stated, none of the numerous experts has any real idea of if and when to repeat the test for patients who are normal, for patients who have osteopenia, and/or for patients who have actual osteoporosis. My recommendation has been for everyone simply to exercise regularly and take the recommended amount of daily calcium (1000 mg/day) and vitamin D (800 IU/day).

Until now, that is. A study just published today in the New England Journal of Medicine (Gourlay ML et al. NEJM 2012; 366: 225-33) answered the question. They studied a group of 4957 women, 67 years of age or older, who had normal initial bone density or had only mild osteopenia on initial testing; these women had no history of fracture of the wrist, hip, or spine and were not taking medications like Fosamax for osteoporosis. They analyzed their bone density at 2 years, 6 years, 8 years, 10 years, and 16 years. They divided their subjects into 3 subgroups: a group with normal bone density and a group with osteopenia (mild, moderate, and severe) and analyzed the time until progression to frank osteoporosis.

The estimated time for women with normal bone density to progress to osteoporosis was 16.8 years. The estimated time for women with mild osteopenia to progress to osteoporosis was 17.3 years, for women with moderate osteopenia, 4.7 years; and for women with severe osteopenia, 1.1 years.

The investigators conclude that the appropriate re-screening interval in which to repeat any type of bone density testing was 15 years for either normal women or women with mild osteopenia. For women with moderate osteopenia, rescreening should take place in 5 years, and for women with advanced osteopenia, rescreening should take place every years.

This recommendation is clear and firmly evidence-based. A majority of the currently carried out rescreening with bone density tests, usually on an annual or biannual basis, should cease. Live a healthy lifestyle, exercise, take your calcium and vitamin D, and say your prayers--"Lord, may I live another 15 years." Then you can get your repeat bone density test and derive some benefit from it. The rest is waste for women with normal bone density or only mild osteopenia.

Why Am I Reading This?

2011-12-01T09:07:00.000-08:00

THE VIEW FROM THE OFFICE

WHY AM I READING THIS?

Before we answer that question, I want to you to read and remember these 4 words.

APPLE MR. JOHNSON CHARITY TUNNEL

Moving on. Now your second task, before I let you go is to: DRAW A CLOCK THAT SAYS 11:15 am.

The question I would like to discuss in this essay is: When is poor and declining memory significant? As we each experience it, do we also need to worry about Alzheimer’s disease? Fortunately, the answer is mostly NOT. But let me explain.

We’ll start with consideration of a case that was recently described in the New England Journal of Medicine (1): A 77-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep tract of appointments and recent telephone calls. The process has been insidious. She lives independently in the community and drives a car. She pays her own bills and maintains good hygiene and an attractive appearance.

This case is an example of what is called “mild cognitive impairment.” To put this into perspective it is worth noting that only 1% of all elderly patients will be fortunate enough to experience NO cognitive decline. For the rest of us, we have to expect some. In fact, 10-20% of us who are over the age of 65 will experience this same condition—mild cognitive impairment. The good news is that, of this 10-20%, only 10% will go on to develop Alzheimer’s disease. As we get even older, among persons aged 70-89, 11% will experience mild cognitive impairment; 4.9% will develop Alzheimer’s disease.

A more recent New England Journal of Medicine published another case, one that I feel can lift some our anxieties if we are among the unfortunate few who develop Alzheimer’s disease.(2) Here is Michael Donohue’s story.

"At the age of 69, a year after retiring from his practice as a Minneapolis trial lawyer, Mike Donohue noticed his driving skills deteriorating. His wife persuaded him to undergo a simulated driving examination. 'I flunked it miserably,' he recalls. Donohue consulted his physician, underwent tests, and learned that he had early Alzheimer's disease. His doctor told him, 'Take this medication, call me in a year, and call the Alzheimer's Association.'"

Try to imagine for a moment your reaction to both this information and this manner of care.

Fortunately, this patient did not resign himself to such implied pessimism. He called the Alzheimer's Association's local office. He volunteered there, where he met other people with early-stage disease, helped to launch some programs for them, and now, 5 years later, serves on an advisory committee about services for people with newly diagnosed Alzheimer's disease and their family. Recently, he and several friends with the condition entered a new program where they’ll serve as mentors for others with a new Alzheimer's diagnosis.

'There's a great loneliness out there, Donohue says. 'It comes from the stereotype that we’re all drooling in a corner,' even though most people living with the diseases are in community settings rather than nursing homes. 'My cognition remains good, and until recently my memory remained reasonably good. These friendships are so important to me.'

One of the pieces of major good news amid the spreading epidemic of Alzheimer’s disease is that we are having larger numbers of people survive and function well with a meaningful social life. The modern Alzheimer’s disease is not the end of the road. This is a more important fact than that research so far has failed to identify any medications that truly make a big difference for persons with Alzheimer’s.

Let’s return to our original point. There is mild cognitive impairment and there is Alzheimer’s disease. Where in this spectrum , for the 99% of us not destined to have no cognitive impairment at all, do we fit in with our ordinary failings of memory. What do you forget? Here are some typical examples.

• Difficulty with word finding (we all do this)

• Difficulty with recalling names (most of us do this at least some of the time)

• Forgetting why you went into a room (we all do this)

• Forgetting where you put something (we all do this)

• Forgetting appointments (this is a little bit more severe forgetfulness)

• Forgetting telephone calls (this is a little bit more severe forgetfulness)

• Forgetting recent events that you participated in (this is quite severe forgetfulness)

So assume you or I are doing at least the first four items a lot. What does it mean? Are they going to take us away in the morning? Fortunately not. The lesson here is that this is the new normal. When 99% of the population repeatedly encounter this kind of experience, on a statistical basis, it is clearly normal behavior.

So, when should I worry?

There are some simple cues.

First of all, if you’re aware enough to be concerned about how memory may be interfering with your overall function, you probably don’t have Alzheimer’s. It is characteristic of the global cognitive defects in Alzheimer’s that the patient is not explicitly aware of the number and nature of the defects and the degree of impairment. Patient’s with Alzheimer’s don’t go on their own to the doctor to ask about their memory. Friends or family members bring them and the friends or family members ask the questions about memory and provide the behavioral details. On the other hand, patients with mild cognitive impairment frequently go to the doctor to express their concern about their slow decline from their peak mental performance. The question they ask the doctor is, “Is this anything to worry about, Doc?” If the patient is asking this question, then the doctor can generally be very comfortable in say, “Nope. This is just part of the new you (and me, I might add).”

Remember the little tasks I asked you to do right at the beginning of this essay. This would be a good time to take a look at the clock you drew. If you drew a clock with a full closed circle, 2 hands, one longer than the other, centered in the middle of the clock, 12 digits, each at least in the appropriate quadrant, and had the hands at the right time, you’re good. You don’t have Alzheimer’s disease.

Figures 1 and 2: This clock passes the test. All the other clocks below do not.

Why can we say this? It is because Alzheimer’s disease affects more than simple memory. One of its prominent effects is impairment or destruction of our sense of space, which is what, is tested with the clock test. The inability to pass this test is one of the earliest signs of Alzheimer’s disease. It’s one you can use yourself for someone about whom you may be concerned. (Just ask them to draw a clock that shows 11:15 a.m.) Generally, as long as all the little cognitive defects are only in the area of memory, and not in the realm of visuospatial sense, motor skills, or coordination, that the worst we are talking about is mild cognitive impairment, which all your friends have too. So don’t feel so bad.

Another way to recognize whether it is more than just mild cognitive impairment is to think about how you function in your life. Can you adequately do all your routine daily tasks? People with mild cognitive impairment can, no matter how irritated they may be at forgetting some of the details. People with Alzheimer’s can’t. They just can’t.
Here are some of the tasks that patients with Alzheimer’s often cannot do:

1. Write checks, pay bills, keep financial records

2. Put together tax records, business records, or personal papers

3. Shop alone for clothes, household necessities, or groceries

4. Play a game of skill or work on a hobby

5. Heat water, make a cup of coffee, or remember to turn off the stove

6. Keep track of current events

7. Pay attention to a TV program, book, or magazine and report the story

8. Remember appointments, special family events, holidays, or medications

9. Drive out of the neighborhood safely in a car, or plan how to use a bus system.

So, if you’re currently doing all these functions OK, you have nothing to worry about at this time. You still, however, will forget things.

OK. So now you’re at the point of accepting that you have some memory lapses and probably have mild cognitive impairment. What do you do about it? First, don’t worry so much about it. Second, become proactive. There’s a lot you can do.

The first proactive step is to get active. Exercise prevents cognitive impairment and a host of other problems too. "Recent epidemiologic, cohort, and clinical-trial data support a role for physical activity in maintaining cognitive health. This was studied in more than 2800 female health professionals over the age of 65 with at least 3 vascular risk factors (e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index > 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. Women in the two highest quintiles of physical activity level--equivalent to brisk walking > 30 minutes daily--had significantly slower rates of cognitive decline than those in the lowest quintile. When the data were compared to an analysis of age-associated cognitive decline, participants in the 2 highest quintiles of physical activity were cognitively 5 to 7 years 'younger' than those in the lowest quintile. A secondary analysis specific to walking showed a possible threshold effect, with at least 30 minutes of brisk daily walking required for significant cognitive benefit." (3)

My recommendation, following the US national exercise recommendation, is to engage in at least 150 minutes of exercise, at least brisk walking, each week—broken up in any way you want to do it.

Second, do mental exercises regularly. In a recent comprehensive review of all studies of various kinds of mental exercises “The data showed statistically significant improvements at the end of training on 44% of objective measures of memory and statistically significant improvements after treatment were obtained on 49% of subjective measures of memory, quality of life, or mood.” (4)

And, of course, I am going to recommend eating healthy—5 servings of fruits and vegetables a day, lots of grains, small (4 oz) portions of red meat, and a regular multiple vitamin with calcium and vitamin D. All this is with a view to keep your BMI (body mass index) below 30.
Of course, you’re not going to smoke because smoking leads to narrowed blood vessels, and, if you care about your memory, you want your precious little brain cells to get every ounce of circulation they can.
Finally, carry out a plan for some time spent relaxing every day. Relaxing can be going for a quiet walk, time with a pet, reading, dancing, reading the Bible, watching a good movie (no sex, no violence, no commercials), of doing something creative—gardening, painting, writing, interior design, refurbishing an old car, whatever gets you in your groove. Memory cells like it when you relax and turn off all the other chatter and clutter of your daily life.
Actually, this advice is rather simple. You’ve heard it before. It’s no more than the Formula for Health. Give it a try!

By the way, if you can still remember APPLE MR. JOHNSON CHARITY

TUNNEL, you’re doing pretty good.

Colin Kopes-Kerr, MD
December 1, 2011

References:
1. Petersen RC. Mild Cognitive Impairment. New England Journal of Medicine 2011; 364: 2227-34.
2. Okie S. Confronting Alzheimer’s Disease. New England Journal of Medicine 2011; 365: 12: 1069-72.

3. Middleton LE et al. Activity energy expenditure and incident cognitive impairment in older adults. Archives of Internal Medicine 2011; 171(14): 1251-7.

4. Jean L et al. Cognitive intervention programs for individuals with mild cognitive impairment: Systematic review of the literature. American Journal of Geriatric Psychiatry 2010; 1

2011-11-10T10:10:00.000-08:00

SOME DRUG INFORMATION

The View From the Office

SOME NEW DRUG INFORMATION

Cholesterol Medications: The cholesterol medication with the greatest name recognition, Lipitor, goes generic at the end of this month; it will then be the preferred generic statin medication. Many people should consider changing their cholesterol medication in order to take advance of this more potent, and now finally, less expensive drug for cholesterol.

Drugs for Osteoporosis: (Fosamax, etc.): The new consensus is that patients should not just remain on these medications forever, once they start. Most experts are calling for stopping the medication after 5 years, unless there is a recent osteoporotic fracture. Some experts recommend stopping after 3 to 5 years and then rechecking a bone density test in 2 to 3 years to see if there is relapse. The problem with taking these medications too long are that you can get a condition called "osteonecrosis of the jaw" (no fun) and/or atypical femoral fractures. All of these drugs are different forms of a chemical called BISPHOSPHONATES, and these stay in the bone for years even after stopping the medication.

Prescriber's Letter recommends that everyone take 1200 mg of elemental calcium daily and 800 to 2000 IU of vitamin D3.

SAW PALMETTO is Losing Its Fans: Prescriber's Letter predicts that saw palmetto will fall out of favor for treating symptoms of enlarged prostate (BPH). Two new NIH-sponsored trials now suggest that saw palmetto is NOT better than placebo for BPH symptoms...even at high doses. "In fact, our Natural Medicines Comprehensive Database is downgrading its rating of saw palmetto to "Possibly Ineffective."

This expert group recommends telling men not to rely on saw palmetto for BPH. Explain that benefits are modest at best. There is no need to be overly concerned, however, if men want to try it, there's no evidence of serious adverse effects.

PROBLEMS with MAGNESIUM and PPI medications (e.g., Prilosec, Nexium, Protonix, Prevacid, Aciphex, etc.): Medications like Prilosec (omeprazole) may lower magnesium levels. These experts recommend checking a blood test for magnesium in patients who have been on PPIs for a long time. Other drugs that can lower magnesium are diuretics for hypertension or heart failure, and some of the cancer drugs like cisplatin. Also, if you are having a problem with either calcium or potassium, consider doing blood tests for all 3 -- calcium, potassium, and magnesium. It will be difficult to correct low calcium or potassium if the magnesium remains low.

If your magnesium is low and you need a supplement, consider the one that is best absorbed--magnesium lactate (Mag-Tab SR), magnesium chloride (Slow-Mag), or magnesium aspartate (Maginex). Magnesium oxide is easier to get (Mag-Ox) and has more elemental magnesium than the others, but it is not well absorbed. Better absorption means less diarrhea. You can use IV magnesium sulfate for severe deficiencies. Ultimately, if the magnesium does improve in a patient on a PPI, stop the PPI, and substitute an anti-histamine acid drug like Pepcid.

Prescriber's Letter recommends avoiding magnesium supplements in patients with renal insufficiency, which is pretty common in our neck of the woods.

A Guideline to Reduce Your Risk of Ulcer from ANTI-INFLAMMATORY DRUGS:

LOW GI RISK MODERATE GI RISK HIGH GI RISK

LOW ibuprofen or 1.Celebrex alone 1.avoid NSAIDs

CARDIAC Alleve 2.ibuprofen, etc, + PPI 2.Celebrex + PPI

RISK or Cytotec

3. NSAID + double-dose

Pepcid or Zantac (etc.)

HIGH Naproxen 1. Naproxen + PPI or Cytotec Avoid all NSAIDS

CARDIAC 2. Naproxen + double-dose

RISK Pepcid or Zantac, etc.

Note: NSAIDs include all anti-inflammatory drugs except aspirin--e.g., ibuprofen, Advil, Nuprin, Alleve, naproxen, Mobic, Relafen, Clinoril/sulindac, etc.

THYROID MEDICATION: You May Not Need As Much: The fact is that younger people, if their thyroid gland is not producing enough hormone, need more hormone replacement (levothyroxine) than older people. Younger adults need about 1.7 mcg/kg/day of levolthyroxine but some seniors need only 0.5 mcg/kg/day. I have been seeing several older patients recently who have been on the same dose of levothyroxine for over 10 years, but all of a sudden on a routine thyroid test (TSH), their TSH is too low, indicating they are getting too much thyroid hormone. The explanation of this is just normal aging. After a certain time, we need to reduce the dose a bit. That is why it is so important to check your thyroid blood test (TSH) at least once a year, if you're taking thyroid medicine. Then check it again 6-8 weeks after any dose change, suggest the editors of Prescriber's Letter.

FISH OIL TO LOWER YOUR TRIGLYCERIDES: The rule of thumb is that 1 gram a day of omega-3 fatty acids from fish oil will lower triglycerides by 5 to 10%. You can go up to 4 grams a day, if you're not having side effects.

THE NEW DRUG FOR ATRIAL FIBRILLATION: Pradaxa (dabigatran) Can Replace Warfarin: Pradaxa is generally very good news. It is more effective at preventing strokes than warfarin (Coumadin) and it does not require any blood testing. It costs about $240 a month (for twice daily dosing) compared to about $80 (with blood testing) for warfarin. There are, however, a few caveats:

If you are already on warfarin and want to switch to this, you should stop your warfarin, wait until your INR is less than 2.0, then start the Pradaxa.
If you are doing well on warfarin, don't change. Changing will create an increased risk of bleeding, particularly gastrointestinal bleeding.
Missed doses of Pradaxa: Pradaxa lasts in the system for about 15 hours. Thus if you miss a dose, you should take the missed dose as soon as you remember it, but NOT if your next dose is due in less than 6 hours. That would increase the risk of bleeding.
If you do experience bleeding on Pradaxa, the old remedy of vitamin K which we use for excess bleeding due to warfarin, will not work. You will need a blood transfusion.
Pradaxa is only good for 30 days after the bottle is opened.
The most common side effects of Pradaxa is upset stomach. Taking it with food, or with an OTC medication like Prilosec or Pepcid or Zantac may help.

Reference: Prescriber's Letter, Vol 18 No 1 January, No 6 June, No 7 July, and No 11, November 2011

PROSTATE CANCER SCREENING IS OUT!

2011-10-07T09:08:00.000-07:00

THE VIEW FROM THE OFFICE

The United States Preventive Services Task Force (USPSTF)
Will Advise Against Routine Prostate Cancer Screening

The U.S. Preventive Services Task Force has concluded that healthy men should not undergo routine prostate-specific antigen (PSA) testing, the
The recommendation, which will be made available for public comment next week, was based on an analysis of five trials and applies to men of all ages. The Times quotes the task force's chairwoman: "Unfortunately, the evidence now shows that this test does not save men's lives ... This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime."

In 2008, the USPSTF recommended against PSA testing in men aged 75 or older, and said evidence was insufficient to recommend for or against testing in younger men.

