Sunday, July 31, 2011

Q&A Session at Wellsphere.com

period problem

Q&A Session at Wellsphere.com


Discharche 2 weeks befor my period ? Is this normal ?

Q&A Session at Wellsphere.com


I'm always regular with my period. I had severe PMS symptoms, (worse then usual) but i missed my entire period.

Q&A Session at Wellsphere.com


Dark brown vaginal discharge.

Q&A Session at Wellsphere.com

Is brown discharge normal after two weeks of period?

Q&A Session at Wellsphere.com


Help 2 bumps on penis and sore throat?

Q&A Session at Wellsphere.com

My 20 yr old son has been sick for 5 days now. it started with an ache in his right side. Then he started vomiting.

Q&A Session at Wellsphere.com

was changing a tire on a big truck and overextended both of my arms heard something pop in boyh arm they both hurt when i try to

Q&A Session at Wellsphere.com

I have stiffness on the right side of my abdomen just below my rib cage. I have no pain other than a little discomfort. 

Q&A Session at Wellsphere.com


Excessive sleepiness in 9 year old

Q&A Session at Wellsphere.com

What are the dangers of thyroid level being 56 when it should be 3?

Q&A Session at Wellsphere.com

is Parkinson's Disease related to inner ear music--or possibly change of PD meds.??

Saturday, July 30, 2011

Q&A Session at Avvo.com


This weekend my family and i were sitting at lunch at a restuarant, when all of a sudden for no reason my father in law seemed

Q&A Session at Avvo.com


I have been experiencing locking of my jaw, for the last two weeks.

Q&A Session at Avvo.com


What to do for a deep thigh bruise

Q&A Session at Avvo.com


My dad woke up with a sore foot, He was not able to walk or put any pressure on it.

Q&A Session at Avvo.com


Should I be worried that my left arm aches when doing my morning walk?

Q&A Session at Avvo.com


What is the recommended dose of Vit. E for the elderly?

Q&A Session at Avvo.com


What is shingles? What are the symptoms? Will they come back after treatment?

Q&A Session at Avvo.com


stiff neck on my left side for about 2 weeks an getting worse

Q&A Session at Avvo.com


My mom is very healthy, she is 89 but her jaw shakes. Can something be done to stop the shaking?

Q&A Session at Avvo.com


My B/P is 119/38. Is the wide pulse pressure a health concern?

Q&A Session at Avvo.com


should we be concerned if taking blood pressure readings on both arms and the right side is 30 to 40 points higher than the left

Q&A Session at Avvo.com


I am a 66 year old woman who has been trying to lose weight so I have been drinking 1 to 2 gallons, or more, of water a day

Friday, July 29, 2011

IGF-1: When More is Less

While some colleagues believe in a more traditional laboratory definition of some conditions, I try to treat the patient but without going overboard.  For a number of issues, more is better.  More home runs hit, more bases stolen, more free throws sunk, more goals scored.  However, when it comes to medicine, I think the Goldilocks theory applies.

On the other hand, some of my former colleagues believe in the more is more strategy, especially when it comes to treating growth hormone deficiency.  When treating their patients, they believe that everyone should have and be treated to an IGF-1 of 300ng/mL or even higher, based upon reference ranges from older equipment that is not currently being used.  This is despite current use of equipment that has a significantly lower upper limit of normal.

Well, in a study released early just 2 days ago (to be published in September), the authors noted a U-shaped curve when comparing all-cause, cancer & cardiovascular mortality to IGF-1 levels.  In other words, those participants who had IGF-1 outside the mid-centile reference range, whether high or low, had a greater risk of death, even though their IGF-1 was still within the normal reference range.  Of course, this begs the question, what is considered normal?

Well, the normal reference range is that range which includes approximately 95-96% of the "normal" population.  Of course, one could always argue whether having two-thirds of our population overweight or obese is really & truly "normal".  Nevertheless, we take a bunch of "normal" participants and throw out the lowest 2-2.5% and the highest 2-2.5%, even though they must be "normal" by definition in order to included.

But that still doesn't make us feel any more comfortable about aiming for high (or low) IGF-1 levels.  The authors analyzed data from 12 population-based cohort & (nested) case-control studies including 14,906 participants who were deemed normal.  For instance, studies of patients w/acromegaly, acute renal failure or liver cirrhosis where excluded.  Children & patients in intensive care units were also excluded.

