Thursday, March 7, 2013

Mirror, Mirror, On the Wall . . .

I know.  The mirror on the wall in Snow White determined who was the fairest of them all, not who was more likely to die over the next 10 years.  But I find myself telling my patients repeatedly that my crystal ball is in the shop getting prepared, since I really have no way to predict mortality, or do I?  In a research letter published earlier this week in JAMA, the authors developed a risk calculator that was reasonably accurate in predicting mortality over the next 10 years.  The score was developed based upon 3 distinct geographic locations (11,701 participants in the West, Central & East) and then validated in a fourth one (8,009 participants in the South)

12 items comprised the risk calculator, including age, gender, tobacco use, body mass index, diabetes, non-skin cancer, chronic lung disease, heart failure, difficulty breathing, difficulty managing finances, difficulty walking several blocks, and/or difficulty pushing/pulling large objects.  Depending upon your answer, you might gain 0, 1 or 2 points.  The lowest sum was zero while the greatest was 26.  It turns out that those without any points (zero score) had a 3% mortality over the next decade while those with scores >14 had a 95% chance of not making to the next decade.

All of the risk factors should not be a surprise to any of you who've been following my posts.  However, you may raise an eyebrow when you find out that you actually score a point if you're "normal" BMI rather than overweight or obese.  But let's not forget that just 2 months ago, a review article was published in this very same JAMA concluding that overweight BMI was associated w/6% lower all-cause mortality compared to normal BMI.

So aside from that anomaly, it's pretty clear that lowest mortality is associated with younger women who don't smoke, don't have diabetes/cancer/lung disease/heart disease or any functional limitations.  Well, while we can't do anything about our age & gender, that still leaves 10 risk factors under our control.  In other words, we are the master of our fate.



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Wednesday, March 6, 2013

Q&A Session at HealthTap.com

Sir.my skin in neck is very dark same is the problem with the underarm skin I consulted a physician he prescribed me glycomet 500 sustn rls.need help?



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I have good muscle size, now I want to gain cuts without loosing size. what should I do?



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What does kidney pain feel like?



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ILF vs ALF vs SNF: Do You Know the Difference?

Recently, an elderly resident suffered a cardiac event while while eating at home.  What makes this daily, if not hourly, event national news is that she had her event in the dining room of her independent living facility, which, by law, is not required to provide any medical assistance.   Despite fervent pleas by the 911 operator to perform cardiopulmonary resuscitation, the resident services director (apparently a nurse) refused to do so citing corporate policy.

Remember that an independent living facility is very different from an assisted living facility which, in turn, is very different from a skilled nursing facility (commonly referred to as a nursing home).  An ILF is most like any apartment complex and provides no medical services or assistance w/activities of daily living.  In contrast, an ALF provides assistance w/ADLs  On the other hand, a SNF provides around-the-clock skilled nursing.

So be very clear where you're going to live.  Is it an ILF, ALF or SNF?  What services will they provide?  Cardiopulmonary resuscitation?  More importantly, do you have your paperwork in order?  If you don't want CPR, do you have readily accessible paperwork stating as such?  And do your family members know what you (don't) want to have happen?

Caveat emptor.



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Tuesday, March 5, 2013

Q&A Session at HealthTap.com

Can i take 200mg of bentyl a day?



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Hi there. My husband and I have been trying to have a baby for about three years now. We've both been checked out and the doctors say we are fine.



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I been had milky stuff comming out my nipples for like 4days?



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Do It Because You Can or Do It Because You Should? Part 2

While there are many ways to categorize heart failure, one of the most commonly used is via ejection fraction. Those with a left ventricular ejection fraction (LVEF) less than 40-50% with signs of hypoperfusion are labeled as systolic heart failure.  Think of your heart as the revolving door at the entrance to a fancy building. Low LVEF can be envisioned as a rusty revolving door that allows less traffic flow than compared to when it's oiled & moving appropriately.