Read the full story in the New York Times here.

http://www.nytimes.com/2011/10/07/health/07prostate.html?_r=1&scp=3&sq=prostate%20cancer&st=cse

As Jerome Groupman says in his new book ("Your Medical Mind"), to make a reasonable decision on screening, you have to look at the numbers. "Prostate cancer is slow-moving; more people die with it than from it. According to one 2004 study, for every 48 prostate surgeries performed, only 1 patient benefits--the other 47 patients would have lived just as long without surgery...Moreover, the 47 who didn't need the surgery are often left with an array of unpleasant and irreversible side effects, including incontinence, impotence and loss of sexual desire. The likelihood of one of these side effects is over 50%--24 of our 47 will have at least one. This means a patient is 24 times more likely to experience the side effect than the cure...Returning to prostate surgery, consider that 6 weeks is the advised recovery period. Coincidentally, the operation will, on average, add 6 weeks to your life. (This averages across the 47 people who had no benefit from the operation and the one person who did.) To my way of thinking, the decision then becomes this: When do you want to 'spend' those 6 weeks? When you're relatively young and feeling well, or at the end of your life, when you're old and only dimly aware of your surroundings?"*

* Quotation taken from the Daniel Levitin, "Heal Thyself," New York Times Book Review, Sunday, October 9, 2011, pp28-29.

COMMENT: As I have previously reported, I do not recommend this test and do not get it for myself. The test cannot tell which men will have a problem with their prostate cancer and which will not. This is the only information we really want to know. There are new tests under development, maybe one of them will provide a better option. I have already had patients asking me about the new urine test for prostate cancer, which is still in the research phase and is not yet commercially available. Another link to information on this test can be found here.

2011-10-06T10:43:00.000-07:00

WHEN TO GET A PNEUMONIA VACCINE

THE VIEW FROM THE OFFICE

(FIRST SNOW: OCTOBER 6TH, 2011)

WHO SHOULD GET A PNEUMONIA SHOT (PNEUMOCOCCAL VACCINE) AND WHEN? This is just a brief note to clarify this question. There are separate recommendations for children and adults.

For children, the recommendations are to do primary immunizations at 2 months, 4 months, 6 months, and a booster immunization any time between 12 and 18 months. This immunization in children is clearly and highly effective. It has dramatically reduced the rates of meningitis, pneumonia, infected arthritis, and high fever in children without an obvious source. This vaccine and the H Flu vaccine are the primary reasons why we almost never see meningitis any more. This is the standard recommendation for healthy children.

For older children the guideline calls for performing a primary vaccine series in any individual who has any kind of immune deficiency or chronic cardiorespiratory condition (like cystic fibrosis or congenital heart disease); for adults under the age of 65 a single dose of the vaccine is recommended for persons with a chronic cardiorespiratory or immune condition with a single booster shot 5 years after the first.

One example of a chronic immune condition is someone who has been in a bad accident and ruptured his/her spleen with the result that it has to be surgically removed. The spleen is a major organ of the immune system which protects against severe bacterial infections. So that anyone who has had their spleen removed for any reason should get a primary series of pneumococcal immunizations; they should also receive immunizations against the H Flu germ and the meningococcal germ. Also any individual who has a chronic cardiac or respiratory condition should receive the pneumococcal vaccine because the occurrence of pneumonia with a weakened lungs or heart could be fatal.

For young and older adults under the age of 65 pneumococcal vaccine, in a single dose, is recommended for patients with cardiorespiratory conditions. These include: asthma, smoking, emphysema, and any form of heart disease.

For ADULTS, the recommendation is simpler. All healthy adults should receive a pneumococcal vaccine at age 65. If you receive it at age 65 and are otherwise healthy, you only need to receive this single vaccine. You do not need a booster. For some reason that I cannot readily explain, a majority of older people in the Portola-Graeagle area believe they need routine pneumonia boosters every 5 years. This is NOT the case.

There are two groups of adults who need pneumococcal boosters after age 65:

(1) Any healthy adult who received their initial pneumonia shot before the age of 65 is recommended to get just one booster 5 years after the first.

(2) Any adult who has a chronic immune system problem (examples include patients on long term systemic cortisone medications, on dialysis from chronic kidney failure, or who have received any organ transplantation, or who have cancer receiving chemotherapy, or who have HIV infection, or who have had their spleen removed) need to get a single booster 5 years after the first. The experts do not recommend repeated pneumococcal boosters for anyone.

SUMMARY: Pneumococcal vaccine is recommended for:

1. Healthy children at 2, 4, 6, and 12-18 months.

2. Any older children with chronic immune or cardiorespiratory problems.

3. For all adults under 65 who have a chronic immune or cardiorespiratory problem.

4. For all healthy adults at age 65.

5. A single booster shot is recommended 5 years after the first immunization for:

a. Healthy adults who received their pneumonia shot before the age of 65.

b. For all adults who have a chronic cardiorespiratory or immune condition.

Chronic Medication is Not the Answer for Chronic Pain

2011-09-16T17:20:00.000-07:00

A VIEW FROM THE OFFICE

Doctors Call For Pullback

On Narcotics For Chronic Pain

Courtesy of NPR: http://www.npr.org/blogs/health/2011/09/16/140540259/doctors-call-for-pullback-on-narcotics-for-chronic-pain?ft=1&f=1001

by Scott Hensley

05:26 pm

September 16, 2011

Sue Ogrocki/AP
Painkillers like these being counted at the Oklahoma Hospital Discount Pharmacy in Edmond, Okla., need to be used far less often, some prominent doctors say.

Sue Ogrocki/AP

In a bracing call to action, three doctors from California are telling their peers to think twice before prescribing potent narcotics for patients with chronic pain.

Drugs such as Vicodin, Percocet and Oxycontin have become among the most prescribed in the country. Between 15 and 20 percent of patient visits with physicians the U.S. include a prescription for an opioid, the modern painkilling medicines whose roots can be traced back to the opium poppy.
But their editorial, published this week in the Archives of Internal Medicine, says there's a troubling shortfall in the evidence to support the use of such drugs for long-term treatment of pain. And, there's ample evidence of harm.
"Unfortuantely, the use of prescription opioids currently results in more deaths in the United States due to intoxication than heroin and cocaine combined," says Dr. Mitchell H. Katz, a co-author of editorial, in a podcast. "That's shocking."
Doctors' prescriptions for the medicines that are supposed to decrease pain and improve patients' ability to function, he says, are "killing more people than two drugs that we think of as lethal, so much so that they're illegal." The death toll from the legal pain pills is about 12,000 a year, he says. "It's a public health problem."
So what's their prescription? Until there's more scientific evidence, doctors "should not continue to prescribe high-dose opioids" for chronic non-cancer pain. Narcotic drugs for short-term relief of pain are fine, but Katz says there's insufficient evidence to support their use over the long haul.
Instead, doctors should talk with patients about the limits of pain relief and give alternatives to opioid drugs, such as physical therapy or yoga, their due. To some patients, doctors may need to give a sobering message, Katz says in the podcast: "This is not something I'm going to be able to completely take away."
The bottom line of the editorial, part of a series in the journal called "Less Is More," is that a rethink on these narcotics is overdue.
What do the pain specialists think? I asked for a comment on the editorial, and got a statement from Dr. Robert Chou, who heads the group at the American Pain Society working on guidelines for clinical practice.

While it's important for clinicians to be more thoughtful about who they prescribe long-term opioids to and to stop opioids when they aren't helping or there is evidence that it is causing problems, the American Pain Society believes opioids have a role in the management of chronic non-cancer pain in carefully selected and monitored patients.
There is evidence from long-term observational studies and evidence coming from some long-term clinical trials that opioids are effective for improving pain in some patients.
For example, we do not believe that a trial of low doses of opioids should be denied to a low-risk woman in her 70's who has severe hip arthritis, who may be able to garden and walk with decreased pain on it.

While the data on overdose deaths and abuse of opioids should concern all members of society, it does not justify an extreme blanket position of no opioids for chronic non-cancer pain.

My observations:

No one has any objection to treating the acute pain of a sprained ankle, broken bone, or sprained back. These are generally 1 to 2 week situations. Of course, we all know plenty of people who have injured their back and are still taking pain medications 3, 6, 9 months later, perhaps even years later.
If you are an astute observer, what you will notice about these people after 6 months, 9 months, or a year, is that they are NOT getting any better. If one looks at it from a strictly objective point on view, the common theme to patients who take chronic pain medicines is that they do not get better. To this some will say, "That's no surprise. They have a condition which is just not going to get better." But what the experts have come to learn is that the mere fact of taking chronic, usually high-dose narcotics, actually and directly keeps you from getting better.
A lot of this, of course, depends upon how you define "better." The patient in chronic pain may simply prefer to be narcotized and out of it so as not to have to deal with life and his or her chronic pain. But pain, whether acute or chronic, is just a small part of life, and life can indeed go on.
The real test of the value of a pain medication in chronic use is whether it is helping the patient to achieve any of their well-planned goals and objectives for their life. For example, taking pain medication right before a painful physical therapy session so that you can get through the session and accomplish to work needed to heal is an excellent use of pain medication, no matter how long it goes on. On the other hand, pain medication that keeps you so foggy and energyless that you won't go out to social events, meet with friends, try something new means you're letting the pain medication kill you.
Thus the usual rule in the context of chronic pain is that most pain medications tend to hold you back from getting on with your life. They all do some terrible things to your system.
Everyone who takes chronic pain killers is going to experience severe constipation, and I mean constipation so severe that stool will be backed up all the way past your rectum, sigmoid colon, transverse colon, right colon, all the way to your appendix. This is a very uncomfortable, frankly miserable way to live. You'll be getting cramps every time you want to eat in the advanced condition and then start losing weight.
Chronic opiates all have an adverse effect on the cardiac electrical conducting system. Methadone is clearly the worst, but they all do it to some extent. They can lead to a condition called long QT syndrome, which can be fatal without warning. Many experts recommend a routine annual ECG for all patients on chronic pain medications just to try to detect this condition early.
The other bad news, particularly for men, is that chronic use of opioid pain medications leads to lower levels of sex hormones. Testicles can start to atrophy; libido goes down; actual serum testosterone levels can go quite low--to low to support adequate sexual function. (This also happens to some extent in women, but the exact effects are not as clear.)
So there are lots of reasons not to be very keen to keep using pain medications long after the time of initial injury.
On the other hand there are a whole host of things that have significant pay-offs. Consider some of these:
meditation
yoga
vegetarian diet
water aerobics
Sudoku
prayer
crossword puzzles
volunteer activity
reading to the blind
being a big brother/big sister
adopting a child online
rescuing a pet
try alternative medicine
try acupuncture
try physical therapy or chiropractic
consider non-habit forming pain adjuvants like antidepressants (amitryptyline, nortriptyline), gabapentin, etc.
pursue a new hobby (like photography, drawing, woodworking, jewelry, etc.)
become an expert on some subject of interest to you.

All of these tend to work towards the development of a better mind. All chronic pain medications work in the opposite direction of numbing your mind and stifling thought and creativity. To go and fulfill your special gift to the world you are going to need an alert open mind, a flexible outlook, and a willingness to try things, anything. If you consciously work on expanding your own possibilities you can build yourself a great palace in the sky and relegate the pain to the hall closet. You just have to think bigger.

The Cough That Won't Quit

2011-09-08T11:42:00.000-07:00

The View from the Office

The Cough That Won't Quit:

Pertussis in Portola

In the middle of this past Winter I wrote an article about the cold that wouldn't quit--that keeps hanging on with a deep cough for 6 to 8 weeks. There I reported that most of that was due to bronchospasm triggered by the infection, which was best treated with an albuterol inhaler or comparable medication.

There was one other cause of cough that won't quit which I didn't mention then because it is much more rare. But now that we have seen several cases of pertussis (whooping cough) in Portola, it is worth discussing this and explaining how it differs from common post-viral bronchospasm.

The Pertussis Quandary

In Plumas County we're now seeing several confirmed pertussis cases. Pertussis (whooping cough) has always been a confusing, poorly understood, commonly misdiagnosed, and always seriously underestimated clinical infection. It is not entirely clear that we know a whole lot more now (in 2011) about this organism than I did when I started my career. Nonetheless, here is a recent update.(1)

The first pertussis vaccine was developed in the 1930s and became routine in the 1940s. A majority of us have probably had the vaccine. A few of us can remember having the classic whooping cough when we were young. One problem is that childhood vaccination confers only limited immunity that wanes after 5 to 10 years and rarely lasts more than 12 years. Another problem is that having the pertussis infection does not leave you with good antibodies against pertussis. Thus one never knows how protected the population is, but whatever it is, it's waning fast. Another problem is that the immunization prior to the 1990s had a lot of significant side effects; in particular, there was concern (overblown as it turns out) that pertussis vaccine could cause brain damage. This led many parents to elect to forego vaccination for their children. We are now seeing the results of this reduced immune protection in the general population.

Classic pertussis presents in 3 stages: a 2 week catarrhal (mucousy) stage with nonspecific symptoms like an ordinary cold in which it is nearly impossible to make the diagnosis; the astute clinician might notice unexplained excessive lacrimation (tearing) and/or conjunctival redness.

The paroxysmal stage begins in the 2nd weeks and lasts for 2 to 3 months. The onset of paroxysmal cough is the hallmark. A paroxysmal cough is defined as a series of coughs occurring during a single expiration; these tend to occur in groups throughout the day and night with few or no symptoms in between. "A cough paroxysm causes low lung volumes, leading to a vigorous inspiration that may result in a whoop, particularly in infants and children, in whom the caliber of the trachea is smaller." Listen to these classic whoops. [Click on link.]

The final phase is the convalescent phase in which the cough slowly disappears over 2-3 months.

So the total illness can run for 6-7 months.

Unfortunately for modern clinicians whose patients have been previously immunized (or infected), the characteristics of the cough illness are atypical and may manifest just as chronic cough. Several recent epidemiological studies have shown that pertussis is present as the cause in 12-32% of prolonged cough illness in adolescents and adults.

Once you suspect pertussis, which test do you use? Alas, there is no good choice. The CDC endorses only the culture and PCR (a specialized DNA assay) methods for diagnosis in community practice. Culture, however, lacks sensitivity (will miss a lot of cases), and PCR lacks specificity (it will be positive in a significant number of people who do not have pertussis infection). Swabs for testing need to be obtained on Dacron swabs since cotton is toxic to B Pertussis and calcium alginate swabs interfere with PCR assay. "Importantly, the sensitivities of PCR, serologic testing, and, particularly, culture decrease with the duration of illness." Direct fluorescent antibody testing (DFA) is inexpensive and rapid but is no longer recommended because of its poor sensitivity and specificity. Serologic testing (with serial titers showing 4-fold change) is useful for epidemiological research, "but is neither widely available nor standardized and no FDA-approved test exists." Thus, in practice, there are many more people who have pertussis as a cause of their chronic cough than we are able to identify on testing.

The CDC Case Definition: The CDC clinical case definition for endemic or sporadic cases of pertussis is a cough illness lasting 2 weeks or longer without other apparent cause with 1 or more of the following:

paroxysms of coughing (sometimes leading to a faint, called tussive syncope)

inspiratory whoop (more likely in children) [Click on link to hear what it sounds like.]

post-cough vomiting

Alas, again--"Importantly, our data do not apply to an outbreak setting [like now in California] in which the pretest probability of pertussis for a patient with a cough illness may be substantially higher and the thresholds to test and empirically treat for pertussis may be lower...[A]n important finding in this study is that the absence of classic symptoms of pertussis may not have sufficiently low probability to exclude the diagnosis of pertussis, and the presence of classic symptoms is common in patients who do not have evidence of pertussis infection."

COMMENT: So what is a reasonable clinician to do?

In the epidemic context, just treat everyone with cough > 3 weeks to prevent secondary spread.

In the sporadic case context, test with PCR (if available) or culture after 3 weeks, and treat empirically after 8 weeks.

I was interested to note that, just before our current epidemic in California had started, I had seen an abrupt increase in patients seeking evaluation for cough > 8 weeks duration (i.e., 4 patients in a 2 month period). None of them were ultimately diagnosed with pertussis, most likely due to the quality of the available tests; but in retrospect I sure do believe that they had pertussis. Of course, it doesn't help them or anyone very much to diagnose it in retrospect.

The Bottom Line for Patients

1. If you have persistent cough for more than 3 weeks, consider being treated for pertussis. If you have cough for 8 weeks, definitely get treated for pertussis. This won't cure you, but it will protect everyone you come into contact with.

2. The treatment is with azithromycin (250 mg tablets); 2 tablets for the first dose, then 1 a day for 4 days. Persons who live with a patient with this infection should also be treated.

3. Understand that treatment prevents the spread of pertussis from one person to another, and is therefore highly advisable from a community health perspective. Treatment does NOT alter the course or symptoms of pertussis infection. Thus patients may have symptoms for up to 2 to 3 months even after treatment. Try not to blame your doctor.

4. The current recommendation is that all adults receive at least one pertussis vaccine booster (called a TDaP). You should receive the vaccine even if you have actually had pertussis infection because the infection does not lead to good antibody levels.

Best yet, ask your doctor for this immunization way before you ever get sick.

Reference:

Cornia PB et al. Does this coughing adolescent or adult patient have pertussis? JAMA 2010; 304(8): 890-6.

PRESERVING OUR MENTAL AND COGNITIVE HEALTH

2011-08-18T11:24:00.000-07:00

THE VIEW FROM THE OFFICE

PRESERVING OUR MENTAL AND COGNITIVE HEALTH

Physical Activity and Cognitive Health

In the office I am often asked by patients--"Could I be getting Alzheimer's Dementia?" "Is there anything I can do to prevent it? I have written a previous article in this series about the difference between mild, normal cognitive impairment and Alzheimer's. Here let's address the question of what, if anything, can you do to prevent Alzheimer's, if you're worried about. Fortunately there's been some good news recently.