As noted above, different assays (lab equipment) were used over time and by different laboratories, each with their own specific reference ranges, precluding direct comparison of IGF-1 levels.  Therefore, the authors compared percentiles of IGF-1, since the distribution of results should be same, regardless of the test used.  Yet, time & again, those in the 10th percentile (lowest grouping) had 56% greater risk of mortality than those in the 50th percentile (mid-range).  And those in the 90th percentile (highest grouping) had 29% greater risk compared to those in the 50th percentile.

Granted, this is observational data.  So one shouldn't necessarily jump to the conclusion that treating to lower (which begs the question, why treat at all) and higher levels is worse or more dangerous/deadly than treating to the mid-range of your lab's reference range.  But until proven otherwise, I think the Goldilocks theory of medicine applies here.  To wit, give the right amount, not too little, and not too much.

Thursday, July 28, 2011

Cell Phone Use vs Brain Function Part 3

Following medical literature reminds me of watching a (table) tennis game, turning our heads back & forth as we watch the competitors fight it out. Initially, cell phones got a free past with regards to a possible link to cancer. Just over a month ago, a very weak link emerged. In a study published yesterday in the Journal of the National Cancer Institute, authors analyzed data from close to 1,000 Western European children and found no link between cell phone use and (brain) cancer risk. The good news is that we can now take a deep collective breath and sigh with relief over our children. The bad news is that this study analyzed data only from students who'd used cell phones for 5 years and hadn't really allowed enough time for slower growing cancers to manifest themselves. So what are we to do? As I mentioned in Part 2, keep the phone away from (your) their faces. This is easier if they text more than they talk. But consider making your children use an earpiece or headset when calling from the phone in order to increase distance and minimize any conceivable damage from radiation. While this is definitely not the definitive and final answer regarding cell phone use, we can certainly feel more comfortable about allowing our children to use this ubiquitous technology. Reporting live from Atlanta, this is Alvin B. Lin.

Wednesday, July 27, 2011

HgbA1c: Readily Available Test Improves Heart Risk Calculation

I started the morning doing an OJ imitation - running thru McCarran, what were you thinking? And now I'm in Atlanta for a meeting. But on the fly, I stumbled upon a study just published today in the Archives of Internal Medicine that demonstrated an improvement in our ability to calculate heart risk with a simple & readily available blood test: Hemoglobin A1c. The authors analyzed data from the Nurses Health Study and the Physicians Health Study over several years. The idea is that HgbA1c is able to assess how poorly one's diabetes is controlled rather than just a blanket statement, as we currently do, to equate any diagnosis of diabetes with heart disease. After all, if you've made the effort to achieve an exceptionally well-controlled HgbA1c, your risk should be lower than the diabetic who doesn't pay attention to his/her nutrition & exercise. So the next time you need blood drawn, see if you can add HgbA1c to your orders.

Tuesday, July 26, 2011

Health Literacy: Does It Matter? Part 3

Two months ago, really close to three months now, I commented on two studies looking at health literacy.  The first study linked low health literacy to greater all-cause mortality in patients w/heart failure.  The second study linked longer pediatric hospitalization length of stay to parents' lower health literacy.  And as I mentioned obliquely last week, low education attainment is considered one of the biggest risk factors for Alzheimer's disease.

Therefore, it's no surprise that I found a systematic review published last week in Annals of Internal Medicine looking at how health literacy affects us.  After poring over 96 good or fair quality studies, the authors concluded that low health literacy is associated with more hospitalizations and greater use of emergency care, both of which drive up health care costs.

Those patients w/low health literacy are less likely to get screening mammograms, less likely to get annual preventive influenza vaccinations, less able to read/interpret labels & health messages, and less able to demonstrate how to take their complicated medication regimens.  In the elderly, the ultimate consequence of low health literacy is lower overall health status and higher mortality.

True, it might not be easy to teach our parents to read, much less understand health-related material.  But before this situation explodes in our collective faces, we need to improve upon the education of our children in order to prevent a mushroom of Alzheimer's disease and depletion of our ability to (pay for) care in the very near future. 