Less commonly, some patients have hypoperfusion (inadequate blood flow to end organs) despite normal LVEF (>50-60%).  This is labeled as diastolic heart failure or diastolic dysfunction.  Think of this as the revolving door now motorized & spinning much too quickly to for anyone to step in & through, therefore, traffic flow is still limited.  While we have plenty of evidence as to what improves outcomes in those with the common systolic HF, we really don't have any regarding the less common diastolic HF.

Well, a prospective, randomized, double-blind, placebo-controlled study was published last week in JAMA in which the authors concluded that long-term use of spironolactone, an aldosterone antagonist, improved diastolic function but did not improve exercise capacity, symptoms or quality of life.  In other words, why do it?  Do you really care what your LVEF is as long as you don't have any functional limitation?  Give me a study which shows that I can improve your quality of life & keep you healthy for a longer duration of time and then I'll be impressed.  In the meantime, I'll keep on doing things because I should, not because I can.



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Monday, March 4, 2013

Q&A Session at HealthTap.com

I've been on antibiotics for a sinus infection for 4 days. There is still ear pain and a very sore throat. Should I go back to the doctor or wait?



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Q&A Session at HealthTap.com

Would any doctors be willing to look at pictures of my perineal area.. in order to help diagnose me? its only of the area..it looks infected?



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Q&A Session at HealthTap.com

Is 500mg daily of inositol hexanicotinate dangerous? I took it for four years but stopped after reading it was ineffective for lipids.



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A Blood Vessel Is A Blood Vessel Is A Blood Vessel Is A Blood Vessel

A rose is a rose is a rose is a rose.
Gertrude Stein

If Ms. Stein were a physician, she might proclaim that "a blood vessel is a blood vessel is a blood vessel is a blood vessel" regardless of what organ it supplies.  The implication is that blockage of one leads to blockage of others.  Thus peripheral artery disease is considered a coronary heart disease equivalent by the Adult Treatment Panel III.  For that matter, so is symptomatic carotid artery disease.  Most recently, twice in January, studies were published in Circulation: CQ&O and PLoS Medicine linking erectile dysfunction to future heart disease.

Along those lines, we're now familiar with the use of coronary artery calcification scoring to provide additional information for risk stratification beyond the Framingham risk score.  While we're struggling to come to grips with primary prevention of heart disease, it's interesting to note that a population-based study published early online last week in Stroke concluded that CAC was useful in predicting future stroke.  4,180 low-intermediate risk participants avg 59yo were followed for ~8 years in order to arrive at this conclusion.  Interestingly, 3 other well known studies failed to demonstrate this association, possibly due to a smaller number of participants.

Should we be surprised at this finding?  Probably not.  In fact, I would go so far as to say that aside from statistics, I was more surprised by the other 3 studies' inability to demonstrate this link.  Bottom line, we need to aggressively heart disease risk factors which are remarkably similar to those for stroke.



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Sunday, March 3, 2013

Q&A Session at HealthTap.com

I have Graves Disease. After my RAI treatment, I am now Hypothyroid. What physical & emotional symptoms should I expect?



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Q&A Session at HealthTap.com

What's the advantage of Levocetirizine over Cetirizine for Pediatrics with allergic rhinitis?



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Can you take paracetamol and Ibropufen at the same time?


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I suffer from severe migraines and have tried all medications with no relief! Desperate for relief! I need something to stop the pain once it starts.



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I have a headache, what could be problem?



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Doctor says I have a mild case of Shingles. Pain on Saturday then diagnosis on Thursday with2 ( now 3 ) bumps on left side. Would I be ok w/o Famvir ?



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Sinius problems are caused by what ? and how does one rid of this problem can be discontinued ?



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Q&A Session at HealthTap.com

Hi I am a newly diagnosed diabetic with 15kg overweight.age 36 .I am adviced metformin 1000 mg b.d along with insulin.



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I want to loose my weight I am 128 kg height is 5feet 10 inch.age 28.please help how I manage diet and exercise.



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Saturday, March 2, 2013

Q&A Session at HealthTap.com

78 year old female w/femur fracture. Diagnosed w/diabetes+emphysema. Has other heart/lung condition. How to best treat fracture or reduce pain?



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I have just taken some tablets and my neck has swollen whats do i do?