"Recent epidemiologic, cohort, and clinical-trail data support a role for physical activity in maintaining cognitive health. To assess the effect of physical activity on cognition in the setting of cerebrovascular disease, researchers conducted a retrospective subgroup analysis of more than 2800 female health professionals over the age of 65 with at least 3 vascular risk factors (e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index > 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. The cognitive evaluation was conducted via telephone; 81% of the respondents completed at least 3 assessments at 2-year intervals....Women in the two highest quintiles of physical activity level--equivalent to brisk walking > 30 minutes daily--had significantly slower rates of cognitive decline than those in the lowest quintile. When the data were compared to an analysis of age-associated cognitive decline, participants in the 2 highest quintiles of physical activity were cognitively 5 to 7 years 'younger' than those in the lowest quintile. A secondary analysis specific to walking showed a possible threshold effect, with at least 30 minutes of brisk daily walking required for significant cognitive benefit.

[Arch Intern Med 2011; 171:1251; abstracted in J Watch Specialties Neurology Aug 2, 2011]

COMMENT: Remember the old healthy lifestyle program--the Formula for Health. It works for everything, at every age. Try it! Each of the 5 steps is directly good for preserving mental function and health. There's nothing better.

A New Treatment for Burns (submitted by a patient)

2011-08-05T10:03:00.000-07:00

THE VIEW FROM THE OFFICE

THE BASICS OF BURNS

Burns come in 3 basic varieties: 1st degree, 2nd degree, and 3rd degree.

Fortunately the first degree burn is most common. It occurs when we touch something very hot, feel a stinging, and pull away quickly. We are left with a tender red mild swelling of the skin. This is a first degree burn. This is also the most common burn you get from sunburn.

Treatment: First aid for minor (1st degree) burns consists of removing the source of the heat, immersing the burn in ice water, or covering with a thick ointment (I used to use "Ammertan," a tannic acid product, in childhood). These will provide some immediate relief. But the tenderness will persist. First line of therapy for the pain is ibuprofen--a good anti-inflammatory agent. If this is not enough, then call your doctor for some vicodin or codeine.

Stage 2 differs from State 1 because the heat penetrates a little deeper in the skin and causes the characteristic blister, which usually rupture, and then leads to loss of skin. So either blistering or skin peeling, means that you have at least a Stage 2 burn. The treatment principles are the same, but with an added step. You have to manage the blisters. Neither Stage 1 or Stage 2 burns lead to scarring, which is the good news. They should both heal completely.

If the blisters are already ruptured, then you want to cover them with a topical antibiotic (Neosporin, Bacitracin, Silvadene, etc.; whatever you have) and pad them with a bulky (several layers of gauze pads which are then held to the burn site by several wraps of cloth around the affected part). If the blisters are still in tact, then, usually with the consultation with a physician, you have to make a decision whether to go ahead an lance them (in order to avoid them breaking at some time and in some place that might be very dirty). The biggest problem from the blisters is that the fluid in them is a great media for bacterial growth, and so, if not managed carefully, can lead to secondary bacterial infection in the wood. My rule of thumb is that, if a blister is on an area of the body likely to get bumped in ordinary daily activities, it should be lanced and dressed carefully.

A third degree burn is the worst. This is what they call a "full thickness" burn. The heat from the burn has penetrated below the level of the skin and has started to cause major adverse effects of muscles and ligaments. These burns usually lead to scarring. These burns are best taken care of by a special burn unit in order to avoid late contracture of a joint due to severe scarring. Sometimes later skin grafting is required to removing the scarring and try to give a more normal appearance.

The key to the care of all burn wounds is:

1. immediate attention. Let someone who knows about burns check it.

2. Clean it right away.

3. Take an anti-inflammatory right away.

4. Bandage it with bulky dressings to provide comfort and protection.

5. Have it checked by some one 3 days after injury to be sure that healing is taking place appropriately.

6. At all times be on the look out for infection (a late, after the first 48 hours, increase in pain, redness, swelling, tenderness, and fluid drainage.). These will all need an antibiotic.

7. Make sure you tetanus immunization is up to date.

And now for another tip on burns, submitted by Ralph Wittick:

BURNS

A young man sprinkling his lawn and bushes with pesticides wanted to check the contents of the barrel to see how much pesticide remained in it. He raised the cover and lit his lighter; the vapors inflamed and engulfed him. He jumped from his truck, screaming. His neighbor came out of her house with a dozen eggs, yelling: "bring me some eggs!" She broke them, separating the whites from the yolks. The neighbor woman helped her to apply the whites on the young man's face. When the ambulance arrived and when the EMTs saw the young man, they asked who had done this. Everyone pointed to the lady in charge. They congratulated her and said: "You have saved his face." By the end of the summer, the young man brought the lady a bouquet of roses to thank her. His face was like a baby's skin.

Healing Miracle for burns:

Keep in mind this treatment of burns which is included in teaching beginner fireman this method. First aid consists to spraying cold water on the affected area until the heat is reduced and stops burning the layers of skin. Then, spread egg whites on the affected are.

One woman burned a large part of her hand with boiling water. In spite of the pain, she ran cold faucet water on her hand, separated 2 egg white from the yolks, beat them slightly and dipped her hand in the solution. The whites then dried and formed a protective layer.

She later learned that the egg white is a natural collagen and continued during at least one hour to apply layer upon layer of beaten egg white. By afternoon she no longer felt any pain and the next day there was hardly a trace of the burn. 10 days later, no trace was left at all and her skin had regained its normal color. The burned area was totally regenerated thanks to the collagen in the egg whites, a placenta full of vitamins.

This information could be helpful to everyone: Please pass it on.

This message in its entirety is circulated Courtesy of Ralph Wittick

A Curable Cause of Severe Chronic Leg Swelling

2011-07-08T17:47:00.000-07:00

The View from the Office

A CURABLE CAUSE OF LEG SWELLING

I had a patient recently, one of our Graeagle gentlemen, who even in his late 70s and after the usual accumulation of minor and major medical nuisances, was still very active, still working in fact, and had lots yet he still wanted to do. He came to see me in the office with a complaint of chronic severe swelling in both legs for several months.

Leg swelling, or what we call 'edema', is a common and very annoying complaint. Your shoes don't fit. Your legs feel heavy and it takes more work to walk. In the heat they swell even more. There are several common causes of leg swelling. The most common for people middle aged and older is chronic weakness of the veins (venous insufficiency). This condition is often preceded by swelling of individual veins in the legs (e.g., varicose veins) and may gradually progress to diffuse edema fluid in the skin and subcutaneous tissue, which we then call edema. In the more chronic stages, venous insufficiency often declares itself by leaving little brown spots and dots like freckles all over the front of the legs. This is called "hemosiderosis" (too much iron in the tissue from the blood), which occurs as blood leaks out of weak veins and just sits in the tissue. Your body's defense system gradually eats up all the material from the red blood cells, but leaves the iron behind. In general, diuretic medications do not help chronic venous insufficiency that much. The big problem is that the stronger diuretics, which are needed, also take too much fluid out of the rest of your circulatory system, and leaves you feeling weak and dizzy. At this point you have to stop the diuretic. In the long term, once the veins have really failed, the only thing that may offer additional help is vein-stripping surgery.

For younger women, pregnancy is a common cause of edema as the enlarging uterus puts pressure blocking the normal vein flow in the pelvis and causing back up of blood and tissue fluid in the legs. The same kind of thing can happen in older people, where a tumor (benign or malignant) can also put pressure on the veins and cause the same kind of edematous fluid back up. The good news is that in adults, tumors that block veins tend to occur on one side or the other but not both. Fortunately this is relatively rare. In both these cases, a fluid pill (diuretic) will not help if the cause of the obstruction is not relieved. In pregnancy, you get that nice dramatic relief of obstruction when the baby is born.

The most feared cause of chronic severe leg swelling is a heart problem--congestive heart failure. In this condition, which usually occurs in people who have already had coronary artery disease, a heart attack, or severe hypertension, the heart muscle becomes weak and is no longer able to pump out the normal amount of blood with each beat. Slowly fluid starts to back up in the veins. When it backs all the way up into the lung veins, then you get acutely short of breath in a condition called pulmonary edema. In less severe and more chronic cases the patient initially feels only severe fatigue, usually for months, and then may slowly developed a decreased ability to do their usual activities and they develop fluid and swelling in their legs, called 'cardiac edema.' The good news is that this will respond promptly to diuretic therapy; the bad news is that this kind of heart failure is likely to recur from time to time. Congestive heart failure, and its related problem of chronic severe leg swelling, occurs overall in about 1% of the population.

Another very rare form of chronic lower extremity edema is a genetic condition called "lymphedema." This is an unusual and very severe form of leg swelling. It is not really a true 'edema' as in the other conditions described, but rather is a 'lymphedema.' Here the problem is abnormal formation of the lymph vessels in growth and development with the result that the flow of lymph fluid is blocked and just slowly accumulates in the deep tissues of the leg. This kind of edema causes the feet to swell so that they look like wooden blocks at times, and the swelling tends to extend all the way up to the knees. This swelling also has a very different feel to it when you touch it; it is very hard and you can feel fibrous scarring in the subcutaneous tissue, whereas common edema is soft and leaves little impressions, indentations, when you press on it gently with your finger. The worst news of all is that there really is no satisfactory treatment for this condition. Probably specialized physical therapy and massage work the best; diuretics are not very effective, and surgery is not an option.

So far, we have discussed a very common form of edema (mild venous insufficiency), and several rarer forms of edema (heart failure, pregnancy, tumor, and lymphedema [which, as you now know, is not really 'edema' at all].

Now let's return to the gentleman described at the beginning of this article. His case is particularly important because it is fully curable. It turns out that he did not have heart failure (our biggest worry), nor did he have significant venous insufficiency (his veins weren't very prominent even though he had a little bit of hemosiderosis), and he certainly did not have lymphedema. The idea of a tumor was unlikely in view of the symmetrical severe swelling he had in both legs. So we considered one more cause--medications. It turns out that he had been taking a very high dose of diltiazem (a common blood pressure medication) for years, and one of the common listed side effects is edema. In fact this applies to a number of high-blood pressure medications. The worst offenders are the group known as "calcium channel blockers" which include diltiazem, amlodipine, verapamil, and procardia. The "beta-blocker" group (metoprolol, inderal, labetalol, pindolol, carvedilol, etc.) can also do it, but usually less severely.

The thing that makes diagnosis hard is that patients can take these medicines for years, not have any problems, and then something tips them over into a full blown edema--from toes to knees. Thus considering this possibility, we slowly reduced his diltiazem by about 33% every 2 weeks and substituted another blood pressure medicine. After the first reduction in dose, we did not notice any change. Two weeks after the second reduction in dose his legs had returned to completely normal. He was cured.

Now that is a very gratifying result in this condition. This is the only form of chronic leg swelling that may offer you a complete cure if you are on one of these medications. So it's a cause of leg swelling worth remembering.

Is It Memory Loss or Dementia?

2011-06-10T15:48:00.000-07:00

A VIEW FROM THE OFFICE

Am I Just Forgetful or Am I Getting Dementia?

This is a question that worries many of us as we creep above the age of 50. For some people it starts even younger. It is my personal observation that we have more brain fatigue in our population than ever in the history of the world just because we have so much information and media to digest and because we tend to be multi-tasking all the time and wired all the time. I can't believe this hyperarousal for the ordinary business of life is any good for us.

So how many of you out there have had the experience of trying to pull up a word from your vocabulary for a common object, something you absolutely know you know, but you can't come up with it? How many of you have stepped into another room to get something and have forgotten what you were looking for before you even get half way into the room? How many of you when taking pills at night can remember whether you have already taken you vitamin pill? How many of you have worried about an important lunch date for weeks then forgot all about it when the time came? How many of you have drawn a total blank on the PIN number for your ATM card and had to go home cashless? These minor humiliations are happening all the time to more and more of us. It is also true that there are more cases of Alzheimer's disease in the general population than there ever has been before--most of this due just to the fact that we are living much longer than we used to.

Generally, as soon as a middle aged person has repeated bouts of memory lapses of the kind described above they start to worry, "Could I have Alzheimer's?"

The good news is that, if you have the presence of mind to ask yourself this question, you probably do not have Alzheimer's disease. The other good news is that even if you did, it's not as bad as it once was. It is now possible to live 20 or more years of completely function life after the initial diagnosis of mild Alzheimer's.

The New England Journal of Medicine has just published an article on "Mild Cognitive Impairment," which is the term for this kind of repetitive memory loss that is not Alzheimer's disease. (Petersen RC. Mild Cognitive Impairment. NEJM 2011; 364: 2227-34)

I thought it might be a worthwhile endeavor to illustrate the range of cognitive function between normal and full-blown Alzheimer's disease. Here the authors identify their subject, mild cognitive impairment, as "an intermediate state of cognitive function between the changes seen in aging and those fulfilling the criteria for dementia and often Alzheimer's disease. Most people undergo a gradual cognitive decline, typically with regard to memory, over their life span; the decline is usually minor, and although it may be a nuisance, it does not compromise the ability to function." Only about 1 in 100 people go through an entire lifespan with no signs of cognitive impairment. Currently it is estimated that the prevalence of mild cognitive impairment in population-based studies ranges from 10 to 20% among persons older than 65 years of age. In the US the incidence of dementia is 1-2% per year.

The authors divide cognitive impairment into two categories:

1. Amnestic mild cognitive impairment: "Typically, these patients and their families are aware of the increasing forgetfulness. However, other cognitive capacities, such as executive , use of language, and visuospatial skills, are relatively preserved, and functional activities are intact, except perhaps for some mild inefficiencies."

2. "Non-amnestic mild cognitive impairment is characterized by a subtle decline in function not related to memory, affecting attention, use of language, or visuospatial skills."

The distinction between these two types of memory function is subtle and somewhat difficult. The memory loss is more severe in patients with the amnestic type. "Typically, they start to forget important information that they previously would have remembered easily such as appointments, telephone conversations, or recent events that would normally interest them (e.g., for a sports fan, outcomes of sport events). However, virtually all other aspects of function are preserved. The forgetfulness is generally apparent to those close to the person but not to the casual observer." The big difference in dementia is that in dementia the cognitive deficits are affecting daily functioning to the extent that there is loss of independence in the community.

What most people with mild cognitive impairment are worried about is whether it will progress to actual dementia. In reality, such progression occurs in only 10% of patients.

If a diagnosis of "mild cognitive impairment" is made there is not much to do. While there are some fancy imaging techniques that are being use in research, they will not help an individual patient, particularly as there is no specific treatment for this condition. While medications offer no benefit as yet, there is some evidence of potential benefit from cognitive rehabilitation, including the use of mnemonics, association strategies, and computer-assisted training programs. One of the most important points for evaluation is to rule out the possibility of depression (from loss of significant others or diminished circumstances or chronic disease), as depression clearly causes major impairment of memory. For the purposes of prevention, traditional cardiac risk factors appear to be markers for a higher risk of this condition. Thus the most effective primary prevention is likely to be, as I have said so many times before, a healthy lifestyle. You know: 0 - 5 - 10 - 30 - 150. (0 cigarettes, 5 servings of fruits and vegetables daily, 10 minutes of relaxation daily, a BMI < 30, and 150 minutes of exercise each week).

For the most part mild memory loss is a normal aspect of aging to which the kindly grace of age helps us to adjust.

I do not expect you to remember any of this article.

The Lowdown on Cancer Screening

2011-06-03T09:51:00.000-07:00

A View from the Office

The Lowdown on Cancer Screening:

How Much Cancer Screening Is Enough

We are all concerned about cancer, but how concerned do you really need to be.

Of course, the first and best approach is just to live a healthy lifestyle.

Fourteen major epidemiological studies suggest that this healthy lifestyle can prevent 36% to 64% of all cancers. When you look at the data, you will realize that this is a greater benefit than all of the Pap smear, mammogram, prostate screening, and colon cancer screening programs put together. It not only costs far less, but is actually tremendously cost-saving in the long run.

The second sound approach is to do you own personal assessment of cancer risk. This practice is based on the fact that the majority of people (not all) who get cancer had clearly defined risk factors. Such obvious risk factors include smoking, asbestos exposure, working with solvents or toxic organic chemicals, etc.

Self-Assessment of Cancer Risks

Cancer is a concern to everyone. This is especially true if someone in your family or among your close friends has had cancer. The general risk of developing cancer in the

is about 0.4% per year. For the most part interventions against cancer and various attempts to prevent the different kinds have had only equivocal effectiveness. In fact, none of them have yet to be proven to actually increase life expectancy. This is an area in which it is particularly important to be an informed consumer. Essential in order to do anything intelligent to mitigate your personal cancer risk is to systematically appraise your personal situation and determine what factors may put you at increased risk for specific cancers.

A wonderfully practical article on this topic appeared in the British Medical Journal.(Jankowski J, Boulton E. 10-Minute Consultation: Cancer Prevention. British Medical Journal 2005; 331: 618) There Janusz Jankowski and Emma Boulton presented a systematic approach to assessing personal cancer risk with respect to a variety of cancers using an alphabet-based memory aid—

ABCDEFGHIJK. The point is, unless you are at specifically increased risk of developing a specific cancer, there is little point in aggressive general cancer screening technology.

Alcohol consumption > 3 units a day: predisposes to squamous cancers, especially cancer of the bladder and esophagus.

Body Mass Index > 25 and certainly > 30: predisposes to all solid cancers. If you don’t know your BMI, see the free calculator at: http://www.nhlbisupport.com/bmi/ .

Cigarette smoking at any level (even passive smoking): predisposes to bladder cancer, lung cancer, head and neck cancer, esophageal cancer, and oropharyngeal cancers.

Diet, especially one that is high in fat: predisposes to all solid cancers.

Exercising < 30 minutes a day: predisposes to all solid cancers.

Family history of cancer: (in at least one first degree relative (e.g., brother, sister, mother, father, son, daughter) and at least 3 people in two or more generations): predisposes to inherited cancer syndromes, including breast cancer, colorectal cancer, diffuse gastric cancer, ovarian cancer, prostate cancer, and uterine cancer.

Genital health (sexually transmitted infections): predisposes to cervical cancer and penile cancer.