Monday, July 25, 2011

Don't Just Sit There, Do Something! Part 4

Just last week, I commented on a new study demonstrating how to lower our collective risk for Alzheimer's disease.  Besides stopping tobacco use and improving educational attainment worldwide, the study noted that physical inactivity accounted for the majority of Alzheimer's disease here in the States.

At the same time, two studies were released early online in Archives of Internal Medicine documenting similar conclusions.  In the first analysis, 2,809 participants average 72yo with known heart disease in the Women's Antioxidant Cardiovascular Study (WACS) were questioned regarding physical activity every two years while cognitive function was assessed 4 times over 9+years.  Those who engaged in the highest quintile of physical activity, equivalent to daily brisk walking for 30 minutes, had slower loss of cognitive decline, comparable to being 5-7 years younger.

In the second study, 197 participants average 75yo in the Health, Aging & Body Composition (Health ABC) study had their total body energy expenditure (TBEE) and resting metabolic rate (RMR) measured along with cognitive function.  Consistent with the more typical self-reported physical activity, the higher one's objectively measured active energy expenditure (AEE=TBEE-RMR), the the lower one's risk for cognitive impairment.

The editorialist commented that ongoing maintenance of physical activity is a worthwhile recommendation for all our patients as we age.  I have yet to read about a downside to physical activity that outweighed the benefits gained.  So let's get out there and do something!  Go set a better, more active, example for our patients.

Sunday, July 24, 2011

Q&A Session at Avvo.com


Should I get a second opinion

Q&A Session at Avvo.com


78 year old mother who abruptly stopped taking prednisone.

Q&A Session at Avvo.com


my legs,feet, hands swell daily is it safe to take over the counter water pill with over the counter potassium daily, age 57

Q&A Session at Avvo.com


Easy question > How do I get the job done? I keep getting sent on to the next doctor and nothings is getting done for anything.

Q&A Session at Avvo.com


My mother was diagnosed with three toxic black mold is here system and I would like to know if this can cause a stroke

Q&A Session at Avvo.com


would like to know about symptoms of toxic black mold

Q&A Session at Avvo.com


I am 50 yrs young and have been numb on my entire left side including my face is there something that I need to worry about?

Q&A Session at Avvo.com


My grandfather was just fine yesterday but today was really CRAZY!!!

Q&A Session at Avvo.com


At 70 years old what causes night swats or hot flashes?

Q&A Session at Avvo.com


Whats wrong with me I have Blood in my Urine after running?

Q&A Session at Avvo.com


when i go to the doctors i am told there is blood in my urine but nothing is done should there be something done what causes

Q&A Session at Avvo.com


i have blood in my urine

Saturday, July 23, 2011

Q&A Session at Wellsphere.com

brown vaginal discharge?

Q&A Session at Wellsphere.com

Am I pregnant?

Q&A Session at Wellsphere.com

can BV cause swollen lymphnodes in chest

Q&A Session at Wellsphere.com

how long implantation bleeding last

Q&A Session at Wellsphere.com

whats going on with my body???

Q&A Session at Wellsphere.com

vas deferens swelling?

Q&A Session at Wellsphere.com

white spots

Q&A Session at Wellsphere.com


Please explain grey skin pallor thx Ken.

Friday, July 22, 2011

A Better Way to Assess Heart Disease Risk

Risk factors only go so far in assessing one's chances of something happening.  The traditional Framingham Risk Calculator divides heart disease risk into low (<10%), moderate (10-20%) & high (>20%) over the next 10 years.  However, the downfall is that its data is based upon Caucasians in the Northeast.

Does this really matter? Well, we know that the population distribution of strokes varies with an increase risk in the Stroke Belt in the South.  Racially speaking, there does appear to a subtle but real difference in prevalence of prostate cancer based upon ethnicity.  Which is why it's so important to look at the participants in any given study to determine whether the data can be generalized to you.

For heart disease, if we're suspicious, we can order a stress test.  But not everyone can get active enough on a treadmill and not everyone wants an IV stuck in their arm for a chemical stress test or nuclear imaging, especially not for screening asymptomatic patients in order to catch someone early enough in the disease process when we can make a difference and prevent a negative clinical outcome.