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Hi Sir my jaws are not in correct position. What should I do?



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Testosterone Is Testosterone Or Is It?

As you know, numerous drugs reach the market place yearly.  It's near impossible to stay abreast of every new development, especially as a family physician, but we try for the sake of our patients.  One way to keep up-to-date is to meet with the ubiquitous but currently out-of-vogue pharmaceutical representatives.  However, in some practices, especially academic ones, exposure to these drug reps is severely limited, if allowed at all.  Recent studies have shown that, try as we might & despite our loud protests, our prescribing pens & now our electronic keyboards are easily persuaded by free meals & trinkets, not to mention the thousands if not millions of dollars paid to fund grants & serve as a thought leader.

So what's the alternative?  Many of the drug databases point out new drugs as they reach the market.  Some even discuss possible options in Phase 3 trials.  One of these databases, Monthly Prescribing Reference, recently reported that testosterone undecanoate received orphan drug designation for constitutional delay of growth & puberty in adolescent boys (14-17yo).  This is the same testosterone undecanoate that is available outside the States as injectable Nebido, a long acting formulation requiring just a few injections a year.

It turns out that when taken orally, testosterone undecanoate is absorbed by the lymphatic system and thus avoids breakdown in the liver prior to reaching its intended sites of action.  This is a fancy way of saying it avoids all the liver issues associated w/older forms of oral testosterone.  You see, if you swallow "regular" testosterone, it'll be absorbed in the stomach & broken down in the liver.  Thus, nothing reaches the end organs, eg muscle, brain, genitals, etc.

On the other hand, if you chemically muck around with testosterone and add a methyl group here or a fluoride molecule there (sorry, I didn't really care for organic chemistry), the liver has to work harder to break down the testosterone molecule and thus it now appears in your blood stream.  But because your liver is working harder, it starts getting "irritated" which is why I never prescribe oral testosterone.

Granted, it won't be cheap, but when SOV Therapeutics' new product hits the market, it will offer a much easier option for testosterone replacement therapy in hypogonadal men, albeit off-label.




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Friday, March 1, 2013

Q&A Session at HealthTap.com

What is my ideal weight my height is 168 cm?



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I have fat in my lower back/sides. How can i get rid of it?



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Q&A Session at HealthTap.com

Is it safe to tke cialis daily dose and fly?



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Never Be The First To Prescribe And Never Be The Last Part 2

About a year & half ago, I commented on a study looking at the risk of pancreatitis when using a new class of diabetes medications.  Due to cost issues, I really hadn't had a chance to prescribe these new medications, instead sticking with inexpensive generics.  But then a patient came in earlier this week asking about the plethora of billboards popping up all over town warning about the risk of pancreatitis & pancreatic cancer after taking these medications and suggesting that any one who's ever taken one call the attorneys immediately.

So I gave him my lottery analogy.  Which is to say, many people toss a few dollars into the lottery hoping to win but just about no one does.  However, for that one lucky person, winning the lottery will change his/her life.  Likewise, many people take these medications hoping that they won't develop pancreatitis or pancreatic cancer.  However, for that one unlucky person, getting either condition will change his/her life.

So of course I'm a day late & a dollar short.  I just stumbled upon a population-based case-control study published early online this week in JAMA Internal Medicine in which the authors concluded that glucagon-like peptide 1 therapies are linked to increase risk for pancreatitis.

To arrive at their conclusion, the authors found 1,269 cases in which the patient was hospitalized for pancreatitis.  Then they found 1,269 controls matched for age, gender & diabetes complications.  Avg age was 52yo w/men accounting for just over half the group.  When the cases were compared to the controls, they were noted to have high triglycerides, alcohol use, gall stones, tobacco use, obesity, biliary & pancreatic cancer, cystic fibrosis and any cancer.  Of note, both GLP-1 mimetics and dipeptidyl peptidase 4 inhibitors were linked to increase risk of pancreatitis.

I guess that means I'm going to have to hunt down this patient and have another discussion regarding this study.  But of course, neither insurance nor Medicare/Medicaid will pay for the phone call to review this study in order to assist him in making the right choice for him.




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