Health promoting drugs that may decrease global cancer risks (but need a careful risk benefit analysis): colonic adenomas can be treated with low dose aspirin but can have serious side effects; hormone replacement therapy is linked with breast cancer)

Intense sunburn: predisposes to melanoma. Job related factors: lung cancer (exposure to asbestos and particulates), skin cancer (contact with arsenic)

Known disease associations: colorectal cancer has predisposing mucosal pathology– adenomas, celiac disease, ulcerative colitis.

The actions they recommend for physicians at the time of a routine check-up are:

1. Review history for any symptoms of cancers of concern (e.g. bleeding in the rectum, altered bowel habits, weight loss) [remembering, as discussed in a recent issue, that most of these red flags do NOT turn out to be cancer]

2. Educate the patient that early investigation of cancer symptoms increases the chances of cancer being successfully treated, but that most of such symptoms are not in fact due to cancer.

3. Emphasize the importance of a good diet. A patient should eat at least 5 portions of fruit and vegetables each day and cut down on fat, salt, and added sugar.

4. Explain that many cancers are preventable through lifestyle modification. Help the patient strategize as to what modification to tackle first–smoking, exercise, dietary modification, or alcohol consumption.

5. If the patient is serious about lifestyle modification, counsel about the advantages and options of various support methods for assisting behavioral change.

6. Offer objective advice about the risks of medical interventions such as x-rays, Pap smears, endoscopic examinations (sigmoidoscopy, colonoscopy, endoscopic esophagoscopy, gastroscopy and duodenoscopy (EGAD)), mammography, Pap smears and additional interventions (e.g. ThinPrep, HPV testing), and fecal occult blood testing (FOBT). The authors state, “Most people asking about the risk of cancer won’t develop it, and in about 10% of people anxiety levels will be raised needlessly.”

7. Provide as much objective (non-cancer society and non-specialty society sponsored) information and web-links as appropriate.

The other obvious risk factor is your family history. Family history is most important when it comes to breast cancer. If any of a woman's first degree relatives (mother, sister, daughter) had breast cancer before the age of menopause, the individual risk is significantly increased. For the average woman for each decade after age 50, the decentennial risk is about 3%. This can be reduced by about 15% with a program of regular mammographic screening. A family history of colon cancer increases your risk by about 50%, but, in general, this means increasing your risk from about 100 cases per 100,000 persons to about 150 cases per 100,000 persons. It is not a big risk. A family history of melanoma increases one's risk, but since the baseline risk is low, approximately 15 per 100,000, even a doubling of risk is not that large a number. Family history is important in lung cancer, not for the genetic aspects, but because it usually means you were exposed to a fair amount of passive smoking while growing up, which increases your risk.

Here are some basic cancer facts for the most common cancers.

Breast cancer: The average risk about 3% per decade after 50; mammography decreases risk of dying about 16%; with currently available treatments, more than 50% of women will survive regardless of whether they received screening or not. While women who receive screening have a lower risk of dying of breast cancer, their overall risk of dying is not changed by mammographic screening. A reasonable recommendation is to undergo mammography every other year between the ages of 50 to 75. The US Preventive Services Task Force, our national expert group, recent stopped recommending routine mammograms for women under 50. They also concluded that a physician breast exam was unnecessary if the woman is going to receive a mammogram.

Colon Cancer: Starting at age 50, the risk of colon cancer is about 57 per 100,000 for men and slightly lower for women. Over the next 30 years, the risk increases to a maximum of about 180 cases per 100,000 at age 80. Screening techniques can reduce the risk of dying of colon cancer about 15%. A healthy lifestyle has been shown to reduce the number of cases of colon cancer by about 24%. There is no clear agreement on what is the best form of screening. The generally recommended approach is to have an annual blood test from the stool for 5 years and then to have a sigmoidoscopy every 5 years; an alternative is to have colonoscopy every 10 years. This program is very expensive and the yield is relatively low. While adhering to a regular screening program after the age of 50 will reduce your risk of dying of colon cancer, there is no evidence that it will reduce your overall risk of dying. Experts agree that colon cancer screening can stop after age 70 or whenever any other medical condition reduces your life expectancy to less than 10 years.

Cervical cancer: The average risk of cervical cancer in women is about 8 cases per 10,000 women a year. Regular Pap smear screening has reduced the risk of dying of cervical cancer by 40-60%. Recent guidelines recommend Pap smear screening for women every year for 3 years after they become sexually active and then every 3 years after that unless they have an abnormal Pap smear in the mean time. The biggest problem with Pap smear screening is that there are a large number of false positive tests. For example, 7 out of 100 smears will show "ASCUS" which means atypical squamous cells of undetermined significance". These are not pre-cancer cells; in fact, as their name implies, we do not really know what they are. Nevertheless, most gynecologists recommend a procedure called colposcopy for this abnormality, the value of which is currently unknown. The other false positive is the finding of HPV virus. It is now known that cervical cancer is caused by the HPV virus, but the confounding factor is that more than 50% of women get exposed to this virus, and in over two-thirds of these cases the virus goes away all by itself. The experts recommendations state that a woman can stop getting Pap smears at age 65, if the last 3 Pap smears were normal. Women who have had a hysterectomy for a benign condition like bleeding or fibroids no longer need Pap smears.

While a new vaccine (in 3 doses) is available to prevent certain high-risk types of HPV infection, it cannot prevent all HPV related cancers. Even if you receive the vaccine, it is still recommended to get routine Pap smear testing. It is now being recognized that HPV can cause cancer in men (of the penis and the throat), but no definitive screening guidelines have yet been developed for men. While receiving routine Pap smear screening will significantly reduce your risk of dying of cervical cancer, there is no evidence that such screening will reduce overall mortality rates.

Melanoma: As mentioned above, the overall risk of melanoma in the US is about 15/100,000 persons. It is higher in patients who have a positive family history of melanoma, but it is still not very high. Since dermatologists and other medical groups have increased their efforts in advocating preventive measures for melanoma, the actual detection rate of melanoma has increased, but the rate of death from melanoma has remained essentially unchanged. [insert] This indicates that screening is detecting more cases, mostly mild cases, but it does not demonstrate a clear benefit. Preventive measures have been advocated, principally avoidance of direct sun (which can be expected to lead to relative vitamin D deficiency) and sun screen application. In over 2 dozen studies on the effectiveness of sun screens to prevent melanoma, only 1 has shown a positive effect. The USPSTF recommends as the primary approach to melanoma prevention is to pay attention to the ABCDEFs of melanoma. Your risk of developing melanoma from a mole or other pigmented spot on your skin increases if:

A: the skin lesion is asymmetric. Benign moles are generally simple round spots.

B: the border of the skin lesion is irregular. Benign moles usually have smooth borders.

C: the skin lesion changes in color, becomes darker, and/or develops different shades of dark pigmentation.

D: the diameter of the skin lesion increases to greater than 1/2 of a centimeter (about the size of a pencil eraser).

E: the skin lesion is enlarging significantly over a relatively short period of time.

A web site to help you calculate your own risk of melanoma can be found at:

http://www.cancer.gov/melanomarisktool/. One last practical tip is to get in the habit of taking a photograph of any groups of moles or pigmented spots once a year on your birthday; your back is the special area of concern. This allows easy identification of when there has been a significant change.

Lung Cancer: Except for persons with rare genetic conditions like alpha-1-anti-trypsin deficiency or asbestos exposure, virtually all lung cancer is caused by smoking. There is no need for screening. The need is to stop smoking and to avoid passive smoking. Period. Routine chest x-rays will not reduce your risk of dying of lung cancer. Periodic scanning with a CT scan of the chest may detect lung cancer earlier leading to a better chance of survival.

Prostate cancer: Prostate cancer is very common in males and increases in risk every year after a man turns 50. The overall average risk is about 156 per 100,000 men. This increases to about 50,000 cases per 100,000 men at age 80. The fact is that half of men will develop prostate cancer over their lifetime, but the large majority of them will never have any symptoms and will die of some other cause like a car accident or a heart attack. So far, numerous studies have failed to show a significant benefit for prostate cancer screening with either a rectal exam or the PSA blood test. In fact, of the major screening expert groups, the AMA, the US Preventive Services Task Force, the American College of Physicians, and the Canadian Task Force on Preventive Medicine recommend against routine screening. Only the American Urological Association and the American Cancer Society recommend for it, and they have a vested interest. The problem with screening is that there are a large number of false positive tests. The major cause of a false positive test is simple prostate enlargement, which most men will experience as they get older. In fact, the scientist who invented the test recently testified before the US Congress that screening with the PSA test should stop because ultimately it cannot tell us what we want to know, namely who will die of their prostate cancer and who will not.

Footnote: One of the biggest problems with the most commonly recommended cancer screening or prevention tests is that they are very expensive and need to be repeated over and over again. For example, Pap smears need to be done annually for 3 years, then every 3 years until age 65 for a typical total of 15 Pap smears. Breast cancer screening with mammography generally requires 20 or more mammograms over a lifetime. Colon cancer screening involves a stool blood test every year between ages 50 and 70, for 20 stool tests plus either 4 sigmoidoscopies or 3 colonoscopies. PSA testing is recommended every year between 50 and 70 for a total of 20 tests. In practice, the main problem with these strategies is that we do not yet have universal health insurance in this country. This means that poor people and people without insurance tend not to get these tests, when these are the people at highest risk who could most benefit. Most of these tests are obtained for those who can pay because they have good health insurance. It turns out that people with good insurance have the lowest risk of cancer, so this is not a particularly effective strategy.

Alternatively, everyone can lead a healthy lifestyle.

Summary: So putting all this information together, what is a reasonable minimalist approach to cancer prevention:

1. Live a healthy lifestyle. In particular this means not smoking, which is the single greatest cancer risk factor among the general population.

2. Perform your own cancer risk assessment.

3. Utilize the best screening tests. For average risk women I recommend a Pap smear every 3 years until age 65 and a mammogram every 2 years between the ages of 50 and 65.

4. For colon cancer screening and prostate cancer screening, that is purely an individual choice. I don't specifically recommend them to my patients, but I do ask patients about their family history and their preferences.

And that's about it.

The Cold That Won't Quit

2011-05-26T10:47:00.000-07:00

A VIEW FROM THE OFFICE

THE COLD THAT WON'T QUIT

We all get colds once in a while. Usually we suffer a couple of days of runny nose, sneezing, the feeling of congestion, and the feeling of being a little run down. Most (but not all) colds are done in 72 hours, and we're used to dealing with them. Colds are caused by viruses and do not require antibiotics. The problem is that many colds lead to secondary complications, what we call a bacterial superinfection. Examples of such superinfection include ear infections (otitis media), strep throat, sinus infection (sinusitis), goopy eyes (conjunctivitis), chest cough (bronchitis), or even pneumonia. These infections happen because the preceding viral infection reduced our immunity and gave these germs a better chance to set up shop in one of our cranial cavities or airway passages. These infections are the reason most patients come to see a doctor after a cold. Most of these will respond to an antibiotic. The usual practice is for a doctor to prescribe an antibiotic for 7 days--usually something like amoxicillin, sulfa, or azithromycin. We are now increasingly realizing that most of these infections do not even require a full 7-days of antibiotics. For most symptoms will resolve in 2-3 days.

The problem I want to talk about today are the exceptional cases--the ones where symptoms have not resolved even after a full 7-days. What do you do then?

There are 3 main patterns to these exceptional cases:

An ear infection that does not resolve. Most often this is caused by retained fluid in the ear. Occasionally, it is a problem because the initial antibiotic used does not cover whatever particular germ was in the ear fluid. The standard approach to this problem is to undertake another round of antibiotics with a different, stronger antibiotic. Occasionally, if the problem is clearly due to fluid in the ear, we will prescribe some form of cortisone, either as a nasal spray like Flonase, or as cortisone pills (prednisone) for 7 to 14 days. Ultimately, failure of symptoms to resolve with this treatment will lead to a referral to an Ear-Nose-Throat (ENT) specialist. Usually, they will repeat this same kind of therapy for another round, and, if that doesn't work, they will offer a surgical option like placing tubes in the ears. It is quite rare that an adult would need this kind of surgery, but occasionally, especially among persons with severe allergies, it is appropriate.
Sinus infections that do not resolve. Sinuses can be notoriously difficult to clear up. In fact, many patients, especially those with allergies, will have repeated bouts of sinus infections during a year. Each episode of infection tends to make it more difficult to clear up the next one. In recent years, the experts have generally recommended delaying antibiotic therapy for at least a week to give it a chance to resolve on its own. If symptoms of face pressure or pain or severe congestion persist for over a week, then amoxicillin is the most often prescribed antibiotic. The exception is when you have previously been treated with amoxicillin for some other infection within the last 2-3 months. In this case, the high-strength form of amoxicillin is used--i.e., Augmentin, which is significantly more potent, but also more likely to cause intestinal upset and diarrhea. For persons with chronic, frequently recurring sinusitis, treatment needs to be for longer periods of time--for 14-21 days. Failure of symptoms of sinusitis to resolve is the most common good reason for using one course of antibiotics right after another and perhaps even for a third time. Failure to resolve with a third course of antibiotics will result in a referral to an Ear Nose Throat specialist and x-rays of the sinuses or a CT scan.
Chest infections that do not resolve. Here the primary symptom is cough, often associated with a sensation of chest tightness, and occasionally even by frank wheezing. One practical tip to remember is that there are basically two kinds of cough: (1) the cough due to a tickle in the throat or drainage in the back of your throat from your nose or sinuses. This usually feels like a scratchy throat and is accompanied by a constant upper airway cough to clear the throat; (2) the second type of cough is the deep in the chest cough. It will be very obvious that the cough is coming from deep in the chest, often with production of yellow-greenish phlegm. This combination of symptoms (cough and yellow-green sputum) is indicative of the common diagnosis of acute bronchitis. The experts are still arguing about what is the best treatment for acute bronchitis, and the majority trend is to believe that antibiotics are usually not necessary for simple, acute sinusitis where symptoms have only been present for 1-7 days. Experts differ on whether you should wait for 7 or 14 days to start antibiotic treatment. I have reviewed all the major bronchitis studies myself and I reach a slightly different conclusion. Basically there are about a dozen major studies (and several studies studying these studies), and the truth is that they split right down the middle on whether antibiotics help the resolution of acute bronchitis symptoms or not. So it's a toss up. It is perfectly reasonable to treat these symptoms with antibiotics, and it is also perfectly reasonable not to treat them. I usually let patients make this decision. My personal rule of thumb is to consider antibiotics if symptoms have persisted for more than 3 days, and definitely to recommend them if they last for 5 days or more. I usually prescribe either amoxicillin or azithromycin for these infections. Usually 5 days of antibiotics is enough.

When cough is associated with more symptoms than just purulent sputum and chest tightness, the other diagnosis that must be consider is pneumonia. Pneumonia is basically just an extension of bronchitis as the germs move all the way down the airways and actually begin to enter into the lung tissue (alveoli) itself. Pneumonia is accompanied by much more severe symptoms--usually including high fever, shaking chills, and shortness of breath, often severe fatigue of just a feeling of being really sick. In fact, just the combination of acute cough, high fever, and shortness of breath (rapid breathing) is enough to make a diagnosis of pneumonia; you don't even need a chest x-ray. There is a variation of pneumonia, however, that is more subtle; in these cases it can present with just a cough, but no fever, and usually with a sense of malaise. This kind of pneumonia is often referred to as "walking pneumonia" or an atypical pneumonia. Pneumonia, of all types, is treated with amoxicillin, azithromycin, or Levaquin (or their equivalents) for at least 7 days. Symptoms usually improve dramatically after 48 hours.

So the real issue for today's article is what do you do if your cold is still causing severe chest cough, tightness, and/or wheezing one to two weeks after onset? I am assuming that you have already made one visit to the doctor and that appropriate treatment with antibiotics was undertaken if there were any signs of bacterial infection. There are basically two courses to follow here:

If the doctor told you that initially all you had was a viral infection and did not prescribe antibiotics, then you may in the mean time have acquired a secondary bacterial infection (otitis media, sinusitis, or bronchitis). The appropriate plan for this is antibiotic treatment for 5 to 7 days with a common antibiotic like amoxicillin and treatment for the most severe symptoms--like a decongestant for severe runny nose or nasal obstruction, a cough syrup for severe cough, and/or asthma medications (an inhaler usually) for wheezing or tightness. In this scenario, symptoms usually resolve quickly and you're done.
The other scenario is the classic prototype of the cold that just won't quit. After your previous treatments, your cough is improving some, you're no longer coughing up as much yellow or green phlegm, you don't have any fever or chills, but you still feel tight in your chest, may have occasionally whistling or wheezing sounds in your chest, and tend to have bad spasms of coughing that make you really breathless and leave you feeling weak with aching ribs. The first thing to do in this scenario is to take a chest x-ray to make sure than no atypical lung infection (pneumonia) has been overlooked, and to make sure there is nothing else there that could cause such symptoms (like a lung mass in smokers). If the chest x-ray is negative, then the most common cause of this scenario is asthma. In many cases there may be a past history of asthma in childhood. For many, there is no history of asthma, but severe viral infections (and bacterial infections) can trigger new asthma (usually short-lived) even in a patient who has never had it before. In others there is a history of smoking. Smokers are the one group of patients who should expect to have recurrent episodes of the "cold that won't quit" since smoking so damages the airways. The treatments for asthma are an inhaler (albuterol, 2 puffs every 4 to 6 hours for coughing spells, chest tightness, and/or wheezing). If this is tried and does not bring enough relief, the next step is cortisone, usually by pills, usually in a dose of 40 mg of prednisone (or equivalent) for 7 to 14 days. This should take care of the asthmatic part of any infection that won't quit. For the rare patient, who is not better even after this, I will prescribe Advair; this is a dry-powder inhaler that combines a long-acting form of albuterol with a long-acting cortisone. It is probably the most effective medication on the market right now for persistent symptoms due to bronchospasm and asthma. Note that once you have had one course of antibiotics for a chest cough and the x-ray is negative, there is no real point in taking any more antibiotics.