That's where the not-so-new kid on the block, coronary artery calcium scoring or CAC, comes in as it does a great job of predicting heart disease but at the risk of radiation exposure.  We like to claim that the radiation is minimal but the truth is that human errors have led to excessive radiation exposure during radiologic imaging.


One solution is the new darling, carotid artery intima media thickness (CIMT) assessment, which involves a very quick ultrasound of (both sides of) one's neck.  In a study published yesterday in the New England Journal of Medicine, the authors concluded that CIMT of the internal carotid artery (ICA) improved heart disease risk stratification beyond that achieved by the Framingham risk calculator alone.  The authors arrived at their conclusion after following 2,965 members of the Framingham Offspring Study cohort for over 7 years. 

Since no physical exertion, ionizing radiation or IV is involved, perhaps we should consider using CIMT as an intermediate step between pure risk calculation and CAC scans prior to stress testing & imaging in asymptomatic patients?  For now, that makes sense if you're a Caucasian from the Northeast.

One last thought: let's say you'd like to see if your coronary arteries have improved from lifestyle modifications after your initial CAC scan.  That means undergoing another scan and thus accepting more radiation exposure.  On the other hand, let's say you'd like to see if your CIMT has improved from lifestyle modifications after your initial ultrasound scan.  No ionizing radiation was required the first time and none will ever be required to repeat your CIMT scan!  Just something else to think about.

Disclaimer:  I serve as a medical consultant to HeartSmart Technologies EyeCare Division which markets CIMT to optometrists (whereas HeartSmart IMTplus focuses on the MD/DO segment).

Thursday, July 21, 2011

More Fiber = Lower Diverticular Risk

In a new study published this week in BMJ, analyzing data from the ongoing European Prospective Investigation into Cancer & Nutrition (EPIC), the authors followed 47,033 participants for 11+years, 15,459 of who self-reported as vegetarians.  When all was said and done, vegetarians had a one third lower risk of hospitalization for and death from diverticular disease.  

But a vegetarian diet isn't for everyone.  What if you have just have to have an (occasional) animal source of protein.  Make sure you also consume at least 25.5g/d of fiber if you're female and 26.1g/d if you're male.  Why?  Compared to those in the lowest quintile for fiber consumption (less than 14g/d for both men & women), those in the highest quintile also demonstrated a similar inverse association with diverticular disease.

So choose wisely.  Eat the colors of the rainbow every day, including at least 5 servings each of fruits & vegetables to minimize your risk for diverticular disease and death.

Wednesday, July 20, 2011

How to Prevent Alzheimer's Disease Part 2

Vindication is sweet.  Two months ago, I commented on a review published in the Archives of Neurology that concluded that "insufficient evidence exists to draw firm conclusions on the association of any modifiable factors with risk".  Well, in a study published yesterday online in Lancet Neurologyy to coincide with its presentation at the Alzheimer's Association 2011 International Conference (AAIC), formerly known as ICAD, short for International Conference on Alzheimer's Disease, the authors concluded that it is in fact possible to reduce the risk of Alzheimer's disease by modifying just 7 factors:  diabetes, midlife hypertension, midlife obesity, smoking, depression, cognitive inactivity low educational attainment, and physical inactivity.

Through a series of statistical manipulations reviewing much of the data available to the National Institute on Aging last year, they noted that up to half (greater than 17 million) of the cases of Alzheimer's disease worldwide are attributable to the above 7 risk factors.  They then went on to state that a population-wide reduction of all 7 risk factors by 10-25% could potentially decrease the number of cases worldwide by 1-3 million.

All told, smoking & low educational attainment accounted for the largest number of AD cases worldwide.  In the States, physical inactivity accounted for the majority of cases.  Note, too, that physical activity is also associated with diabetes, hypertension, obesity, and even depression.  From a public health standpoint, we need to focus our on limited resources on education, physical activity and smoking cessation.  Healthy living is good for more than just a healthy body; it just might prevent Alzheimer's disease.  It's nice to know I'm not the only who interprets the available data this way.

Tuesday, July 19, 2011

No Such Thing as a Free Lunch

In an ideal world, we'd only need to swallow a risk-free, side effect-free, interaction-free pill just once and never have to worry again about whatever condition we were treating.  To date, we're not even close to reaching that goal.  There is no such thing as a free lunch.  

We can provide up 10 years worth of protection against tetanus, diphtheria, and pertussis but this requires an injection.  Screening colonoscopy is recommended starting at 50 years of age in low risk patients, but there is still a small but real risk of perforation.  The statins are extremely powerful at lowering cholesterol but at the risk of myalgias and liver irritation.

For those men suffering from lower urinary tract symptoms of benign prostate hyperplasia (BPH) despite alpha blockers (which themselves have been associated with an increase risk of heart failure), 5 alpha reductase inhibitors (5ARI) have been a God-send, shrinking the prostate (and thus, PSA) by 50% within 6 months and generally improving their quality of life.  This class, as exemplified by finasteride & dutasteride, works by inhibiting the conversion of testosterone (T) into dihydrotestosterone (DHT).  Therefore, testosterone is forced down the metabolic pathway towards estradiol (E2), which accounts for the 5ARI's known risk of gynecomastia, erectile dysfunction & loss of libido, all from having too much E2.  Imagine a seesaw with testosterone as the fulcrum and DHT & E2 balanced on opposite sides before starting a 5ARI.  Upon starting either finasteride or dutasteride, the seesaw is thrown out of balance as T is converted into more E2 and less DHT.

This much we've known for a while.  We've also theorized that by shrinking the prostate, we might be able to prevent prostate cancer, which then lead to the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial, both of which did demonstrate an overall 23-25% reduction in prostate cancer.  However, the flip side is that both trials also demonstrated an increase risk of high grade prostate cancers.  After PCPT and before REDUCE, we tried to explain this by any number of statistical models.  However, with both studies arriving at the same conclusion, the FDA's advisory panel denied the claim for chemoprophylaxis last December after concluding that one additional case of high-grade prostate cancer would be diagnosed for ever 150-200 health men treated long-term with a 5ARI.

The FDA has left open the option to continue to treat men with symptomatic BPH and/or hair loss with 5ARIs.  But last month, the FDA updated the Warnings & Precautions section with the above discussion & concerns as noted in this week's NEJM (thanks to Dr. Peter G's keen eyes).  It's now up to us to deliberate whether the risk is worth the benefit in this specific situation for each individual we see.  It would be all too easy if we could foretell the future but unfortunately, my crystal ball is at the repair shop.  For now, we'll need to discuss/warn our patients who need something besides an alpha blocker to treat their BPH.  Remember, there's no such thing as a free lunch.  And there are no risk free, side effect free, interaction free medications.

Monday, July 18, 2011

Caught Between A Rock And A Hard Place - Part 4

Wow!  Non-steroidal anti-inflammatory drugs (NSAIDs) are really taking a hit.  Just last Monday, I pointed out a link with atrial fibrillation.  A few months ago, I pointed out a link with erectile dysfunction.  Granted, these results are associative in nature rather proof of cause & effect.  However, a third strike comes this month linking NSAIDs to all-cause mortality, mainly due to cardiovascular disease in patients w/known hypertension & heart disease.

What's interesting is that aspirin is also a member of the NSAID class yet it gets a pass and multiple studies have demonstrated benefit in preventing deaths, heart attacks & strokes (although there is a small but real risk of hemorrhagic stroke & major bleeding).  Far be it for me to be able to explain why this is.  We've attempted to cull the benefit of aspirin and separate it from its pitfalls by developing Cox 2 inhibitors, a subclass of NSAIDs.  However, of the many Cox 2 inhibitors that reached the market at the beginning of the century, only one remains on the market, and even that one, celecoxib, has lost much of its glow.

So how did the authors reach their conclusion linking NSAIDs to mortality?  They analyzed the data after the fact from 21,694 individuals who didn't use NSAIDs regularly and 882 who did in the INternational VErapamil Trandolapril STudy (INVEST).  Any time the results from a study are used in a manner not originally intended, any conclusions derived are only good for generating hypotheses.  The authors noted that after less than 3 years follow up, there were a statistically significant 4.4 events per 100 patient-years in the those who took NSAIDs regularly compared to just 3.7 events per 100 patient-years in those who didn't, mostly due to cardiovascular deaths.