Sometimes there is still a nagging cough and a general feeling of fatigue and just not feeling well. This is very distressing to patients, and they generally want the doctor to do something and to do it quickly. If we have already run through the steps described above, there is not much else to do. For some infections, and certainly at this stage of the cold that won't quit, you just have to wait it out. It will go away. About once in every 5 years most adults will get a severe infection like this that seemed to start as an ordinary cold, but it keeps them feeling sick and miserable for as long as one to two months. If you have run through the protocol above, there is nothing else to do. You just wait. After a while, simple time will cure most everything. While you're waiting to feel better, just ask yourself if you've had any other cold this bad in recent years. If you haven't had one like this in the last 5 years, then you can tell yourself that everything is normal, and you've paid your dues for another 5 years.

Hanging on to Your Feet!

2011-05-19T16:46:00.000-07:00

The View from the Office

Hanging on to Your Feet!

Now this article will only apply directly to relatively few readers. I would nonetheless urge you all to read it (it is brief and with pictures) because undoubtedly you know people--friends and relatives--who have problems like this with their feet. You can be very helpful in their care. The biggest problem for these persons and their feet is the natural and understandable urge to put off seeking intensive medical care. But that is exactly what is needed. And in so many cases it is the prodding of friends and relatives (especially spouses, if they have them) that finally brings them to the office.

The problem with the foot disorders that I am talking about is that, if you do not take early and aggressive care of ulcers in your feet, you are at risk for losing them--that is an amputation, which is, of course, a disaster.

The people who tend to get the kinds of foot problems I illustrate below are those primarily with one of two conditions (or perhaps both at the same time)--diabetes and/or peripheral vascular disease. Take a look at 3 different variations on the same theme.

Figure 1: Early severe heel blister which often turns into an ulcer. Get in to see your physician as soon as possible when you see this in order to prevent the problem seen in Figure 2.

Figure 2: Evolving heel ulcer: This will be difficult to heal at this point.

Figure 3: Severe foot ulcer over the ball of the foot. These are extremely hard to heal because they are subjected to dirty conditions and constant pressure.

Figure 4: Early gangrene of the 2nd toe. The tip of this toe clearly has to be amputated. The real problem, however, is that it is poor circulation that led to all of these ulcers. If the underlying problem with circulation is not diagnosed and treated, the patient will just continue to lose more and more of his foot until finally s/he has a below knee amputation. Below knee amputations are generally entirely preventable if patients receive the proper evaluation in these early stages of diabetic foot complications and peripheral vascular disease.

So what happens when patients with this kind of foot problem presents to the doctor or the emergency room. The treatment that is usually focused on is antibiotics to control any related infection; these can be given either orally or intravenously in the hospital. What you have to remember is that the primary problem here is not infection; infection is only a secondary side-effect. The primary problem is inadequate circulation.

To get these wounds to heal there are two basic steps are required:

You have to surgically clean the wound and remove all excess dead tissue. The nature of the circulatory insufficiency process is that tissue gradually dies and leaves behind yellow, soupy dead tissue. This dead tissue is just a natural breeding ground for bacteria, which is how the infections get started. But remember--infection is NOT the primary problem. All the antibiotics in the world won't do any good unless you remove the dead tissue, which creates the seeds for continuing infection. The problem here is that 99% of all primary care physicians (including most Emergency Physicians) have no specific training in the cleaning (surgical debridement) of these wounds, which is so crucial to care. You really want to take these wounds to someone with a lot of experience and expertise. In most major hospitals, the doctor who takes care of these wounds is a VASCULAR SPECIALIST. Thus, effective care of these kinds of wounds requires evaluation by a vascular specialist. In our area I have already had good experience with two vascular specialists in Reno, Dr. Ahktar and Dr. Desai; in Truckee, we have Dr. Kitz.
You have to perform an evaluation of the circulation to the feet. This process starts with a measurement of your blood pressure in the ankle comparing it to your blood pressure in the arm--a measurement that is called the "Ankle-Brachial Index". If the blood pressure in the ankle is less than 90% of the blood pressure in the arm, it is likely that there is a circulation problem. This is usually considered an indication for a vascular specialist to perform an "angiogram" (injecting dye into the arteries in the leg to see where the flow is good and where it is not). There are a number of highly effective procedures to restore circulation to areas of the leg with impaired blood flow. These include balloon angioplasty--stretching the artery out with an inflated balloon to improve flow; a kind of "roto-rooter" procedure where a special instrument is passed through a catheter in your artery that chops up the plaque that is blocking circulation. These are the two quick and simple procedures. There are a number of full surgical bypass approaches to the problem where the arteries are reconnected in a special way to bypass the area of worst obstruction.

Bottom LIne: Foot ulcers tend to occur in patients with diabetes and/or peripheral vascular disease. If not adequately treated initially, they tend to progress to a need for amputation over many years. These ulcers can NOT be treated just with antibiotics and dressings. They require surgical wound cleaning (debridement) and vascular evaluation. Good healing does not take place without an adequate circulation. Don't ever ignore this kind of problem or resort to just hoping it will go away. Get the full evaluation early in order to prevent having similar ulcerations and infections occurring again and again over many years.

Taking Care of Your Health in Hard Economic Times

2011-05-12T11:36:00.000-07:00

The View from the Office

Taking Care of Your Health in Hard Economic Times

Sad to say, in America it is commonplace not to have any health insurance. Yet as we all age we gradually accrue more health conditions needing chronic attention and more acute health problems. For citizens without health insurance taking care of yourself is very challenging since health care has become so expensive. But there are things you can do to stay healthy and minimize the impact on your budget. Remember—taking care of things now saves you a lot of money over the long-term.

Step 1: Work on developing a healthy lifestyle.

If you smoke, start cutting down immediately. This is the fastest and healthiest way to save money. If you need help, call 1-800-NO-BUTTS. Help there is free, and, if you complete the telephone program for smoking cessation, they will pay for your medication, if you need it to quit smoking. The first and most important step for any health program is to stop smoking—and then to help those you love stop smoking and help your kids never to start.

Eat right. The simplest way to do this is to focus on eating 5 servings of fruits or vegetables a day. This is a healthy source of vitamins, fiber, and just good general eating habits. The more fruits and vegetables you eat, the less junk you eat. If you reduce your red meat intake to no more than 4 ounces (a portion size about the size of a deck of cards), you save money, which will help pay for the fruits and vegetables. Studies have shown that when you make these kinds of changes in your diet at the same time, the net effect on your pocketbook is a wash.

Focus on ways to relax and be religious about attending to whatever relaxes you. Many people feel guilty if they focus on doing things to relax when economic times are tough or they are out of work, but, in fact, it is during these times that it makes the most sense. Being out of work or otherwise on a tight budget or having health problems without health insurance are sources of extreme stress. These are usually the worst of times. It is exactly during times like these that you benefit the most by taking some time out of the day to just relax, unwind, let it all go. Your body needs this. And it has a very helpful effect on chronic diseases like hypertension, diabetes, and depression.

When things are tight is also an ideal time to work on your weight. Step one is to know your BMI (body mass index). To calculate this you just need to know your height and weight. If you have a computer, there are lots of free BMI calculators on the Internet. If you don’t have a computer, stop by the library, and they can help you do this calculation. For your weight and BMI there is a magic number—30. If you’re below that, you are at a perfectly healthy weight for your height. If you are above that, you have some work to do. Tough economic times are a good time to work on weight—both because you have more time and because the money you save from eating less will really make a difference. For most of us, BMIs over 30 are due to snacking or junk food on a long-term basis. This is a great time to stop this. You will appreciate the health benefits (more energy, less fatigue, more exercise tolerance) right away if you make a change. All chronic diseases will be improved by losing weight—particularly hypertension, diabetes, and depression.

Finally, such times are a great time to get back to exercise. Usually these periods are periods where you have more time to spare. Your exercise program does not need to be more vigorous than brisk walks once or twice a day. Your goal is to get 150 minutes of exercise in each week. The more the better. Exercise has been shown to have an equivalent effect to treatment with standard anti-depressant medications for people with depression. You can’t afford not to be exercising.

A healthy lifestyle is your first line of defense against having health problems at all times of life.

Step 2: But what if you have some chronic conditions already, how do you take care of those during tight times?

Let’s take a look at some of the most common chronic medical problems—hypertension, high cholesterol (hyperlipidemia), and diabetes. For these conditions you need to be able to track certain basic numbers (lab tests) and to take certain medications.

Hypertension: You can have your blood pressure checked for free at the drugstore or many supermarkets. There are no regular blood tests that you absolutely need to have done, but, if you can, it is good to check your cholesterol and your kidney function once a year. You can get all of the most common blood pressure medications (generics) for just $10 for a 3-month supply at Wal-Mart or Target or other stores with this special drug pricing program.

Hyperlipidemia: For this you want to check your cholesterol tests at least once a year. The cheapest way to adequately measure cholesterol levels is to have a total cholesterol level done and an HDL (good) cholesterol level done. You don’t even have to be fasting for these tests. You can make all important treatment decisions, just based on these numbers. The most cost-effective way to have your cholesterol checked is to wait for the nearest health fair in your community. They often offer bargain basement prices in order to provide you with access to this important testing. We have our health fair for Portola coming upon September 10^th. In addition the hospital offers specials on testing for cholesterol at various times during the year.

During really tight economic times, you don’t necessarily need to have your cholesterol checked. If you know, for example, that several members of your family have had heart problems at an early age, then you would be better off on a cholesterol medication regardless of the test results. The same is true if you know you have multiple risk factors for heart disease, like smoking, overweight, high blood pressure, diabetes, lack of regular exercise, chronic high stress. In cases like these it is easier, cheaper, and more effective just to go to Wal-Mart (or Target, or similar programs) where they have $4 a month, $10 for 3 months prescription discounts for the most common medications. For cholesterol what you want is a statin medication like lovastatin, which these programs cover.

Diabetes: This is the most serious common disease that you might have to manage during tough economic times. It’s a challenge because there is a lot to do to take care of diabetes, and a lot of it is expensive. It is very important to take care of it well during such times in order to prevent much worse problems later. There are simpler approaches, however.

One is to follow my ABCDEF approach:

A-Get yourself an A1c test at your local health fair or through a special with your hospital. Eastern Plumas District Hospital offers a special program to allow patients to get their A1c tests done regularly at a discounted price.

B-Check your blood pressure at your local pharmacy for free and keep it under 140/90 mm Hg.

C-Check your cholesterol through your local health fair or hospital program and keep taking your cholesterol medication through a Wal-Mart discount program for $10 for each 3 month period.

D-Check your kidney function once a year. The basic panel you can get at a health fair will do this for you.

E-Have an eye check once a year or every other year. Often, after the first check, your doctor will tell you they don’t need to see you again for 2-3 years.

F-Check your feet. You can do this yourself. Check for any areas of numbness or tingling. Check for any breaks in the skin or severe fungus infection of the skin or nails. If you have bad fungus, use the over-the-counter Lamisil 1% cream twice a day for the skin (it won’t help with the nails).

This simple approach will keep your diabetes in very good control until you get your health insurance back and can have the full check-up.

To keep up with your medications, the Wal-Mart program has most of the common diabetes medicines (except insulin) on their $10 for a 3-month supply list. If you are currently on a fancy, brand name diabetes medicine, change to a $10 per 3-month generic. Your results will be about the same with really substantial cost savings.

Here is a link to the full list of drugs that Wal-Mart and Target cover at these reduced prices: [link] http://www.walmart.com/cp/PI-4-Prescriptions/1078664 Other plans: http://billeater.com/tips/use-new-flat-rate-4-dollar-prescription-plans

Some other conditions:

Depression: This is a very important condition to take care of during tough economic times, which are likely to make depression worse. Of course, the place to start is with the 5-steps for a healthy lifestyle as described above. Exercise is particularly important for people with depression; it is as effective as most depression medications. If you need medications, Wal-Mart covers the full range of generics for the treatment of depression for just $10 for 90 days. Some of the Wal-Mart antidepressant medications can also be used to treat insomnia, if that is a problem.

Arthritis: A healthy lifestyle is going to help this a lot. Wal-Mart has most of the common generic anti-inflammatories for discount prices, but since these are available over-the-counter, places like Costco often offer the cheapest source of medication over the long-term.

Common Infections: If you get an acute cold or skin infection or other common infection (sinuses, ear infections, bronchitis, etc.) while you are without adequate health insurance, your doctor can work with you to find low cost ways to manage them. If you have had a general check-in with your doctor recently and have explained your situation [See below.], it should be no problem just to call your doctor, explain your symptoms, and get reasonable treatment for the most common and probable conditions. If any special evaluation is required, your doctor will let you know, but usually ear infections, sinus infections, bronchitis, simple skin infections, and bladder infections can all be managed over the phone with a prescription for common antibiotics. If the initial round of antibiotics doesn’t work, however, then it will be necessary to come in for a visit. Most doctors will work with you in this way, but you have to have had a check in visit to explain the situation, review your overall health status, and make a general plan. Often this “check-in” visit as described below, will be the best investment you can make.

Other conditions unique to you and your situation: Don’t forget your doctor. Your doctor will often not be aware of your financial situation or lack of insurance unless you tell him/her. If you do tell, most of us are very willing to work with you to see that you get the care you need when you can’t afford regular visits or testing. What I would suggest, if you are just entering a period of economic uncertainty, is to make an appointment with your doctor to discuss the situation and share your concerns. Together you can make a cost-effective plan for how to manage your conditions with less frequent check-ups or testing. I know that, if I have such an initial meeting with a patient, I am very willing to manage most chronic conditions with just telephone consultations for extended follow-up with no charge and refills of medication by phone. If you stay in touch with your doctor, then s/he can tell you when it is important that you actually come in for a visit or for testing.

You should also be aware that if you need any special medications that are not on the Wal-Mart or Target discount list, there are ways of getting help with the cost of these prescriptions for most drugs. Sarah in the Eastern Plumas District Hospital business office can provide you with more information about these programs.

The bottom line is that it is very possible to take care of yourself when you don’t have the benefit of a full health insurance program. Let’s talk about it and see what we can do for you.

Great Reading: Mountains Beyond Mountains

2011-05-06T10:07:00.000-07:00

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Tracy Kidder Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World. 2003

    Tracy Kidder met Paul Farmer when Paul was 35. Farmer had graduated Harvard Medical School, also with a PhD in anthropology from Harvard. Worked in Boston 4 months of the year, living in a church rectory in a poor neighborhood, worked the rest of the year without pay in Haiti. Saw himself as a poor people’s doctor and an action kind of guy. About medicine, “I don=t know why everybody isn’t excited by it.”
    He claimed as his mentor, Rudolf Virchow, the principle architect of the foundations of scientific medicine--the first to propose that the basic units of biological life were self-reproducing cells, and that the study of disease should focus on changes in the cell. Virchow made important contributions in oncology and parasitology, coined at least fifty medical terms still in use today, defined the pathophysiology of trichinosis, led a successful campaign for compulsory meat inspection in Germany, designed a sewage system for Berlin that transformed it from a fetid sty into one of Europe’s healthiest cities, found a nursing school and hospitals, was a practicing archaeologist who played a role with Schliemann in discovering Troy, helped to define the field of medical anthropology, was a teacher, physician, and politician (so effective that Bismarck once challenged him to a duel). Most important to Farmer was Virchow’s emphasis on a fundamental law of epidemiology: “If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life.” For this his prescription was “full and unlimited democracy.” Among other apt conclusions, Virchow had stated: “Medicine is a social science, and politics is nothing but medicine on a large scale…It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation…Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community...Physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”
    Tracy Kidder started out with the attitude, “The world is full of miserable places. One way of living comfortably is not to think about them or, when you do, to send money.”
    Haiti has the distinction of being Latin America’s first independent nation and the world’s first black republic. Haiti is the poorest country in the Western Hemisphere. Per capita incomes are about one America dollar a day. It has the worst health statistics in the Western world. 25% of Haitians die before they reach 40.
    Paul did his main work in Cange in central Haiti, which he first encountered in 1983, in a hospital that he built known as Zanmi Lasante (“Partners in Health”). Patients were supposed to pay user fees, about 80 cents per visit. As the policy was enforced, every patient had to pay the eighty cents, except for women and children, the destitute, and anyone who was seriously ill. And no one, Farmer ruled, could be turned away. A million peasant farmers relied on Zanmi Lasante. A hundred thousand lived in its catchment area, which was served by 70 community health workers. Seven doctors worked there. Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area. It had vaccinated all the children, and had greatly reduced both local malnutrition and infant mortality. It had launched programs for women’s literacy and for the prevention of AIDS; in its catchment area it had reduced the rate of HIV transmission from mothers to babies to 4%, about half the current rate in the US. In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988. The money came from a small public charity set up by Farmer called “Partners in Health” with headquarters in Boston. It cost about $150 to $200 to cure an uncomplicated case of TB (vs. about $15,000 to $20,000 in the US).
    Mr. Kidder noted that his local hospital in Massachusetts was treating about 175,000 patients a year and had an annual operating budget of $60 million. In 1999 Zanmi Lasante treated roughly the same number of people for about $1.5 million.
Farmer’s lifestyle involved about 4 hours of sleep a night, no investment portfolio (his paycheck went straight to PIH), no family around, no electricity, no hot water, and lots of unsavory food, what he called “the fifth food group.” Of his work he says, “I feel ambivalent abut selling my services in a world where some can’t buy them. You can feel ambivalent about that, because you should feel ambivalent. Comma.” [“Comma” is a Farmerism that is short for “asshole.”]