These results aren't just due to chance but you're looking at "only" 5 extra deaths per 1,000 patient-years.  We already know that NSAIDs are hard on the kidneys, increase blood pressure and your risk of gastrointestinal bleeding & intracerebral hemorrhage.  It's up to you to decide if chronic pain control is worth the potential for an increase in all-cause mortality if you also have high blood pressure & heart disease.  Remember, this is currently just an association, not a proven cause & effect.

Sunday, July 17, 2011

Q&A Session at Wellsphere.com

Can menopause cause your thyroid tests and antibodies to read as hyperthyroid? Part 2

Q&A Session at Wellsphere.com

Can menopause cause your thyroid tests and antibodies to read as hyperthyroid? Part 1

Q&A Session at Wellsphere.com


what causes an itchy and tight feeling in your throat?

Q&A Session at Wellsphere.com



 I'm 57 and still having regular periods--WHY???

 

Q&A Session at Wellsphere.com

I am just about to turn 52. I missed a period in May, in June I had two periods and now in July 2 weeks since my last period I 

Q&A Session at Wellsphere.com

groin pain

Q&A Session at Wellsphere.com

i have large joints in my body and they are starting to hurt..can someone tell me why??

Q&A Session at Wellsphere.com

Bunionectomy and restless legsyndrome are they connected in anyway

Q&A Session at Wellsphere.com

can a p.a. over write a physicians prescriptions

Q&A Session at Wellsphere.com

I have constant "tingling" on right side of my scalp. I have seen several neurologists and they cant seem to figure it out?

Q&A Session at Wellsphere.com

apple cider vinegar

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I have decided to stop taking Actonel; are there any withdrawal symptoms

Saturday, July 16, 2011

Q&A Session at Avvo.com


If your thyroid number dropped from last reading should your meds be adjusted?

Q&A Session at Avvo.com


I am taking HCTZ 25mg daily for the past 4years. 41 year old, Male. No diabetics whatsoever as far as I know. Then ..

Q&A Session at Avvo.com


can u drink grapefruit juice if u have diabetes and high blood pressure

Q&A Session at Avvo.com


my 75 year old friend i watch her sometime her tiolet has what looks like coffee grounds

Q&A Session at Avvo.com


What causes a 77 year old man to loose control of his legs?

Q&A Session at Avvo.com


My husband has Alzheimer's disease. He has episodes when he is very, very shaky, dizzy and confused. Is this a seizure?

Q&A Session at Avvo.com

My father is 87 yrs old and when he goes to bed at night he thinks little bugs are biting his feet. His feet are also hot.My father is 87 yrs old and when he goes to bed at night he thinks little bugs are biting his feet. His feet are also hot.

Q&A Session at Avvo.com

My Mom is 81 yrs old. Her sweat is sticky. Should I be concerned? What can I do for her?

Q&A Session at Avvo.com

How can I help my husband? He has Alzheimer, not tragic state yet. Bad back, leg pain. COPD and emphysema, uses O2 when sleeping

Q&A Session at Avvo.com

father is walking tripping over himself almost like he is drunk. Trying to sit where there is no seat. He is dragging his feet

Q&A Session at Avvo.com

Is 15mg meletonin excessive dosage. 74 year old male. Normally take 5mg; used 15mg last night, got better sleep.

Q&A Session at Avvo.com

How low is too low for BP?

Friday, July 15, 2011

Health Care Reform: Revamp Reimbursement

Exactly a month ago, I wrote about how a greater availability of general internists & family physicians was associated w/lower hospitalization & mortality rates.  Call me a cynic but I suspect part of the reason for this may be due to our current (dysfunctional) reimbursement system whereby physicians are paid for doing something but not for caring for someone.

Granted, most of us went to medical school because we wanted to make a difference for the better.  Most of us did not go to medical school to get rich (although getting paid for our efforts was an added benefit).  However, somewhere along the way, starting with our indebtedness, we realized that specialists who perform procedures are remunerated dramatically more than generalists who don't perform procedures.