    Dr. Farmer speaks of “WLs”—White liberals. “I love WLs, love ‘em to death. They’re on our side. But WLs think all the world’s problems can be fixed without any cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches.”
    When he first came to Cange he started his work with a simple needs assessment. He enlisted five Haitians and went from hut to hut through Cange and two neighboring villages tallying up the numbers of families, recent births and deaths, and the apparent causes of morbidity and mortality. He then planned the first line of defense--vaccination programs, protected water supplies and sanitation--and at the heart of the defenses, a cadre of people from the villages trained to administer medicines and give classes on health, to treat minor ailments and recognize the symptoms of grave ones like TB, malaria, typhoid. Then he planned a project for women’s gynecological services, health education, and family planning to reduce local maternal mortality, which led to so many subsequent health and economic disasters in families. The second line of defense was the hospital.
As he undertook the treatment of TB and noted his initially poor results, he designed a study. During the study, each group of TB patients got free treatment, but one group got other services as well, including regular visits from community health workers and small monthly cash stipends for food and child care and transportation to Cange. Of the patients who received only free medicine, a mere 48% were cured. By contrast, everyone in the group that received the cash stipends ($5 per month) and other services made a full recovery. Whether a patient believed that TB came from germs or voodoo made no difference. This study became for him a command to worry more about his patients’ material circumstances than about their beliefs. No patient has died of TB at Zanmi Lasante in 12 years.
    As a footnote, Kidder notes that one of the major causes of the poverty in Cange and Zanmi Lasante was the Peligre Dam in the Lac de Peligre. This project was planned by the US Army Corps of Engineers and built by corporations in the mid-1950s during the reign of one of Haiti’s American-supported dictators with money from the US Export-Import Bank. It was advertised as “a development project.” Under the rubric of improved irrigation and power generation land was taken from peasants (now under water) without compensation while agribusinesses downstream, mostly American-owned back then, benefited. The wealthy in Port-au-Prince received electricity. The peasants received neither irrigation nor electricity.
When asked, “How can you expect others to replicate what you’re doing here?”, he responds, “Fuck you.” Then adds, “The objective is to inculcate in the doctors and nurses the spirit to dedicate themselves to the patients, and especially to having an outcome-oriented view of TB...In other words, ‘Fuck you.’...Do you know what ‘appropriate technology’ means? It means good things for rich people and shit for the poor.”
Farmer got a break o make his vision come into being. He found a like-minded, retired Bostonian, who had run a construction company and done well, and who now wanted to see his money used for work like this.
AIDS came to Cange about two years after Farmer arrived in 1985. One of the things that Farmer is incensed about was the action of the CDC in formally classifying Haitian origin as a risk factor for AIDS. When Farmer did his own research, which he later published, he found that, in fact, AIDS came to Haiti from the US via tourists who mingled with prostitutes in Port Au Prince.

    At the end of the 20th century TB was still killing about 2 million people a yea--more adults than any other infectious disease except for AIDS; TB shared a ‘noxious synergy’ with AIDS. In poor countries, TB was the most common proximate cause of death among people who died with AIDS. About 2 billion people on earth, one-third of all humanity, have TB bacilli in their bodies. It turns into clinical illness in about 10% of those infected. Each year about 2 million people die from TB. The new standard of treatment for TB in the developing world was with standard first-line drugs in a program of directly observed treatment (DOTS). The new problem in TB control and in Haiti was multi-drug resistant TB (MDR). About 750,000 people around the world now have this disease.
    Unfortunately, the official WHO DOTS manual contained the following statement: “In settings of resource constraint, it is necessary for rational resource allocation to prioritize TB treatment categories according to the cost-effectiveness of treatment of each category...In developing countries, people with multi-drug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries.” This was unacceptable to Farmer. He noted with some annoyance that when there was an outbreak of multi-drug resistant TB in New York City in the late 1980s, centered in prisons, homeless shelters, and public hospitals, no one took this attitude. About a billion dollars were spent and effectively ended the outbreak. In 1993, at the best US center for this disease, National Jewish in Denver, only about 60% of cases could be cured and at a cost of up to $250,000 per case. There seemed no solution to the cost problem. Farmer recruited some allies and went on the international lecture circuit giving speeches citing and rebutting WHO policy. WHO stated that “MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease.” To which he responded, “But is treating MDR-TB really too expensive? Even if TB control is to be governed by considerations of cost-effectiveness, it s should be easy to show that failure to diagnose and treat MDR-TB is what is really costly. Consider the case of the family in Texas in which one member had exposed nine others to MDR. Care for these ten persons alone exceeded one million dollars.”
    “Myth number two: Some people think DOTS alone will stop outbreaks of MDR. This is nonsense. What will happen if programs treat drug-susceptible TB successfully and let MDR flourish? Transmission of MDR will continue, and even where MDR cases are now a tiny percentage of all TB cases, their relative importance will grow. Moreover, DOTS will amplify already existing drug resistance. In short, failure looms for programs now deemed success stories.” His audience often responded to his talk as “provocative,” to which he responds: “What’s provocative. I just said we should treat sick people, if we have the technology...I remember signing an oath to assist the patient and do him no harm. I don’t really remember signing that I would do it in a cost-effective way. The only time that I hear talk of shrinking resources among people like us, among academics, is when we talk about things that have to do with poor people...Strictly speaking, all resources everywhere are limited, but they’re less limited now than ever before in human history. Making a distinction between prevention and treatment is artificial--merely an excuse for inaction.”
As Margaret Mead has stated, “Never underestimate the ability of a small group of committed individuals to change the world. Indeed, they are the only ones who ever have.” Farmer and friends found a way out of the cost dilemma. They analyzed the structural pieces of the problem. The price of a drug has little to do with either its usefulness or the costs of manufacturing it. Often, the price is high simply because only one company makes it. In the case of second-line drugs used in the treatment of MDR-TB, huge amounts of drugs are required because treatment lasts so long. Most candidates for treatment, however, have no money. Thus there is no incentive for drug companies to manufacture quantities of the drugs at “reasonable” prices. Capreomycin is one of these second-line drugs; it is manufactured exclusively by Eli Lilly. Eli Lilly was selling it for $21 a vial in Peru; the same vial in Boston, where Farmer got his supply, cost $29.90. Farmer found out that the drug cost only $8.80 in Paris, and he tried to buy some there. He was told he couldn’t. “There’s a global shortage of capreo due to an emergency in Peru.” Then Farmer encountered someone named Guido Bakker, a Dutchman in his twenties, who worked for a nonprofit company, the International Dispensary Association, IDA. It specialized in driving down the prices of essential drugs, the kinds of drugs that poor countries need most urgently. IDA tended to deal only with generic drug manufacturers. IDA got the MDR-TB drug scarcity problem some relief by teaming with Doctors Without Borders to sponsor generic production. The solution to the problem got a further boost when, after intense political lobbying, they got the WHO to add second-line TB drugs to its list of ‘essential medicines’. This acted as a major inducement to generic manufacturers to get involved. Oddly, various eminent TB experts wrote to the WHO saying that they ‘couldn’t countenance’ the elevation of second-line antibiotics to the essential drugs list. Increased generic supply gradually reduced the cost of these drugs. By the year 2000, projects working with MDR TB paid 95% less for four of the second-line drugs than they would have in 1996, and 84% less for two others. The drugs to treat a 4-drug resistant case of MDR now cost Partners in Health/ Zanmi Lasante about $1500 instead of $15,000.

    Then there is the Cuban example. Cuba has life expectancies about the same as in the US. It has achieved control over diseases still raging in Haiti only 90 miles away. By American standards Cuban doctors lack equipment, and even by Cuban standards they are poorly paid. They are, however, well-trained, and Cuba has more of them per capita than any other country in the world--more than twice as many as the US. Everyone has access to service and even to procedures like open heart surgery. According to a study by WHO, Cuba has the world’s most equitably distributed medicine. Cuba was now in the position of exporting doctors to other needy countries. Cuba also has the lowest per capita incidence of HIV in the Western Hemisphere, and it has the most accurate HIV statistics in the world. (Testing is mandatory.) On an island of 11 million, only 2,669 tested positive as of 2000; the virus progressed to AIDS in 1,003 of these, and 653 died. Only 5 children caught HIV from their mothers, and all of those children were still alive. Because Cuba had acted quickly to clean up its blood supply, only 10 people had contracted HIV from transfusions. Yet Cuba is not a particularly rich country.
    The book concludes with a dramatic story of a boy named John. John’s official age was unrecorded, but he appeared to be about eleven or twelve. He had swellings in his neck, but they were harder than the usually fluctuant swellings of scrofula. Dr. Farmer was concerned about cancer. A PIH physician found an oncologist in Mass General who was willing to make the diagnosis for free, if they could get the tissue there. This required a biopsy that Farmer did not feel comfortable doing. A competent Haitian surgeon was willing to do the biopsy for a thousand dollars. Time for the specimen to travel to MGH resulted in a diagnosis of cancer four days later. It was nasopharyngeal carcinoma, which, if caught early, could be cured in 60-70%. It was decided that it was only practical to stage the disease and administer chemotherapy in Boston. It took a month to negotiate with MGH to do the treatment for free. John was much worse by this time. Now his legs and arms were emaciated; you could see all the bones. He had been given a tracheotomy, required regular suctioning, and was in constant pain from the masses in his neck. It was very difficult to look right at him. In fact, he was too sick to be transported by commercial airline. It was determined that a private flight would cost about $20,000. The question was, Could/should PIH/ Zanmi Lasante use their resources in this way for this patient? When this decision had to be made Farmer was on an international trip and could only be reached by e-mail. Two of his young PIH doctors had to decide what to do and whether to act without his direct involvement. The first e-mail that was sent was:
    “John’s condition is growing more tenuous. He is curious, sweet as can be, interactive with us and they would not have let him on the plane. And yet weak, weak, weak, and I fear would not survive the trip to the airport and they would not have let him on the plane. Polo [Farmer], I know this sounds crazy but he still has his fighting chance. This could still be a localized tumor with abscess tipping him over and increased mass size. I will take responsibility to pay for this flight. We are proceeding with plan while we wait to hear from you.”
    The initial response was, “Serena, honey, please consider other possibilities.”
    This was interpreted as a ‘no.’ Usually Dr. Farmer would say something like, “I trust you. Go ahead.”
Other staffers were injecting comments like, “What are we going to do if another kid like this comes to us?”
    “I'm looking at only one child, The fact that he has free care at the other end makes it excruciating,” Serena said.
    A staffer got on the computer and wrote Dr. Farmer, “You have to say yes or no.”
    The reply came, “Well, it could be worse. I’ll be there within twenty-four hours, but would not try to second-guess all of you there. Getting him on a plane is the only way to save his life, so I’m for it. In any case, his hope is in leaving Haiti, by one way or another, like many other Haitians, alas.”
John made it to MGH, but only to have the initial scans show invasion of bone and metastases through out his body. He is made comfortable, spends some hospice time with his mother in the home of a PIH staffer in Boston, and died in a few weeks.
    In reaction to observing all this, Mr. Kidder feels a need to ask Farmer, only after a decent interval, what were his thoughts on this whole case. Finally, on another 11 hour hike for a house-call, he does. “What about the case of John? What about the twenty thousand dollars that PIH spent on the medevac flight to get him out of Haiti? Not long after John died, a PIH staffer, a relatively new one, said to me that she couldn’t help thinking of all the things they could have done with that twenty thousand dollars. What is your response to that?”
Dr. Farmer responds:
    “Let me say a couple of things about this particular case, if you like. One is, remember of course that John was referred to Boston as dying of a treatable tumor, a very rare tumor. He wasn’t referred to Mass General before we knew what he had. So when he was referred, it was for free care because ha had such a rare thing and it was treatable, and the predicted cure rate was sixty to seventy percent. All right. Good enough. That was what the decision was made on. And there as no way for us to find out that John didn’t have locally invasive disease without metastases, because it required a diagnostic test that we can=t do here. So the other thing is, the bottom line is, why do we intervene as aggressively as we can with that kid and not with another? Because his mother brought him to us and that’s where he was, in out clinic...

    “I have to tell you, though, I’m a little troubled by these comments from the new PIH-er. Because I have to work with these people. The last thing I want to do is expend my energy trying to convince my own co-workers. Now I have to, of course. But I don=t like it.”
Kidder tries to apologize for the staffer, “Your PIH-er wasn’t saying you shouldn’t have brought John to Boston. Only that it was a shame you had to spend so much, given what else you could do with twenty grand.”
    “Yeah, but there are so many ways of saying that,” Farmer replies. “For example, why didn’t the airplane company that makes money, the mercenaries, why didn’t they pay for his flight? That’s a way of saying it. Or how about this way? How about if I say, I have fought for my whole life a long defeat. How about that? How about if I said, That’s all it adds up to is defeat? A long defeat.
“I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing. Now I actually think sometimes we may win. I don’t dislike victory.
    “You know, people form our background--like you, like most PIH-ers, like me. We’re used to being on a victory team, and actually what we’re really trying to do in PIH is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat.
    “And most of the time when people ask about triage, most of the time they’re asking not with open hostility but deep distrust of our answer. They already have the answer. And that of course is the energy-draining process, because you understand that a substantial proportion of the questions are asked in a, you know, in a very, what’s the word?”
    “With an animus?” Kidder suggests.
    “Yeah.” Farmer is silent for a moment.
    “The salary of a first-world doctor. How about that? Talk about all the money that could have been spent on other things, what about a doctor’s salary?
    “Well, of course. See, the truly humble think of that before they say the other. I’m not truly humble. I’m trying to be humble. So let me ask you another question. What is it that makes people not think that? Why doesn’t a young American doctor say, ‘Gee, my salary is five times what John’s airplane ride cost. And I’m twenty-nine or thirty-some years old.’ If you say that stuff out loud, you sound like an asshole. Whereas if you say the other stuff, you just sound thoughtful. Now what’s wrong with that? What’s wrong with this picture? If you say, ‘Well, I just think how much could have been done with twenty thousand dollars, you sound thoughtful, sensible, you know, reasonable, rational, someone you really want on your side. However, if you were to point out, But a young attending physician makes one hundred thousand dollars, not twenty, and that’s five times what it cost to try to save a boy’s life.’ “That just makes you sound like an asshole. Same world, same numbers, same figures, same currency. It’s just, you know, I never have been able to figure it out. I mean, I’ve figured it out, but I realize now it takes so much time to get to that point, to explain it, without offending someone. I have to limit the amount of time I put into explaining all that or it just sucks your soul dry. “
    This conversation then leads to the last rumination of the book as they complete the seven hour house-call trek. Kidder ponders that some would say that this is what is wrong with the Farmer approach. “Here’s an influential anthropologist, medical diplomat, public health administration, epidemiologist, who has helped to bring new resolve and hope to some of the world’s most dreadful problems, and he’s just spent seven hours making house calls. How many desperate families live in Haiti? He’s made this trip to visit two. All the serious, sympathetic critiques of Farmer’s work comes down to these two arguments: Hiking into the hills to see just one patient or two is a dumb way for Farmer to spend his time, and even if it weren’t, not many other people will follow his example, not enough to make much difference in the world.” To this he imagines Farmer’s response as something like this: “If you say that seven hours is too long to walk for two families of patients, you’re saying that their lives matter less than some others, and the idea that some lives matter less is the root of all that=s wrong with the world.”
    Farmer’s creed has been expressed as, “Patients come first, prisoners second, and students third; that doesn’t leave out much of humanity. He doctors first of all because he believes it is the right thing to do. If you do the right thing well, you avoid futility. Doctoring is the ultimate source of his power. Every sick person is a potential patient, and every healthy person is a potential student. He is fighting poverty all the time, in a long defeat. For him the reward is inward clarity, and the price perpetual anger or, at best, discomfort with the world. Paul Farmer was not put on earth to make anyone feel comfortable, except for those lucky enough to be his patients. He does not want his hospital to be some laboratory for the world. It should be enough just to serve the poor.”
As Kidder leaves Haiti on the long, muddy, unpaved road from Cange to the airport, they get, at one point, stuck behind a slow-moving cart with a sticker on it that in Creole says, “Lord, a word on all this.”
    In an afterword, Kidder notes that Cange / Zanmi Lasante saw its first open-heart surgeries, performed by teams from the Brigham and South Carolina. He feels tempted then to ask Farmer if this was ‘appropriate technology’? He wants, not to hear the answer, but just to hear Farmer say it.

COMMENT: This is an absorbing story of a fiercely independent man who elevated common sense to the genius level and has changed the world.

Doctors' Work: The Advantages of Growing Old

2011-04-21T11:13:00.000-07:00

The View from the Office

What I’ve Learned in 30 Years of Family Medicine

You can’t prevent 100% of anything. You’re not responsible for guaranteeing anything. Most of the power lies on the patient’s side of the partnership, and a healthy lifestyle is the primary tool. Your job is to help them unleash their power to be healthy.

Health is not freedom from disease. Health is a matter of being aware, content, and eagerly looking forward to the future with whatever physical or emotional limitations you might have and being firmly rooted in your community and your family and committed to their general welfare.

What you really owe your patients is to think for yourself. The experts don’t know your patient, and most of them are paid by a drug company. Your loyalty to your patient is uncompromised. No one knows their details like you do.

Every visit should be treated as a new patient visit. Going over the family situation, lifestyle score, job, and problem list and medication list should be routine. Just as when you join any practice, every patient is new to you and deserves the same basic intake and assessment from you. These assessments need to be global and represent your best effort to get to know their place in your community. There shouldn’t be any visits where you just treat a cold and let them go. Every visit is an opportunity to get to know them better. Colds don’t matter. Not being thorough just because you’re rushed is a lack of discipline. Discipline is what makes you efficient and keeps you from getting behind in your schedule.

Every visit should start with a conversation about lifestyle. This is, after all, the key to health. Using the formula 0-5-10-30-150 (for 0 cigarettes, 5 servings of fruits and vegetables a day, 10 minutes spent relaxing in some way every day, maintaining a BMI < 30, and getting at least 150 minutes of exercise a week) makes this a simple conversation. Try it. Your patients will respond positively to it.

You can’t beat the 80/20 rule. The 80/20 rule states that 80% of your best results come from just 20% of your best efforts. Medical school curricula were designed by a bunch of obsessive-compulsives who didn’t know a thing about time management. You can’t do everything for every patient. It is pretty easy to identify 80% of traditional practice standards that can just be tossed out. A simple example is the physical exam. What’s a complete physical. Here is my version:

“Vitals reviewed. Constitutional: She is oriented and well-developed, well-nourished, and in no distress. She appears not diaphoretic. No distress. HENT: Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate. Eyes: Conjunctivae and extraocular motions are normal. Pupils are equal, round, react to light and accommodate. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Neck: Normal range of motion. Neck supple. No JVD present. No tracheal deviation present. No thyromegaly present. Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal. No stridor. No respiratory distress. She has no wheezes. She has no rales. She exhibits no tenderness. Abdominal: She exhibits no distension and no mass. Soft. No tenderness. She has no rebound and no guarding. Musculoskeletal: Normal range of motion. She exhibits no edema and no tenderness. Lymphadenopathy: She has no significant adenopathy. Neurological: She is alert and oriented. Gait normal. Skin: Skin is warm and dry. No rash noted. She is not diaphoretic. No erythema. No pallor. Psychiatric: Mood, memory, affect and judgment normal.”

This is not a list of the most relevant findings, rather it is evidence of a brief survey of the body that is systematic, easy to perform, and keeps all the Medicare auditors happy. This has the advantage of focusing on the most readily apparent and easy to observe abnormalities; most of the time no abnormalities are recorded for most of the parts of the exam that are done. With repetition this becomes very quick and effortless. My complete physical takes only 2 minutes; problem focused exams take only half that.

The physical exam is only one example. There are many more. Just to take another simple one. Don’t focus on every preventive measure that could possibly be done. This would cost too much in time and money, and since the USPSTF has recommendations for 169 interventions, you would find it just overwhelming. Besides we can’t prevent 100% of anything anyway. The simple rule is to pick up to 7 of your top priorities, and use every visit to make sure they are very well taken care of.

In order to be efficient you have to work in your own way. Any physician who is using a progress note form (whether paper or electronic) that is designed by someone else has been dealt a major blow to efficiency, productivity, and creativity. There is no single common denominator to medical care. The methods of effective practice are as rich and varied as the people who are practicing medicine and the patients who see them. As a craftsman, you are simply negligent if you don’t design your own tools for the way you work. Your efficiency, accuracy, and creativity all depend critically on getting in your groove and just humming along in a way that comes natural to you. Your progress note form should be a brief map for the interaction you want to have with patients. Below is my basic progress note template for both new and established patients, acute or chronic care issues.

It starts with the chief complaint from the patient’s perspective since, if you don’t address this right up front, you have lost their attention and you have missed an opportunity to map your use of time together. Then the very next thing I want to get to is social history where I learn as much about the patient’s milestones through life and role in the community as I can. I spend 2 minutes on completing a lifestyle score using my formula for health (0-5-10-30-150) and remind them how central these 5 behaviors are both to health and the care of any disease. My review of systems includes a search for any and all problems (my note uses a list of the top 16 to prompt me to think of common problems that need not be obvious; you would be amazed at how easy it is to take care of a cold for a patient and not realize that they have cancer) for which the patient has been treated in the past. The added advantage of this is that it expedites your review of chronic diseases giving Medicare the 3 pieces of information they want about at least two each visit (current disease status: whether progressing, improving, or stable; whether it is well-controlled or not; and whether there are any side-effects of treatment); this process also creates a nice mini-report card of the effectiveness of your care.

I also review some basic housekeeping details like whether they need glasses, use hearing aid, have dentures, or need a dental checkup too.

I review what laboratory testing has been done recently and make sure I have values for my top 5—lipid panel, renal function, A1c (if BMI > 30 or have HTN), TSH, and a CBC.

Finally I do my review of my top 5 preventive medicine tasks (lifestyle score [already done], lipid testing, immunizations, Pap and mammogram review for women (particularly noting any past history of abnormals) and offering a PSA test to men, if they want it, and a general discussion (not necessarily any testing) of the pros and cons of colon cancer screening (not essential in my opinion), prostate cancer screening (not recommended), and skin cancer screening. It is worth remembering that a healthy lifestyle avoids more cancer than all of the traditional cancer screening programs put together at a mere fraction of the cost. After that I am just jotting a few notes to myself about abnormalities on exam and the “to do’s” I take away from the visit, and we’re done.

All in all, this is a rich, 15 minute experience that gets the job done. And, of course, I’m not done yet. I hope to get better.

Figure 1: My Basic Progress Note

Visit #: Age: Gender: Name: DOV: 4/21/11

CC:

HPI:

Social: Lives with: Occupation:

Lifestyle score: 0 5 10 30 150

Smoking: Etoh: Known drug issues:

FamHx:

ROS: glasses? Hearing? Last dental check? Other assistive device?

Chronic Problem List:

Status Control Side Effects:

Major 16:

HTN Lipids CAD DM BMI > 30 Smoker CHF

Hx of cancer Depression Hep C Thyroid

BPH Asthma/COPD Afib Warfarin CVA/TIA Chr Pain

GERD Sleep apnea

Surgeries: ________________________________________________________________________

Diabetes: A B C D E F: _______________________________

Major Labs: LDL: (cholesterol) Cr/GFR: (kidney) A1c: (diabetes) TSH: (thyroid) LFTs (liver) PSA (prostate)

Allergies:

Last Pap: Last Mammo: Last colonoscopy: Last PSA: Flu: Last DT Pneumovax Shingles:

Exam: BP: BMI

Other:

Assessment:

Follow-up:

_________________

Creating this global yet intensely targeted health assessment process has been the work of the last 30 years. It takes some experience to get both an adequate perspective (i.e., you can’t worry about every detail) and a confident ability to select what to focus on (that works for you). It takes 30 years to be both relaxed and confident (they don’t naturally go together). Residents starting out in practice are at such a disadvantage in trying to practice good medicine. They are still stuck trying to do it all (impossible), trying to know everything (impossible), trying to keep the experts happy (impossible), and trying to have a life (not quite impossible). Thirty years down the road, one is able to accept that one can neither knows everything nor attends to every detail and one doesn’t give a damn about the alleged experts any more. Moreover, we have a life, for better or worse, the one we made. It is no longer subject to the doubt or speculation that is so distracting to younger physicians. Finally, we are by now firmly entrenched in our communities, and they are taking care of us every bit as much as we take care of them, and the beautiful cycle of nurture completes once again.

Getting to Know Your Heart Risks

2011-04-08T23:31:00.000-07:00

The View from the Office

Does a Healthy Lifestyle Mean That You Never Have to Take Pills?

If you have a healthy lifestyle, does that mean you shouldn't have to take pills? Of course, I believe that everyone should have a healthy lifestyle. And increasingly more and more of us are achieving this goal. I've noticed that one of the things that happen to people who have healthy lifestyles is that they think they shouldn't have to take pills. The belief is this: If I keep working on my healthy lifestyle that should bring my blood pressure down, lower my cholesterol, and prevent me from ever getting diabetes. This principle is sound and applies most of the time, but there are many, many exceptions. The logic is especially true if you've had a healthy lifestyle all your life since childhood. But even then there is the matter of your genes. A healthy lifestyle does not change your DNA. The purpose of this week's article is to show you a way to know if taking some extra pills for your blood pressure, cholesterol, or general vascular disease prevention (like aspirin) is a good idea.

The problem that I am addressing is the fact that so often in my office I am trying to urge patients to start taking a blood pressure medicine so that their blood pressure doesn't linger around 148/94 mm Hg, but actually gets down to 120/80, where your heart and blood vessels will function optimally. Similarly, when it comes to cholesterol, I have no problem convincing the patient whose total cholesterol is over 300 mg/dL that they should take a medication called a "statin", but when I try to convince a patient whose blood pressure is just a little high, like 148/94 mm Hg, or whose "bad" cholesterol (LDL) is only 10-20 points above normal, which is 100 mg/dL, that they would really benefit (i.e., add years to their life) if they got that cholesterol way down into the good range like around 70 mg/dL, they just don't want to do it. They don't want to add a new medication, possibly for life, for just a minor abnormality. The problem, however, is that even a minor abnormality over a long, long period of time does significant harm. When you add several minor abnormalities together over a long time, they do a great deal of harm. This is the whole rationale of analyzing cardiac disease risk over multiple risk factors. Treatment is not just for those with severe abnormalities; it is for anyone who wants to enjoy the benefit of health for a much longer period of time.

Think of it this way: Would you have ask your auto mechanic to do just "half" of a tune-up? Would you want to put used motor oil into your engine? Remember that your body has pipes and pumps that need engine cleaning agents regularly titrated to your biological parameters (e.g., blood pressure, lipid levels, glucose, etc.). Just think of your blood pressure medications, cholesterol lowering medications, aspirin, etc., as engine-cleaning detergent gasoline.

Of course, not all medications will make a big difference. How do you know which ones will give you the biggest bang for the buck. Until recently this has been a very difficult calculation to do and the scientific evidence has been hard to interpret. But now we have some wonderful tools from the American Diabetes Association that gives you a simple graphical visual illustration of just how much benefit you will get from lowering your blood pressure just 5 points, or 10 points, or 20 points. You can do a similar calculation for your weight and dramatically see how much difference losing 5 lbs, 10 lbs, or 20 lbs will make for you. In this article I am going to demonstrate how the ADA's program, "My Health Advisor" (My Health Advisor (http://www.diabetes.org/diabetes-basics/prevention/my-health-advisor/ or search for "my health advisor" in Google), can help you pick exactly what medication, or what level of blood pressure or cholesterol will do you the most good.

To start with you have to enter some basic data about your self. Here is a summary of the data the program collects.

Then based on this profile, the program (which takes some 10-15 minutes to run your numbers through the extensive Archimedes database) produces a report to show you the your probability of a heart attack, stroke, diabetes, etc., if you just keep tooling along just as you are. One of the nice things about the program is that it lets you save a copy of your data and your report so you can revisit it in the future and play out a variety of "what if" scenarios based on where your biological parameters are and where you would like them to be.

You see in the graphic above that there are slider bars next to your weight, cholesterol, and blood pressure, and there are check-mark boxes for other interventions such as stopping smoking, taking a baby aspirin daily, or taking a prophylactic heart medication like an ACE-inhibitor or a beta-blocker.

In the graph above the pink bars shows the reduction in my risks if I just get my blood pressure down to 120/80 mm Hg.

In this graph you see the effect if I go all out and lower my weight from 210 to 185, if I lower my LDL cholesterol from 94 to 70, and lower my blood pressure from 130/80 to 120/80 mg Hg, and start taking a heart-protective medication (an ACE-inhibitor). The combination of interventions would lead to a very impressive reduction in overall risk.

Major reductions in risk like this are a very good thing, and the way to get there is by taking a medication. Thus my advice is to try to move away from the hostility towards taking medications. Stop telling yourself that it is all a plot just to make money for the drug companies, or that it will cause you lots of problems from side-effects. What these medications give you, if you lower your cardiac risk, is extra years of life--very high quality life, in fact, if you have a healthy lifestyle. When you evaluate the trade-off--a good number of extra years of life against a few annoying side-effects, the balance of benefits to risk is very positive. On the other hand, if you chose not to avail yourself of the wonderful benefits of these medications, that too has a side effect--dying early is a rather nasty one.
We are blessed to live in an era in which we have truly effective medications, now all blissfully available as low-cost generics. Unfortunately, we have come to take for granted this embarrassment of riches. We forget that 30 years ago the medications to achieve these goals were not available or were so expensive that they were out of reach of many. I think we are all well aware of many, many people who died back then from diseases that are now easily treatable. That simply doesn't need to happen any more.

To maximize your life opportunity you should build your health on two firm pillars: (1) you should create and sustain a healthy lifestyle for you and your children based on the formula for health (0-5-10-30-150); and (2) You should use the "My Health Advisor" program to really understand your risks and to make your own decisions about blood pressure, cholesterol, and heart-protective medications. These are all very inexpensive and very effective. No corporation needs profit from your decision if you use a generic, and the generics are every bit as good as the fancy brand names (which are all destined to become generics anyway). If you really value health, you will get aggressive about asking for these medications because they can do for your health such an amazing thing--keep you on this earth so you can be with your friends and family a good bit longer. All your friends and family would want you to.

COMMENT: In my separate publication in April, FP Revolution (FP Revoluation recent issues) I will describe in detail how to use the other ADA program for risk assessment in diabetic patients (Diabetes PHD, http://www.diabetes.org/living-with-diabetes/complications/diabetes-phd/ Diabetes PHD or enter the search term "diabetes phd" into Google). This program allows diabetic patients to change their risk not only for heart attacks and strokes, but also for kidney failure, blindness, and foot amputation. All of this represents high-tech medicine at its best. And best of all--you are in control all the way!

Ear Infections: To Treat or Not to Treat?

2011-03-31T16:34:00.000-07:00

The View from the Office

EAR INFECTIONS IN CHILDREN: TO TREAT OR NOT TO TREAT?

A brief history of ear infections (otitis media) is in order before going on to intelligently review the current state of the art. Once upon a time that a few of us still alive well remember, there were no antibiotics, and recurrent ear infections in children were a serious problem. Untreated, they could lead to mastoiditis, meningitis, and even death. When antibiotics came along, the attitude was "Of course, we'll treat. This is a bad disease." And treatment worked. Mastoiditis became a rare problem. Meningitis became even more rare, especially after new vaccines. Ultimately, ear infections in children became a very benign and simple problem. For the last 50 years or so, there have been hundreds of studies comparing every new antibiotic made by a pharmaceutical company to the old traditional ones trying to show that the new one was better in some way--either it cured more cases or had fewer side effects. The general lesson we have learned from these studies is that the choice of antibiotic doesn't make much difference, so you just use the least expensive one.

Then, a funny thing happened in the 1970s. Since otitis media was becoming a minor illness with just a few days of fussiness and moderate discomfort which would in the majority of cases go away even if it was not treated, European investigators started asking the question or whether you really need antibiotics at all for this newly less serious infection. The Netherlands pioneered this effort, and there it became standard policy NOT to treat ear infections with antibiotics at the first visit. At the first visit doctors would just recommend tylenol and analgesic drops (like Auralgan) in the ears. Then parents were given instructions that if symptoms were not much better by 3 days, they should return to get antibiotics. It turns out that this policy worked very well. The overall cure rates were the same as in the US, where antibiotics were being used routinely, and there were no increases in complications like mastoiditis.

It took a while for this approach to drift over to the US, but in the 80s and early 90s there were a number of studies that compared antibiotic treatment of otitis media to the outcomes in children who were not treated with antibiotics. What these studies showed consistently is that there was a small, statistically significant, short-term benefit in the children who were treated with antibiotics. The precise benefit was one day less of symptoms (shorter duration of illness) in 1 out of 7 children treated. This was shocking, of course, to physicians who were trained to treat ear infections. Thus, despite the very clear literature, only a minority of physicians actually stopped prescribing antibiotics; old habits change hard. In my practice I have always preferred to share the evidence with the patients (in this case, the parents) and let them make their own decision. I neither urged nor discouraged antibiotic use. Instead I asked the parents if they would want to use antibiotics for their child for the sake of possibly (a 1 in 7 chance) having one day less of symptoms at the risk of a drug reaction, most commonly a rash, upset stomach, or diarrhea. In my experience about 75% of parents chose to use the antibiotic.

Since the 1990s there have been very few studies of ear infections in children and absolutely no change in the bottom line--antibiotics confer a 1 in 7 chance of 1 day less of symptoms. That is why it is a noteworthy event that 2 recent studies have just been published in the New England Journal of Medicine on the treatment of ear infections in children--one in children less than 2 years of age in Pittsburgh PA, and the other in children aged 6 to 35 months in Finland. They both reach the same conclusion--that the benefits of antibiotic treatment are greater than has previously been estimated.

Let's take a look at those two studies and see how convincing this conclusion is.

In the under-2 years of age study, 291 children aged 6 to 23 months were diagnosed by experts using stringent criteria for the diagnosis of ear infection, and when an ear infection was diagnosed one group received a potent antibiotic (Augmentin) and the other group received a placebo. Among the children who received Augmentin (amoxicillin-calvulanate), 35% had initial resolution of symptoms by day 2, 61% by day 4, and 80% by day 7. This compared to rates of, 28% resolution by day 2, 54% resolution by day 4, and 74% resolution by day 7. These small differences were NOT statistically significant. For sustained relief of symptoms, the rates were 20% vs 14% at 2 days, 41% vs 36% at 4 days, and 67% vs 53% at 6 days. This result achieved borderline statistical significance (P value=0.04). Mean symptoms scores over the first 7 days were lower for the children treated with antibiotics than for those who received placebo (P=0.02). The rate of clinical failure--defined as the persistence of signs of acute infection on otoscopic examination--was also lower among the children treated with antibiotics than among those who received placebo: 4% vs 23% at or before the visit on day 4 or 5 (P < 0.001) and 16% vs 51% at or before the visit on day 10 to 12 (P < 0.001).

The second study randomized 319 children aged 6 to 35 months in Finland who were diagnosed by strict criteria as having ear infections to either placebo or the same antibiotic as above. Treatment "failure" occurred in 18.5% of the children who received the antibiotic vs 44.9% of the children were received placebo (P < 0.001). At 3 days after diagnosis, the failure rate was 13.7% in the antibiotic group vs. 25.3% in the placebo group. Overall, the antibiotic reduce the progression to treatment failure by 62%. Side-effects were much more common in the antibiotic group, and 47.8% of the treated children experienced diarrhea. The authors of this study comment, "Future studies should identify patients who may derive the greatest benefit, in order to minimize unnecessary antimicrobial treatment and the development of bacterial resistance."

An editorialist reviewing these two studies concludes "Is acute otitis media a treatable disease? The investigators in Pittsburgh and Turku, Finland have provided the best data yet to answer the question, and the answer is yes; more young children with a certain diagnosis of acute otitis media recover more quickly when they are treated with an appropriate antimicrobial agent."

Fig 1: An acute ear infection: a very bulging tympanic membrane.