In fact, it's been demonstrated that generalists perform quite a bit of work each day that goes unpaid: make 24 telephone calls to patients, specialists, pharmacists & insurance companies; write 12 prescriptions (in addition to all those written during a patient visit); read 20 lab reports; review 14 consultant reports; review 11 imaging reports; and write/send 17 emails interpreting test results, consulting with other physicians, and/or advising patients.  I'm sure the specialists' day is no different or less hectic.

Yet, when it comes to remuneration, the specialist has a significant advantage over the generalist: procedures. Economics 101 defines marginal revenue as the additional income derived from selling one more unit of a good above that necessary to cover overhead.  So while most physicians do not consciously perform procedures with marginal revenue in mind, the way our remuneration system is set up, it's difficult to ignore as these procedures are priced at hundreds if not thousands of dollars.  On the other hand, for generalists to squeeze in an additional patient, we're looking at marginal revenue measured in tens of dollars per patient visit.  Plus now, we face the wrath of those patients kept waiting who now want to bill us for their time.

All this ranting & raving is my preamble to a study published last week in JAMA that concluded that 16,838 (11.6%) of 500,154 percutaneous coronary interventions (PCI) reviewed were deemed inappropriate.  At $20,000 per procedure, that's $340 million more that could have been better spent, perhaps on medications & dietary counseling & physical activity instruction to prevent clinical heart disease in the first place.  After all, previous studies published in April 2007 & August 2008 have demonstrated no benefit from PCI in addition to optimal medical therapy in stable heart disease.

Don't get me wrong.  I'm not saying we shouldn't be paid for what we do.  But I think we need to minimize the disparity in remuneration between generalists & specialists.  Also, let me be absolutely clear and point out that the majority of the inappropriate procedures occurred in a minority of facilities authorized to perform them.  In other words, most physicians are trying to do the right thing, whether they're specialists or generalists.

Still, before you agree to undergo some procedure, ask the treating specialist if it's really necessary and what difference it will make to your clinical outcome (not just an image or a lab test).  And if you have time, get a 2nd opinion.  Or at least chat with your family physician (or general internist).  Any time someone who doesn't have skin in the game says you need something done, you need it done.

Our Largest Export: Our Leading Causes of Death Part 2

Just over 2 weeks ago, I commented on how one of our leading exports was our leading causes of death.  Now, of course, one can't export death, well not in the sense of heart disease, cancer, stroke & lung disease.  However, when we are looked at as the model of success (at least by most aside from the Middle East), it stands to reason why non-industrialized cultures to emulate our lifestyle.  After all, Coca-Cola, McDonald's, and Marlboro are some of the most well recognized brands around the world.

So it should come as no surprise, then, that even those who live around the Mediterranean Sea, whose diet we should emulate, have been eating less like their forebears and more like us.  It's this Mediterranean diet that, when consumed regularly, decreases risk of sudden cardiac death in women as noted last week,  amongst many other proven benefits.  Of course, this doesn't make me proud but rather saddened that most global deaths are due to non-communicable diseases from lifestyle choices modeled after our poor habits.

Just as I try to teach my oldest son to be a better example for his younger siblings, industrialized nations should attempt to provide a better example of how to eat in a healthy manner for our non-industrialized neighbors.  Too bad, it's less expensive to eat poorly and more expensive to eat healthily.

Thursday, July 14, 2011

Please Help Me! I Just Lost My Job and Can't Afford . . .

I've lost track of how many times I've heard that phrase.  Despite what the government keeps saying, I'm not convinced that we're better off now compared to before.  Many individuals & families remain devastated by the recent economic downturn.  As a result, they've lost their health (and dental) insurance, including medication coverage.  Luckily, there are options for those down on their luck.

A list of free or low cost medical clinics can be found at
http://www.freemedicalcamps.com/.  This listing includes free dental clinics, too.  Federally funded health centers can be found at http://findahealthcenter.hrsa.gov/Search_HCC.aspx.  These facilities are mandated to care for you, even if you don't have any health insurance.  Instead, you're asked to pay what you can afford, based upon your income.

By the way, guess who provides the vast majority of care at all these clinics?  Family docs!  Tell your Congressperson that we need more funding to train more family docs, especially if they intend to expand the number covered by insurance.  It doesn't do any good to give more people insurance if you don't have enough physicians to care for them.

Many older, generic medications are available for $4/mo or $10/90d and can be found at many big box chains, chief among them KrogerTarget and WalMart.