To all this I have to say, "Not so fast!" First, the authors used, as is appropriate for a formal study, a "strict" definition of an ear infection. In the Pittsburgh study, the criteria for a diagnosis of ear infection were: (1) onset within 48 hours preceding the office visit; (2) a symptom assessment score of at least 3 on a scale of 0-14; the symptoms evaluated on a 3 point scale (none, a little, a lot) were: tugging on ear, crying, irritability, difficulty sleeping, diminished activity, diminished appetite, and fever. This is, in fact, admirably rigorous. The problem, however, is that out in the real world of general practice, primary care physicians do not do all this. Their history is very brief, no symptom scores are assessed, the ears are looked at very quickly, and lots of cases are diagnosed as ear infections that have no actual bulging of the tympanic membrane. What this means is that the group of patients being treated in ordinary offices is significantly different, probably with milder disease, than the patients included in the study. Thus we do not know if the conclusion from the formal study should apply to children with less severe illness.

Clinical "failure" was strictly defined as either a lack of clinical improvement (and this is what parents really care about) or worsening of signs on otoscopic examination (which parents don't care about). My perspective as a practicing physician is that, if the child is not having any symptoms, I don't care what the ear drum looks like. I would never extend or repeat an antibiotic just because the ear drum look abnormal, whether moreso or not. What matters is how the patient is doing.

Finally, both studies arbitrarily chose to use an advanced antibiotic (Augmentin). This is a powerful (probably more powerful than one needs) and effective antibiotic, but it causes a very high rate of gastrointestinal side-effects. In one studied it caused diarrhea in almost half of the children treated. This would mean that treatment is like trading one problem (an ear infection) for another (diarrhea), and it is hard to say which is worse. I can tell you which is messier. Certainly there is a need for additional studies, if we are going to making a recommendation to change general practice, to determine which antibiotic will cause the least side-effects while retaining most of the effectiveness. There are many good candidates.

Thus in my opinion these studies don't change anything. It still comes down to a close call whether young children with mild ear infections should be treated. This decision should be made by the parents, not by the doctor. The doctor's role is continue to give parents the benefits of the latest information and help them to make a reasonable decision.

Another strategy that has been well-defined as safe and effective in multiple studies is for the physician not to treat at the time of the first visit, but to give a prescription for an antibiotic to use if the symptoms become worse or do not resolve in 2-3 days. This was called a "delayed prescription" for an antibiotic. Only about 50% of parents given a "delayed prescription" actually get them filled, which means that many, many children get better all by themselves. This strategy significantly reduces the use of antibiotics and thus will lead to less emergence of antibiotic resistance among common bacteria. I use this strategy a lot.

References: Hoberman A et al. (Pittsburgh) Treatment of acute otitis media in children under 2 years of age. NEJM 2011; 364:105-15. Tahtinen PA et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. NEJM 2011; 364: 116-26. Klein JO. Is acute otitis media a treatable disease? (editorial) NEJM 364: 168-9.

The Truth About Osteoporosis

2011-03-17T21:41:00.000-07:00

THE VIEW FROM THE OFFICE

OSTEOPOROSIS: WHAT WE DON'T KNOW IS A LOT MORE THAN WHAT WE KNOW

The primary predictive risk factor for osteoporosis is how old you are. One simple preventive, therefore, is not to grow old. If we're not interested in this strategy, what do we do?

The most effective preventive strategy is to keep active and eat a good diet throughout life. Live a healthy lifestyle and generally you don't have to worry about problems like this. [See healthy lifestyle formula below.]

Smoking directly reduces bone strength and mineralization. 5 servings of brightly and multi-colored fruits and vegetables a day give you lots of extra calcium. Having a high body mass index actually protects you from osteoporosis, but leads to such an unpleasant assortment of other problems, it is not worth it. Exercise is absolutely essential both for a healthy life and for the prevention of osteoporosis. If you do all 5 steps of a healthy lifestyle, then you won't need to worry about osteoporosis when you're older. You just keep doing what you're doing.

Well, you're older now, and you may not have done all that lifestyle stuff as regularly as you would have wished. What now? The current national recommendation from the US Preventive Services Task Force (USPSTF) is to a risk assessment for osteoporosis at age 65 for women. There is insufficient evidence yet to recommend such screening for men. There are multiple ways of doing this. Getting a DEXA bone scan for bone density is the most popular (and the most lucrative for those who run the machines), but it is not the only way. I actually prefer something called the "Osteoporosis Risk Assessment Instrument"; you only have to answer 3 questions to calculate your risk. [Click on this link, Osteoporosis Risk Assessment Instrument,to calculate your own risk. You get 9 points if your age is between 64 to 74, and 15 points if your age is 75 or older; you also get 9 points if your weight is less than 60 kilograms or 132 pounds.]

Now the website will say, if your score is 9 or greater, you should get a DEXA scan. I say, if your score is 9 or greater, then you should proceed to some reasonable treatment for osteoporosis. If you end up taking calcium, vitamin D, and getting more weight-bearing exercise and you don't have osteoporosis, you have really done yourself no harm. If you do have osteoporosis, then you're doing the right thing. I don't really see what the DEXA scan gets you other than the illusion that you know what's going on and what to do about it. The DEXA scan itself is not the criteria to use to decide whether to take a medicine like Fosamax. The occurrence of a fracture is the definitive criteria for that decision. Many will argue that it seems better to take the Fosamax before you get a fracture, and this is a perfectly reasonable leap of faith, but you will be acting beyond the limits of our current knowledge.

Anyway, in my view the simple Osteoporosis Risk Assessment Instrument is a much, much simpler way of seeing if you should get serious about your risk of osteoporosis. It is also a great deal cheaper than a DEXA scan. As you can see the major risk is age, followed by weight, and the third factor is whether you take estrogens for menopausal symptoms, which relatively few women do anymore.

So, if you do have a high risk score, what you do you do about it. The primary treatment is--guess what? Exercise, calcium, and vitamin D. No secret here. The recommended amount of exercise is 22 minutes of weight-bearing activity (walking does fine) a day, 1000 mg of calcium a day, and at least 800 IU of vitamin D. The special medications (the most common one being Fosamax (alendronate) are not indicated unless you have already had a fracture from osteoporosis.

Some practical tips:

1. A DEXA bone scan is not the only way to assess risk. A simple 3 question score (Osteoporosis Risk Assessment Instrument) will do the job more easily. Try it.

2. There is no evidence that repeating a bone scan leads to any clinical benefit. The proven value of the test is a one-time thing only--it confirms that you have osteoporosis. It is clear from the studies that repeating the scan in less than 2 years leads to inaccurate results--either false reassurance or unnecessary worry. If the DEXA scan gets worse after 2 years, there's not much else to do. Just exercise, calcium, vitamin D, and Fosamax (or other bisphosphonate).

3. Drugs for osteoporosis still have several controversial aspects.

a. They are clearly beneficial only for patients who have had prior fractures. In this case, they definitely reduce the rate of subsequent fractures.

b. We do not have any proven evidence of benefit from receiving treatment for more than 5 years. The studies haven't been performed for longer than this. There is some evidence of harm from prolonged treatment--primarily increased brittleness of the bones and a possible risk of a relatively rare complication, osteonecrosis of the jaw bone. It is quite reasonable just to stop this medication after 5 years of use; you have received most, if not all, of the benefit.

4. The amount of calcium that is recommended is 800 to 1500 mg per day. You can get this in a single supplement tablet, but you can also get it naturally. The dark green leafy vegetables like kale have lots of calcium. One cup of kale is equivalent to a cup of whole milk in calcium content--about 400 mg.

5. Vitamin D is the subject of increasing controversy. In recent years it has been learned that higher levels of vitamin D in the blood are associated with a reduced risk of heart disease and cancer, not just osteoporosis. What is not clear is whether giving a vitamin D supplement, of 800 to 2000 IU a day makes a difference. There are no studies confirming this, but it is widely expected to be helpful based on the basic science of human vitamin D metabolism. There are, of course, other ways to get vitamin D, of which regular exposure to sunlight is the best. You only need 10-15 minutes a day and not every day.

What is becoming clear is that around the world large numbers of people are deficient in vitamin D. In my last practice at Kaiser, I was routinely testing for vitamin D in all of my patients and found that about 20% of them were significantly deficient as the Kaiser laboratory defined the test (below 30 pcg/mL was considered deficient). What was really surprising is that a number of patients who were deficient were younger, had good diets, and exercised regularly. So what gives? A recent Institute of Medicine report suggests that we don't need to worry until the level is less than 20. Another problem, however, is that there is considerable variation from lab to lab in the way vitamin D levels are measured and reported. So what is considered deficient in one laboratory may be considered adequate in another.

There is enough controversy and uncertainty about the efficacy of routine screening for serum vitamin D levels that I no longer endorse it. What I do endorse, however, is routine supplementation for everyone with a multivitamin containing vitamin D, at least 800 IU per day for the average adult.

6. Not all exercise is considered exercise from the perspective of preventing osteoporosis. This rather strange conclusion was brought to my attention by a patient in my practice here in Graeagle. He is a regular bicycle rider. He had heard that, since bicycle riding is not strictly weight-bearing, that it was ineffective in preventing osteoporosis, and he requested a DEXA bone scan for himself. I ordered it for him, expecting it to be fine, but it turns out he was right. He had osteoporosis. I did a search through the literature and found a number of well-substantiated reports confirming that intense bicycle riding does not prevent osteoporosis. A similar problem may present itself to vigorous swimmers as well. The results suggest, in fact, that the more intense the bike riding, the greater the risk of osteoporosis (at least on the bone scan). Another factor that may be adding to the problem is that sweat contains a substantial amount of calcium; the more you sweat, the more you lose. You can lose up to 20 mg of calcium per hour through heavy sweating. Some clinical studies suggest that this effect is significant.

Of course, my patient has never had a fracture and may never get one. He does not want to take the Fosamax medication, and it is not clear that he should. So he is left with going back to calcium (which he prefers to do through natural diet), vitamin D, and exercise. He should add some regular walking to his bike riding.

Who would have thought that a healthy person who is an avid bike-rider would need to worry about osteoporosis? We're still not really sure what all this means. It is not clear that he has any disease. It is clear that his bones look thinner than average on a DEXA scan. The real test of whether he has a disease or not is whether he experiences any clinical problem, and this has not happened yet. So we wait and see. The big question is what does he or you do in the meantime, while you're waiting. That's a personal decision.

How To Take Care of Your Diabetes

2011-03-10T11:56:00.000-08:00

THE VIEW FROM THE OFFICE

TAKING CARE OF YOUR DIABETES

Diabetes is common, all too common. The first thing to say about it is that it can be prevented. The Healthy Lifestyle (Formula for Health) that I have previously described [see below] has been shown to prevent up to 93% of all cases of type 2 (adult-onset) diabetes. Now that's a bargain. No fuss, no mess. Think about it. If you already have type 2 diabetes, you can make it go away by changing to a healthy lifestyle.

   From a physician's point of view, diabetes is the most complicated disease we manage in primary care. There can be so many complications. Our job, and yours too, of course, is to prevent each and every complication. To achieve this we need teamwork--you and your physician working together.
   One of the things that makes diabetes so complicated is that there are so many experts out there who are publishing "guidelines" for an ideal world. The American Diabetes Association (ADA), for example, is a very well-intended organization which has done a lot of good work. They publish a set of guidelines ("Standards of Care") for diabetes based on the recommendations of experts, which make diabetes so complicated that no one could do it in the real world. They were apparently conceived for the world of specialists where they have a lot more time to manage their patients--an hour or more. In primary care we average only 15-20 minutes. The ADA recommended standards, if followed to the letter, would take on average about 2 hours per visit. I did a survey in a prior practice of mine in Pennsylvania in a rural setting (Hershey) among primary care physicians. It turns out that not one was following the published ADA guidelines--because they just didn't have the time. The reality, moreover, is that no one has ever done a study to see either if the specialists themselves are actually following the ADA "standards of care" or whether, if they do, it really makes a big difference in patient outcomes.

   Well, my prevailing principle in medical practice is to Keep It Simple. With that in mind, I have reduced the necessary steps for high-quality care of diabetic patients to 6 simple steps, which I make easy to remember by giving it the little memory clue the first six letters of the alphabet "ABCDEF". Here is all that you need to keep track of for your diabetes:

A = Hemoglobin A1c; this is the basic measure of sugar control in diabetes. It is a test that assesses your average glucose level for the past 3 months. The goal is to keep the hemoglobin A1c at 7.0% or below.

B = Blood Pressure; Blood pressure control is extremely important in diabetes to prevent the development of renal failure. The goal is to keep your blood pressure averaging < 140/90 mm Hg.

C = Cholesterol. The primary measure of cholesterol that is used for patients with diabetes is what we call your "bad" cholesterol or LDL cholesterol. For diabetic patients the goal is to keep your LDL below 100 mg/dL. It usually takes medication, a statin, to do this.

D = is for MDRD method of assessing kidney function. This is the only letter of our mnemonic that is not intuitive. The MDRD stands for the Modified Diet in Renal Disease study, which is where this method of assessing renal disease and its progression in diabetes was developed. The MDRD number is your estimated glomerular filtration rate (it may be easier to refer to your kidney function as GFR)--i.e., how many milliliters of fluid can your kidneys filter every hour. The goal is for this number to be anywhere above 60. Most adults start with a normal GFR between 100-120. You won't really run into serious problems until it falls below 30, which is when you will want to consult a kidney specialist and start getting informed about dialysis options and procedures. As soon as it crosses below 60 you want to track it regularly. Some medication doses may have to be adjusted. The important thing to know is that kidney failure and the need for dialysis can be prevented. The secret is to keep good control of your blood pressure and monitor your renal function with the MDRD number.

E = eye checks by an ophthalmologist. You should have one at the time your diabetes is first diagnosed, and then every 2 years thereafter. This is to check for diabetic eye disease which is a major cause of blindness; it is preventable. Your ophthalmologist may suggest a different interval for follow-up checks ranging from every year to every 3 years. Your doctor needs to have a copy of the ophthalmologists latest report in his chart for you. You can help by asking your ophthalmologist to be sure to send your doctor a copy.

F = foot exams. A major complication of diabetes is loss of circulation and nerve function in your feet. This in turn can lead to repeated injury (since you won't feel any pain) and ultimately to difficult to treat foot ulcers, and finally, if these can't be controlled, to amputation of a part of your foot or leg. Your doctor should perform a good foot exam at least every 6 months looking for signs of severe fungus infections, bacterial infections, ulcers, or other sores or breaks in your skin. Just doing a good visual inspection of your feet on a regular basis has been shown to reduce the rate of amputations in diabetics by 50%.

   And that's it. It's really not all that complicated. There is absolutely no reason why you cannot track these 6 measures yourself. And, if it is not your doctor's usual practice to check any of these things, you can simply ask. If you are prepared and aware, you can insure that every thing that needs to be done is done. What you need, in a nutshell, is to ask for 3 blood tests--a hemoglobin A1c (should be checked every 3-6 months), a cholesterol panel, and a kidney function test (creatinine, which is how they calculate the MDRD number). You can check your own blood pressure at home; this is a really good idea. Then just ask your doctor to check your feet every 6 months and review with them when they received the last report from your eye doctor, whether you had any changes from diabetes in your retina, and when you are due for your next eye check up.

HealthFinder.gov: A Great Resource

2011-03-09T18:49:00.000-08:00

Obesity Is Not the Problem

2011-03-03T19:47:00.000-08:00

Obesity is Not the Problem.

A BMI > 30 is the Problem.

People often come in to see me for care of their diseases. I routinely ask them what chronic medical problems they have, and they tell me all about their high blood pressure, diabetes, thyroid problem, and osteoporosis, etc. They usually don't think to mention the fact that they are significantly overweight. This is very understandable. Obesity is an unpleasant word to use about anyone. Yet our nation's economy depends heavily upon being able to sell junk food to almost everyone, with obesity as an obvious natural result. Therefore I propose getting rid of the word obesity, at least as a medical term.

The problems with it as a medical term are that it is too vague. The term "obesity" is generally used to mean someone is 20% or more overweight. Unfortunately, most people do not know their ideal weight, and, even if they did, it is no simple matter for most of us to multiple it by .2 and add it to our ideal weight in order to determine if we are obese. Who does that? Furthermore, some people are finicky and refer to themselves as overweight at a mere 10% over ideal body weight, while others at 30% over ideal body weight consider themselves normal because everyone else in their family is that way. "Normal" is relative after all. And, of course, in our society "obese" is a stigmatizing word that is used to attach a label to people as though they were all of the same nationality and ought to be blamed for a host of our country's ills. All of this is unhelpful.

The good news is that obesity itself is not a disease, and its health hazards have been overstated. The trend in the medical profession has been away from classifying people as obese. Instead the clinical measure has become Body Mass Index (BMI). This number takes your weight (in kilograms as it turns out) and adjusts it for your height (in meters); the specific formula is: BMI= weight(kg) / height(meters)^2 (squared).

There are a couple of really handy things about this number: (1) With the new electronic medical records that all health systems use, your weight and height can be automatically converted into this single number without anyone having to do any math; and (2) It turns out that there is a nice, simple dividing line for separating all those people whose weight, however much over ideal body weight it may be, is not a problem clinically from all the rest who have a significant, in fact, major medical problem.

The magic number is 30 (kg/m^2). If your BMI is less than 30, your weight is not a medical problem. The experts define a normal BMI as between 18 and 25, but being over 25 is not associated with any significant increase in medical complications until you hit 30. A BMI > 30, however, is associated with significant increases in the risk of developing diabetes, high cholesterol, hypertension, heart disease, stroke, and dying. It is a real problem.

Thus, when you come in to my office, I will always check your recorded height and weight to calculate your BMI. I will tell you if it is greater than 30, and I will record it in your chart as a medical problem, just as I do for hypertension and diabetes. And we will have a discussion about what you can confidently do to bring it back down under 30. We don't have to shoot for your perfect weight. We just have to get your BMI down under 30. This is a much easier goal to accomplish. For most people it can be achieved with an increase in exercise and conscious eating to lose around 10 pounds.

Here's a handy little tool to calculate your own BMI. Let me know if it is over 30, and we can do something about it.