As much as we tend to malign Big Pharma, they do make an attempt to assist those who cannot afford their new & branded medications.  You can search for those drugs that aren't available generically at 

Of course, you're then left with expensive lab tests.  Never pay retail for anything.  Check out some of these (lower cost) options


Good luck!

Pertussis Vaccination: It's Not Just For Kids Anymore

When I first started training almost a quarter century ago, the immunization schedule was pretty easy to memorize.  Of course, the Centers for Disease Control & Prevention (CDC) along with the Advisory Committee on Immunization Practices (ACIP) was constantly updating the schedule semi-annually as new vaccines were developed and new indications were approved by the Food & Drug Administration (FDA).  

Back in the day, all infants got a series of 5 tetanus, diphtheria & pertussis (TdaP) vaccinations followed by tetanus & diphtheria (Td) every 10 years during adolescence & adulthood.  We got used to asking our patients when they last had their tetanus booster whenever they came in for a laceration repair or puncture wound evaluation.  But we ignored pertussis since whooping cough isn't really a big deal, right?

Wrong!  In an unintended side effect of the measles, mumps & rubella vaccine (falsely linked to autism) fiasco, many children were not being vaccinated against other preventable illnesses.  So it should be no surprise that more than 6,200 patients were sickened by pertussis last year in California alone, including 10 infants who died.  Sure, adults can tolerate a (whooping) cough for a prolonged period of time (with scattered outbreaks in nursing homes & hospitals since 2007).  But it's our infants who can't.  Nationwide, more than 21,000 cases were reported last year, including 26 deaths, of which 22 were in infants less than a year old.

Unfortunately, those at greatest risk of death from pertussis can only receive 3 vaccinations against the infection prior to their 1st birthday out of the 5 shot series with the 4th coming 6 months later and the 5th around 4-6 years of age.  So what's the best way to protect our children?

Immunize the adults!  Immunize the caregivers!  Immunize anyone with close contact to newborn infants!  TdaP had its indication expanded to include adults up to 64yo back in December 2008.  But just last week, the FDA approved Boostrix brand of TdaP for administration to adults 65 years & older.  Why?  Grandparents often have close contact with their newborn grandchildren!  So the next time one of your Medicare-age patients comes in showing off pictures of his/her new grandchild, consider updating his/her tetanus status with TdaP.

Wednesday, July 13, 2011

Newly Diagnosed Diabetes: To Do or Not To Do?

As I mentioned yesterday, physical activity is a good thing while inactivity is bad, at least for our health.  But in a study published over the weekend in the Lancet, physical activity offered no additional benefit on top of intensive dietary intervention compared to usual care in newly diagnosed diabetics.  Before you tell me, "I told you so!" let's remember to look for trends, not flukes.  More specifically, I'd label this study a fluke since most all other studies demonstrate some outcome benefit from physical activity (or at least the converse/inverse, eg harm from inactivity).

In this study, the authors randomized 99 newly diagnosed diabetics to usual care, consisting of an initial dietary consult with follow up every 6 months.  248 newly diagnosed diabetics were randomized to intensive dietary intervention consisting of the same initial consult but with follow up every 3 months and monthly nursing support.  The 3rd group of 246 newly diagnosed diabetics received a pedometer-based activity program in addition to intensive dietary intervention.

What amazed me was the small percentage (1-2%) of individuals who failed to complete their assignment and/or were lost to follow up at 6 and 12 months.  In fact, diabetic control, as assessed by hemoglobin A1c (HgbA1c), worsened in those randomized to usual care while it improved in the intensive dietary intervention group.  Those randomized to activity in addition to intensive dietary intervention also demonstrated improvement in HgbA1c compared to usual care but not statistically significant to intensive dietary intervention alone.

Why was there no additional benefit gained from physical activity?  Perhaps the participants weren't active enough?  In fact, the editorialists noted that the individuals randomized to physical activity actually did participate in 30 minutes of brisk walking at least 5 days a week as encouraged.  So perhaps it was the lack of resistance exercise as noted in another recent study?  In the end, even the editorialist supported the trend of evidence demonstrating the benefit of physical activity despite being unable to explain this fluke result.